Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to ensure that Level II PASARR recommendations were implemented timely and appropriately for one resident. The resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, personality disorder, anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and was assessed as having mildly impaired cognition on a quarterly MDS assessment. A Notice of PASRR Level II Outcome dated 08/25/25 specified several recommendations: 1:1 staffing due to a history of head banging and fire starting, keeping self-injurious items out of reach, provision of group therapy with a trained group therapist, development of a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Record review and staff interview showed that these PASARR recommendations were not addressed or implemented as required. The Business Office Manager, who was serving as Social Service Director at the time the Level II PASARR recommendations were issued, confirmed that the recommended 1:1 staffing, environmental controls to remove self-injurious items, group therapy, behavior management safety plan, and ongoing psychotropic medication evaluation had not been put into place. The same staff member also confirmed that the resident had not exhibited head banging, self-injurious behavior, or fire starting since admission, but the PASARR-directed interventions still had not been implemented.
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