Failure to Complete Required PASRR Screening Prior to Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete required Pre-admission Screening and Resident Review (PASRR) Level I and, if indicated, Level II screenings prior to admission for one resident with multiple documented mental health diagnoses. The resident, an adult male, was initially admitted on 9/5/2025 with diagnoses including anxiety disorder, bipolar disorder, recurrent moderate major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia, with onset dates for these conditions ranging from 2010 to 2020. During interview and record review, the Social Service Coordinator and Social Service Director acknowledged that no PASRR had been completed for this resident prior to admission, despite the presence of these mental health conditions in the record. Surveyors later reviewed a PASRR Level I outcome notice dated 12/17/2025, which showed a determination of “No Level II Required – No SMI/ID/RC,” confirming that the PASRR process was not initiated until well after the resident’s admission. The Social Service staff stated they typically receive PASRR documentation from the hospital for new admissions and rely on a psychiatric NP who visits weekly to help identify residents with new or possible mental disorders, intellectual disabilities, or related conditions after admission. They also stated that the social service department is responsible for making referrals to the state-designated authority when such conditions are identified. The facility’s written Admission Criteria policy, reviewed on 4/12/2025, requires that all new admissions and readmissions be screened for MD, ID, or related disorders per the Medicaid PASRR process and specifies that the facility conducts a Level I PASRR screen for all potential admissions regardless of payer source, which was not followed in this case.
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