Failure to Complete Required Level II PASRR for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with documented serious mental illness diagnoses received a required Level II PASRR evaluation upon admission. The resident’s Level I PASRR, dated 7/23/25, indicated that no mental health diagnosis was known or suspected and concluded that no Level II PASRR was required, stating there was no evidence of a PASRR condition such as intellectual/developmental disability or serious behavioral health condition. However, the resident’s care plan, dated 1/6/26, shows that at the time of the most recent admission the resident had diagnoses of Bipolar Disorder, Major Depressive Disorder (MDD), and Attention-Deficit Hyperactivity Disorder (ADHD), and the LPN/MDS coordinator confirmed these diagnoses were present on the original admission. The LPN/MDS coordinator also confirmed that no Level II PASRR had been completed for this resident and that the former Social Services Director had been responsible for reviewing records and PASRR results at the time of the original admission, during which the resident’s mental illness diagnoses were not listed on the Level I screening. This discrepancy between the resident’s known mental health diagnoses at admission and the information recorded on the Level I PASRR screening led to the failure to initiate the required Level II PASRR review for a resident with Bipolar Disorder, MDD, and ADHD.
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