Failure to Request Level II PASRR for Resident With Serious Mental Health Disorders
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II PASRR evaluation request for a resident admitted with serious mental health disorders. A PASRR Determination Notification dated 12/05/25 showed the resident had a Level I PASRR with no expiration date. The resident was admitted with diagnoses including non-Alzheimer’s dementia, anxiety disorder, major depressive disorder, and bipolar disorder. A physician’s progress note dated 12/12/25 documented dementia and anxiety with depression, treated with escitalopram 10 mg daily, buspirone 15 mg three times daily, and divalproex sodium 125 mg every morning and 250 mg nightly. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but listed active psychiatric/mood disorder diagnoses of anxiety disorder, depression (other than bipolar), and bipolar disorder, and documented the use of antianxiety, antidepressant, and anticonvulsant medications during the assessment period. A NC MUST inquiry on 03/17/26 confirmed the resident only had a Level I PASRR effective 12/05/25 with no subsequent PASRR requests submitted. During interviews, the Regional Social Worker/Discharge Planning Consultant explained that when a resident is admitted with mental health disorders not reflected on the existing PASRR, the social worker should submit a Level II PASRR request, and acknowledged that this was not done for this resident. The Social Worker confirmed she was responsible for submitting Level II PASRR requests, verified the resident had mental health diagnoses and a Level I PASRR on admission, and stated that failing to submit the Level II request was an oversight. The Administrator also stated that the Social Worker was responsible for Level II PASRR submissions per regulatory guidelines and indicated that this resident’s PASRR was overlooked during review and auditing.
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