Failure to Maintain Current PASARR Evaluations for Residents With Serious Mental Illness
Penalty
Summary
The facility failed to obtain required Pre-admission Screening and Resident Review (PASARR) evaluations for three residents with serious mental illness or related conditions, resulting in outstanding or expired PASARR determinations. During an interview, the Social Service Director stated that outstanding reports meant the PASARRs had expired and that new Level I screenings were required when PASARRs expire or when there is a new onset mental illness diagnosis. The Social Service Director also stated that submitting requested reports is important to complete PASARRs because, for residents with mental health illness, the facility needs to ensure it is following their plan of care, determining the need for psychosocial therapy groups, addressing billing, and confirming that residents are in the appropriate setting. Record review showed that one resident with dementia and a delusional disorder had an initial Level I PASARR marked as an Exempted Hospital Discharge with a 30-day approval, requiring re-screening by or before the 30th day if the stay extended beyond that timeframe; this Level I PASARR had expired and was not updated. A second resident with schizophrenia had an initial Level I PASARR with a short-term approval without specialized services that had an end date, and this Level II PASARR had expired without a new Level I being completed. A third resident with bipolar disorder and schizoaffective disorder also had an initial Level I PASARR with a short-term approval without specialized services and an end date, and this Level II PASARR had expired without a new Level I being done. These actions and inactions were inconsistent with the facility’s PASARR policy, which requires completion of Level I screens for all potential admissions and review of Level II recommendations to determine the facility’s ability to provide specialized services.
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