Failure to Complete and Accurately Document Required Level II PASARR Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with mental illness diagnoses received required Level II PASARR evaluations and that PASARR documentation accurately reflected their mental health conditions. The facility’s policy dated 2/2/24 states that all individuals with a mental disorder or intellectual disability applying for admission will be screened in accordance with state Medicaid rules and that recommendations from Level II PASARR determinations will be incorporated into assessments and care plans. For one resident (R43), the care plan dated 5/27/25 shows an admission date of 5/27/22 and diagnoses including psychoactive substance abuse, alcohol dependence, major depressive disorder, mood disorder, and schizoaffective disorder. However, the current medical record does not contain a Level II PASARR, and the Level I PASARR dated 4/29/22 does not list the resident’s substance abuse-related disorders or schizoaffective disorder and indicates that a Level II PASARR is not required due to no serious mental illness or related conditions. Another resident (R2) had a care plan dated 6/4/25 with an admission date of 5/22/24 and diagnoses including schizophrenia, bipolar disorder, insomnia due to another mental disorder, paraphilia, generalized anxiety disorder, unspecified intellectual disabilities, and cognitive communication deficit. R2’s Level I PASARR dated 3/21/22 documented that the resident was referred for a Level II PASARR, but the current medical record contains no documentation that a Level II PASARR was ever completed. During an interview on 1/14/25, the Admissions Coordinator (V10) stated she is responsible for PASARR screens on admission and with updates and acknowledged she could not locate a Level II PASARR for R2 in the system or in the electronic medical record. V10 also stated she was not aware of R43’s schizoaffective disorder diagnosis and did not realize it was missing from the Level I PASARR, confirming that R43 should have been referred for a Level II PASARR and that mental illness diagnoses should be included on PASARR screenings so appropriate support services can be obtained.
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