Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of the PASARR Level I Identification Screening for two residents with documented mental health diagnoses. For one resident, the face sheet showed an admission with diagnoses of anxiety disorder and major depressive disorder, recurrent severe without psychotic features. The resident’s care plan documented use of antianxiety and antidepressant medications related to these conditions and included monitoring for signs and symptoms of depression, such as crying, shame, worthlessness, agitation, irritability, and suicidal ideation. However, the PASARR Level I Identification Screening dated 09/16/25 documented that the resident did not have a diagnosis of or suspected mental illness. During interview, the Admissions Director acknowledged that the PASARR did not include the resident’s mental health diagnoses and stated that if the PASARR screening does not include all pertinent diagnoses, the resident may not be properly screened. For the second resident, the face sheet documented an admission with multiple readmissions following hospitalizations and included diagnoses of generalized anxiety disorder and major depressive disorder. Two separate PASARR Level I Identification Screenings, dated 12/21/24 and 12/11/25, both documented that the resident did not have a diagnosis of or suspected mental illness and did not list generalized anxiety disorder or major depressive disorder. The resident’s care plan documented use of hydroxyzine for anxiety disorder, goals related to decreasing signs and symptoms of anxiety, and monitoring for side effects and effectiveness of anti-anxiety therapy. In interview, the Admissions Director confirmed that these mental health diagnoses were not reflected on the PASARR screenings and stated that if diagnoses are missing, the PASARR process would be inaccurate and residents may not receive all required services or may be improperly placed and not have all of their mental health issues addressed and treated.
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