Failure to Complete Accurate and Timely PASRR Level 2 Screenings and Renewals
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate and timely PASRR Level 2 screenings and renewals for residents with serious mental illness (SMI) and intellectual disabilities. One resident was admitted with documented diagnoses including schizophrenia with auditory and visual hallucinations, intellectual disabilities, suicidal ideations, bipolar disorder, depression, anxiety, and adjustment disorder. However, this resident’s PASRR Level 2, completed prior to admission, recorded only intellectual disabilities, anxiety, and adjustment disorder, and explicitly stated the resident did not have an SMI. As a result, the PASRR did not include the resident’s schizophrenia and bipolar disorder diagnoses and did not recommend specialized mental health services. A facility LPN later acknowledged that the PASRR was incorrect because the resident had several SMIs and intellectual disability and stated she would normally be the person to call for a repeat PASRR when such errors occur. The facility also failed to ensure timely PASRR renewals for two other residents approved only for short-term stays. One resident with paranoid schizophrenia, cannabis abuse with psychotic disorder with hallucinations, major recurrent depressive disorder, and anxiety had an initial PASRR Level 2 authorizing a short-term stay until a specified expiration date, but the subsequent PASRR Level 2 was not completed until after that expiration. Another resident with mood disorder, bipolar disorder, depression, and post-traumatic stress disorder had a PASRR Level 2 that authorized a short-term stay ending on a specific date, and the regional nurse confirmed the facility missed completing the PASRR Level 2 redetermination by that expiration date and only requested a reassessment after the lapse was identified. These findings show that three residents out of nine reviewed for pre-admission screening did not have accurate or timely PASRR determinations in place as required.
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