Failure to Ensure Accurate PASARR Screenings and Level II Referrals for Residents With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate PASARR Level I screenings and appropriate referrals for Level II evaluations for two residents with known serious mental illness diagnoses. One resident was admitted with documented diagnoses including bipolar disorder, current episode depressed, severe, with psychotic features, and post-traumatic stress disorder, yet the PASARR screening dated 06/09/2024 indicated the resident did not require a Level II PASARR due to no SMI/ID/RC. Another resident was admitted with diagnoses including schizoaffective disorder, bipolar type, other recurrent depressive disorders, and mild neurocognitive disorder due to a known physiological condition without behavioral disturbance. This second resident’s orders showed ongoing treatment with aripiprazole for psychosis, and the care plan documented a diagnosis and history of severe mental illness requiring psychotropic medication. Despite these documented mental health conditions and treatments, the second resident’s PASARR screening dated 02/13/2023 stated that the resident did not have a mental health condition requiring evaluation through the PASRR process, noted only depression as a DSM diagnosis, and concluded that no further PASARR evaluation was required. The Admissions Director, who had been responsible for completing PASARR screenings for 2.5 years, reported that he enters resident diagnoses and medications into the screening agency’s website and relies on the agency’s alerts to determine if a Level II PASARR is needed. He stated he was unsure who is responsible for ensuring PASARR information is accurate prior to admission and acknowledged that incorrect information entered into the Level I PASARR can result in inaccurate screening results. He further stated that one resident’s current PASARR screening was inaccurate and required a new screening due to the resident’s severe mental health diagnosis, demonstrating that the facility did not ensure accurate PASARR Level I screenings and appropriate referrals for Level II evaluations as required by its PASARR policy.
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