Failure to Obtain Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental illness diagnosis. The resident was admitted with documented diagnoses including bipolar disorder, dementia, hypertension, heart failure, and diabetes mellitus. A Level I PASRR had been completed prior to admission with instructions to resubmit paperwork for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change in condition. The admission MDS assessment identified bipolar disorder as an active diagnosis and documented that the resident had not been evaluated by a Level II PASRR, despite being on multiple antidepressant and psychotropic medications. Hospital discharge records listed bipolar disorder as a diagnosis and included prescriptions for bupropion XL, duloxetine, rivastigmine, and trazodone, which were continued after admission. Psychiatry notes from the facility’s Psychiatric NP documented ongoing treatment and monitoring for bipolar disorder and dementia, with continued psychiatric oversight deemed medically necessary due to chronic psychiatric illness and the need for structured monitoring. The resident’s care plan included focus areas for antidepressant use related to bipolar disorder and insomnia, as well as a mood problem related to bipolar disorder, with interventions such as administering medications as ordered, monitoring for side effects and effectiveness, and behavioral health consults as needed. Despite these documented mental health diagnoses, medications, and ongoing psychiatric management, there was no evidence in the medical record that a Level II PASRR request was ever submitted. The Social Work Director, who was responsible for PASRR paperwork, reported that he had submitted paperwork only for a Level I PASRR and did not include psychiatric or medical progress notes or a signed FL2 form. The facility received a letter stating that the existing Level I PASRR could be used until it expired, but no expiration date was provided, and no further action was taken to obtain a Level II PASRR. Both the Social Work Director and the Administrator later acknowledged that, based on the resident’s bipolar disorder diagnosis, a Level II PASRR evaluation should have been completed, but it was not submitted.
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