Failure to Request Level II PASRR for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident with serious mental health disorders. Documentation showed the resident had a Level I PASRR determination with no expiration date, and the North Carolina PASRR Level I screen did not list major depressive disorder or bipolar disorder. However, the resident was admitted with diagnoses including metabolic encephalopathy, vascular dementia, anxiety disorder, major depressive disorder, and bipolar disorder. A quarterly MDS assessment documented active psychiatric/mood disorder diagnoses of non-Alzheimer’s dementia, anxiety disorder, depression (other than bipolar), and bipolar disorder, and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The resident was also receiving antianxiety medication during the assessment period. Further record review and interviews revealed that psychiatry had been consulted to review the resident’s psychotropic medications, confirming diagnoses of dementia, insomnia, depression, anxiety, and bipolar disorder, with continuation of buspirone ordered twice daily. The facility was unable to provide documentation that a Level II PASRR evaluation request had been submitted for this resident. The Admission Coordinator stated he did not have access to the NC MUST system and relied on the hospital to initiate PASRR screenings and on the Social Work Assistant to provide PASRR determination letters. The Social Work Assistant reported she did not verify new residents’ diagnoses before providing the PASRR Determination Notification letter and had not been informed by the clinical team to request a Level II PASRR evaluation for this resident. The Administrator confirmed that residents were discussed in daily clinical meetings and acknowledged that a Level II PASRR request should have been submitted for this resident based on the mental health diagnoses.
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