Failure to Request Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental illness conditions were identified in residents who previously had Level I PASRR determinations. For one resident with a Level I PASRR dated 05/06/13, the admission MDS showed no serious mental illness per the state Level II PASRR process, although active diagnoses included major depressive disorder and anxiety disorder, and the resident was receiving antidepressant medication. On 11/19/25, a NP documented that the resident was experiencing nighttime hallucinations, with staff reporting the resident was screaming and terrified at night, and Seroquel 50 mg at bedtime was initiated. A psychiatric note on 02/27/26 documented follow-up after Seroquel was increased to 100 mg, with decreased hallucinations and mood disturbance. Despite these developments, an NC MUST inquiry on 03/17/26 showed no PASRR reevaluation requests had been submitted after 11/19/25. A second resident had a Level I PASRR dated 09/19/24, with no further screening required unless a significant change suggested a mental illness diagnosis or change in treatment needs. A psychiatric progress note dated 02/06/25 documented that on 01/30/25 the resident was started on prazosin 1 mg at bedtime and sertraline 50 mg daily for nightmares and PTSD symptoms, with diagnoses of PTSD and depression. The annual MDS later reflected active diagnoses of depression (other than bipolar) and PTSD, and antidepressant use, while still indicating the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. An NC MUST inquiry on 03/17/26 confirmed no PASRR reevaluation requests had been submitted after 01/30/25. In interviews, the social worker stated she was responsible for submitting Level II PASRR requests but was not always notified of new mental illness diagnoses and acknowledged not submitting requests for these two residents as an oversight. The administrator confirmed the social worker’s responsibility for Level II PASRR requests and stated these residents were overlooked during PASRR reviews and audits.
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