Failure to Complete Required PASRR Screening Prior to Admission
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.
Penalty
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PASRR screening was not completed correctly for a resident with schizophrenia, encephalopathy, severe cognitive impairment, and antipsychotic medication needs. The admission MDS and hospital discharge paperwork documented serious mental health history and impaired communication, but the PASRR level 1 was marked no for serious mental illness and no corrected PL1 was found. MDS staff were unsure who reviewed the form, and the DON and MDS Nurse stated the form should have been completed to trigger a PASRR level 2 evaluation.
A resident admitted with PTSD did not have a Level II PASRR evaluation requested even though the diagnosis was present on admission and listed as an active psychiatric/mood disorder on the MDS. The SW Assistant said she relied on a recent Level I PASRR from the hospital and did not request a Level II review, while the Administrator stated that a Level II PASRR request should be made for a resident with a serious mental health diagnosis.
A resident admitted with bipolar disorder had an inaccurate PL 1 from the hospital that coded no mental illness, even though the admission MDS listed bipolar disorder as an active diagnosis and the resident had a BIMS of 14. The baseline and admission care plans did not mention the bipolar diagnosis except in the diagnosis list, and the DON, ADM, and MDS RN stated the PL 1 should have been reviewed for accuracy before admission.
PASRR assessments were not accurately completed for 3 residents reviewed for PASRR and unnecessary meds. One resident with paranoid personality disorder, delusional disorder, dementia, and HF had a Level I PASRR indicating a Level II referral was required, but no referral was made. Another resident with PTSD, COPD, and CKD had an exempt hospital discharge PASRR, but when the discharge did not occur there was no documentation of a Level II referral. A third resident with depression, anxiety, and HF had a hospital PASRR that did not reflect the mental health diagnoses, and the SSD stated it should have been corrected with a Level II referral.
Failure to complete PASRR screening before admission for a resident with PTSD. The record showed the resident had a prior Level I PASRR letter stating no further screening was needed unless there was a significant change in condition, but the facility admitted the resident without obtaining a new PASRR evaluation. The SS Director said she did not realize a new PASRR was needed, and the Administrator said he was unaware a new evaluation was required and that the SS Director handled PASRR requests.
PASARR assessments were not accurately completed for three residents. One resident had depression and anxiety documented in the chart and psychiatry notes, but the PASARR did not list those diagnoses; another had anxiety documented with psych meds and a psych consult, but anxiety was omitted from the PASARR; and a third had bipolar disorder, major depressive disorder, and anxiety documented in the record, while the PASARR did not fully reflect the psychiatric diagnoses. The DON and NHA stated the PASARRs were incorrect and not being updated when new psych diagnoses were added.
PASRR Screening Not Completed Correctly for Resident With Schizophrenia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident with a documented history of schizophrenia. Resident #2 was admitted to the facility with diagnoses that included encephalopathy and other schizophrenia. The admission MDS showed the resident had unclear speech, was rarely or never understood by others, had a BIMS score of 00, used a manual wheelchair, and had schizophrenia marked in section I6000. The resident’s care plan included impaired cognitive function and impaired thought processes, and the resident required antipsychotic medications with monitoring and physician notification interventions. Hospital discharge paperwork also documented a history of schizophrenia, inability to answer questions appropriately, and calling out for a deceased sister. The resident’s PASRR level 1 screening was dated 5/12/26 and marked no for serious mental illness, and no corrected PASRR level 1 screening was found in the EHR. During interview, MDS Nurse 2 stated he could not identify who reviewed the PASRR screening for accuracy and believed schizophrenia would not require a level 2 evaluation unless the resident had been recently hospitalized for mental illness. The DON and MDS Nurse later stated the MDS Nurse was responsible for reviewing the PASRR level 1 for correctness and should have completed form 1012 to trigger a PASRR level 2 evaluation. The facility policy required review of the PASRR level 1 screening for completion and correctness prior to admission and submission of the PL1 form per regulations.
Failure to Request Level II PASRR for Resident With PTSD
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health diagnosis. Resident #90 was admitted with diagnoses that included PTSD, and the admission MDS identified PTSD as an active psychiatric/mood disorder diagnosis. A PASRR Determination Notification letter dated 7/21/25 showed the resident had a Level I PASRR with no expiration date, and the resident’s physician progress note dated 9/3/25 also documented PTSD in the resident’s health history. During interviews, the SW Assistant stated she was responsible for ensuring residents had PASRR determination letters and requesting evaluations as needed. She confirmed that when Resident #90 was admitted, a Level I PASRR determination letter had already been completed at the hospital and that PTSD was present on admission. After reviewing the Level I PASRR screening, she acknowledged that PTSD is a mental health diagnosis but stated that because the Level I PASRR had been done recently, the diagnosis did not trigger her to request a Level II PASRR evaluation. The Administrator stated that a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis should be done.
Inaccurate PASARR Screening for Resident with Bipolar Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for Resident #53 prior to admission. The resident was admitted with a diagnosis of bipolar disorder unspecified, and the admission MDS completed on 06/03/26 listed bipolar disorder in Section I Active Diagnoses with a BIMS score of 14, indicating intact cognition. However, the PL 1 completed at a local hospital identified the resident as having no mental illness, despite the active bipolar diagnosis in the record. The resident’s baseline care plan initiated on 05/27/26 and the care plan completed on 06/04/26 did not mention the bipolar diagnosis except in the diagnosis list on the last page. During interviews, the DON, ADM, and MDS RN stated the MDS RN was responsible for ensuring PL 1 forms were completed at or prior to admission and reviewed for accuracy against the resident’s diagnoses. The MDS RN stated she had recently taken time off and that was probably why she missed Resident #53’s inaccurate PL 1.
PASRR assessments not accurately completed for 3 residents
Penalty
Summary
PASRR assessments were not accurately completed for 3 of 8 sampled residents reviewed for PASRR and unnecessary medications. Resident 13 was admitted with diagnoses including paranoid personality disorder, delusional disorder, dementia, and heart failure, and was able to make needs known. The EHR showed a Level I PASRR completed on 11/29/2022 indicating a Level II evaluation referral was required because of serious functional limitations during the past 6 months related to mental illness, but the facility did not refer the resident to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Resident 14 was admitted with diagnoses including PTSD, COPD, and chronic kidney failure, and was able to make needs known. The EHR showed a Level I PASRR completed on 03/17/2026 stating the attending physician certified the individual was likely to require fewer than 30 days of NF services under an exempted hospital discharge, with no Level II indicated at that time unless the scheduled discharge did not occur; however, there was no documentation that the facility referred the resident for a Level II PASARR evaluation and determination when the discharge did not occur. Resident 150 was re-admitted with diagnoses including depression, anxiety, and heart failure, and was able to make needs known. The hospital-completed Level I PASRR showed no serious mental illness indicators checked and stated no Level II was indicated, but the SSD stated the PASRR should have been corrected to reflect the resident’s depression and anxiety and that a referral for a Level II evaluation should have been completed.
Failure to Complete PASRR Screening Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed prior to admission for one resident reviewed for PASRR. The resident was admitted from home with a diagnosis of post-traumatic stress disorder and the admission MDS indicated the resident was cognitively intact, was not currently considered by the state Level II PASRR process to have a serious mental illness, and had been identified as having a serious mental illness with a diagnosis of PTSD. The MDS also noted the resident had not exhibited behaviors or rejection of care during the assessment period and had received antipsychotic medications. The North Carolina DHHS PASRR determination letter in the record showed a Level I screen dated 5/11/2023 with a PASRR number valid for the duration of the individual's stay, and stated no additional PASRR screening was required unless there was a significant change in condition suggesting a mental illness diagnosis. In interview, the Social Services Director stated she was responsible for ensuring PASRR was completed prior to admission when required, but did not know the resident needed a new PASRR evaluation because the prior PASRR had no expiration date. The Administrator stated the resident's Level I PASRR screen was provided on admission, that he was unaware a new evaluation was required, and that the Social Services Director was responsible for submitting PASRR requests and evaluations.
PASARR assessments were incomplete and did not match residents' psychiatric diagnoses
Penalty
Summary
The facility failed to ensure PASARR assessments were accurately and completely documented for 3 residents reviewed for preadmission screening and resident review. For one resident, the admission record listed multiple medical diagnoses, a physician order for a psych consult was present, and a psychiatric note documented depression, anxiety, and nicotine dependence disorder, but the PASARR did not document anxiety disorder or depressive disorder in Section 1A. For another resident, the admission record included depression and anxiety disorder, and physician orders included Risperidone, Hydroxyzine, Xanax, and a psych consult for anxiety, but the PASARR did not include anxiety disorder as a diagnosis. For the third resident, the PASARR documented bipolar disorder as a mental illness or suspected mental illness, while the medical admission record listed major depressive disorder recurrent, other specified anxiety disorders, and other bipolar disorder, and physician orders included Clonazepam for severe anxiety and Bupropion for major depressive disorder. During interviews, the DON stated the PASARRs did not include the appropriate diagnoses and should have, and the NHA stated the PASARRs were not correct and that the interdisciplinary team was not updating them when new psychiatric diagnoses were added. The facility policy stated that if a Level I PASARR is incomplete or inaccurate, a corrected Level I PASARR must be completed.
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