Inaccurate and Incomplete PASRR Screenings for Residents With Mental Health Diagnoses
Summary
The deficiency involves the facility’s failure to ensure that Level I PASRR screenings were accurately completed and updated for two residents with documented mental health diagnoses and psychotropic medication use. For one resident with Parkinson’s disease, schizoaffective disorder, and anxiety disorder, the Level I PASRR dated May 6, 2024 indicated that a Level II PASRR referral was not necessary. However, the section of the Level I PASRR that asked whether the resident had a diagnosis of schizoaffective disorder was not checked, despite the resident’s documented diagnosis and use of psychotropic medications including bupropion, trazodone, and Depakote. The resident’s care plan was later revised to include a focus on psychosocial well-being related to schizophrenia, and a quarterly MDS showed intact cognition with a BIMS score of 15. During an interview, the Social Services Director confirmed that this resident had a PASRR I in the record and acknowledged that the schizophrenia diagnosis was not listed on the form. He stated he was unsure why the diagnosis was not included and indicated that he would have expected the schizophrenia diagnosis to be identified on the PASRR I if the resident had that diagnosis. This reflects that the documented mental health condition and related psychotropic medication use were not accurately captured on the PASRR screening, despite being present in the clinical record and care plan. For the second resident, who had diagnoses including anxiety disorder, bipolar disorder (including a current manic episode with psychotic features), depression, and generalized anxiety disorder, the Level I PASRR dated December 14, 2023 showed no evidence of mental illness, no symptoms, no history of psychiatric treatment, and no psychotropic medications. This conflicted with the admission MDS, which documented severe cognitive impairment (BIMS score of 5), multiple depressive symptoms over the prior 14 days with a severity score of 12 indicating moderate depression, social isolation, and diagnoses of anxiety disorder, depression, and bipolar disorder. The MDS also documented that the resident had been taking antianxiety medications, and the care plan included focuses on risk for adverse reactions to psychotropic medications, mood problems related to depression, bipolar disorder, and anxiety, and the use of behavioral health consults as needed. The resident’s record further showed multiple psychotropic medication orders over time, including buspirone, trazodone, lorazepam, suvorexant, doxepin, and bupropion, with indications such as anxiety, depression, insomnia, agitation, restlessness, hallucinations, and anhedonia. Care plan focuses documented use of psychotropic, antianxiety, and antidepressant medications related to bipolar disorder, anxiety disorder, and depression, as well as limited activity involvement related to anxiety and depression. Despite this, the PASRR form for this resident contained no evidence of diagnoses or medications. In interviews, the Social Services Director stated he had never been formally trained on the PASRR process, was not familiar with what a completed PASRR form should look like, and had difficulty using the website he believed was for PASRR submissions. He acknowledged that the resident’s diagnoses and medications would have been triggers for a Level II PASRR submission and was unsure how to address inaccurate PASRR information. The DON stated that the PASRR process involved receiving a form from the hospital to ensure appropriate placement and treatment, and that if a resident stayed beyond 30 days and had an appropriate diagnosis, a Level II form should be sent to the state agency. She reported there was no in-house PASRR training and that additional training could be requested for the Social Services Director. She also stated she had only learned that a corporate contact in another state handled the facility’s PASRR process and was unsure if that person knew Arizona regulations. Regarding the second resident, the DON stated that the diagnoses of anxiety, depression, bipolar disorder, and bipolar disorder with psychotic features would have been appropriate for a Level II PASRR submission and identified inaccurate completion of PASRR sections requiring information on exemptions, mental illness diagnoses, symptoms, psychiatric history, and medications. She confirmed there was no evidence of a Level II PASRR for this resident and stated that not submitting a Level II form for a resident who could benefit from state agency review could leave the resident at a disadvantage in receiving appropriate review of behavioral health interventions. The facility’s PASRR policy required validation that each resident is screened for mental disorder or intellectual disability before admission, referral of residents with newly evident or possible mental disorder or intellectual disability to the state authority, and incorporation of Level II determinations and recommendations into assessments and care plans, which was not followed in these cases.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to submit Level II PASRR requests for two residents admitted with PTSD, depression, and anxiety diagnoses. Both residents had Level I PASRR screenings that did not document mental health diagnoses, while later psych notes showed active psychiatric conditions and treatment with antidepressants and anxiolytics. The SW confirmed she was responsible for PASRR re-evaluations and said the omission was an oversight.
A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
A resident with PTSD and major depressive disorder had a PASRR Level I screen that identified personality disorder and PTSD as major mental illness, but the record lacked documentation of referral for a PASRR Level II evaluation. During review, the CEO could not determine whether the screen had been sent for Level II review and stated it should have been.
Inaccurate PASRR screening for residents with mental health diagnoses: The facility failed to ensure PASRRs accurately reflected mental illness for two residents at admission. One resident had major depressive disorder, agitation, depression symptoms, and psychotropic treatment, yet the PASRR showed no mental illness. Another resident had dementia, anxiety, and cognitive impairment, but the PASRR also showed no mental illness. Staff stated PASRRs were reviewed on admission and that diagnoses not checked should be investigated or updated.
PASRR screening and re-submission were not completed as required for two residents. One resident had PTSD documented on the MDS and was later started on an antidepressant, but the PASRR did not include the mental health diagnosis and no new PASRR was submitted. Another resident had a Level II PASRR with a 180-day time limit, but the record did not show an updated PASRR determination after the approval expired.
PASARR screening was not completed appropriately for 3 residents reviewed. One resident with anxiety-related diagnoses had no Level II PASARR despite the facility’s Level I screen, another resident with major depressive disorder, anxiety, and depression had a positive Level I screen but no Level II documentation, and a third resident with schizophrenia and anxiety had no PASARR 1 or PASARR 2 completed even though the record showed a hospital discharge exemption.
Failure to Submit Level II PASRR Requests for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for two residents who were admitted with serious mental health diagnoses. One resident was admitted with PTSD, depression, and anxiety disorder, and the record showed a Level I PASRR screening that did not document mental health diagnoses. The admission MDS indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, and a psychiatric evaluation later documented ongoing treatment with sertraline and lorazepam for depression, anxiety, and PTSD. The facility could not provide documentation that a Level II PASRR request had been submitted for this resident. The second resident was admitted with PTSD, major depressive disorder, and anxiety disorder, and the Level I PASRR screening again noted a PASRR-only review with no mental health diagnoses documented. The admission MDS showed the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, while psychiatric notes documented active diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and dementia with behaviors, along with antidepressant treatment and later lorazepam for anxiety. The facility was unable to provide documentation that a Level II PASRR request had been submitted for this resident. The social worker confirmed she was responsible for submitting PASRR re-evaluation requests and stated the omission was an oversight; the administrator stated she would expect a Level II PASRR request when a resident was admitted with a Level I PASRR and mental health diagnoses.
PASARR Level II Screen Not Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident reviewed for PASARR screening. The resident was admitted with diagnoses including major depressive disorder and had a quarterly MDS assessment with a BIMS score of 15, indicating cognitive intactness. The resident’s PASARR Level I Screen Summary stated that the person had a major mental disorder and that the screening result was that the resident was suspected of having a serious mental illness, but the medical record did not include a PASARR Level II screen. During interview, the Social Worker stated she was responsible for obtaining PASARR screenings, confirmed the resident did not have a PASARR Level II screen, and stated the resident should have had one completed but did not.
Failure to Obtain PASRR Level II Evaluation After Positive Mental Illness Screen
Penalty
Summary
The facility failed to ensure that a resident identified as having major mental illness received further evaluation after a positive PASRR Level I screen. Resident #8 was admitted with diagnoses including PTSD and major depressive disorder, and the PASRR Level I assessment dated 4/30/25 documented personality disorder and PTSD, both classified as major mental illness. The resident’s record did not contain documentation showing referral for a PASRR Level II evaluation. During review on 6/25/26, the CEO reviewed the PASRR Level I assessment and stated it could not be determined whether it had been sent for Level II assessment, and further stated that it should have been sent for Level II evaluation.
Inaccurate PASRR Screening for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate PASRR was completed for residents with serious mental disorder diagnoses at the time of admission for 2 of 6 residents reviewed. Resident #15 was admitted and later readmitted with diagnoses including major depressive disorder, recurrent, unspecified, and restlessness and agitation. Although the PASRR dated 5/08/2026 documented no mental illnesses or suspected mental illnesses, the resident’s psychiatric admission note dated 5/15/2026 documented an active mental health diagnosis, including major depressive disorder, recurrent, mild, and restlessness and agitation, with symptoms of depression, anxiety, insomnia, loss of energy, and diminished interest. The resident’s care plan and physician orders also reflected depression, agitation, and treatment with escitalopram and quetiapine. Resident #176 was admitted with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The PASRR dated 6/17/2026 documented no mental illness or suspected mental illness. However, an acute care progress note dated 6/19/2026 described the resident as a medically complex skilled nursing facility resident with encephalopathy, acute kidney failure, dementia, end stage renal disease, and dependence on renal dialysis. The note stated the resident had underlying cognitive impairment and communication limitations, was alert and oriented, and had limited speech with brief verbal responses and nonverbal gestures. During interviews, the Regional Nurse Consultant stated the Social Services Assistant was responsible for reviewing PASRRs when residents were first admitted and that the IDT reviewed them the next day to identify whether a resident might need special services or a level II PASRR. The Social Services Assistant stated she reviewed PASRRs on admission and would look for diagnoses that might trigger special services or additional review, and if a diagnosis was not checked she would investigate whether there was a history of the condition, whether it was active, or whether the resident was being treated. The ADON stated that if a resident was admitted with a diagnosis of mental illness and it was not on the PASRR, the PASRR should have been updated.
PASRR Screening and Re-Submission Failures
Penalty
Summary
The facility failed to refer a resident with a negative Level I PASRR result and an identified mental disorder to the appropriate state-designated authority for Level II PASRR evaluation and determination. Resident #3’s MDS documented a BIMS score of 14 and a diagnosis of PTSD on admission, but the PASRR screening notice completed before admission did not list PTSD under the mental health diagnoses section. The resident was later started on mirtazapine, an antidepressant, and the Administrator stated the facility did not currently have anyone assigned to do PASRR review or submission and acknowledged that the PTSD diagnosis and antidepressant medication should have been included on the PASRR or a new PASRR should have been submitted. The facility also failed to re-submit a Level II PASRR for Resident #14 after the 180-day time-limited approval expired. Resident #14’s quarterly MDS showed a BIMS score of 15, diagnoses of depression and bipolar disorder, and extensive assistance needs with ADLs and mobility. The care plan included the resident’s Level II PASRR and the 180-day approval, and the Notice of PASRR Level II Outcome showed the approval was limited to 180 days. The EHR miscellaneous tab did not include an updated Level I PASRR determination after the time-limited approval ended, and the Administrator stated the resident PASRRs were not up-to-date.
PASARR Screening Not Completed for Residents With Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed appropriately for 3 of 5 residents reviewed. The facility did not complete a Level II PASARR for R6, who was admitted with diagnoses including adjustment disorder with anxiety and generalized anxiety disorder, and whose Level I PASARR indicated “No” to a major mental disorder. The nursing home administrator told surveyors that the facility did not have a Level II PASARR for R6 and that it should have been done. The facility also did not complete a Level II PASARR for R7, who was admitted with diagnoses including major depressive disorder, anxiety disorder, and depression. Surveyors reviewed R7’s Level I PASARR, which indicated “Yes” to whether the person had a major mental disorder, but no Level II documentation was available. For R27, who was admitted with diagnoses including schizophrenia and anxiety disorder and was prescribed medications to treat symptoms of schizophrenia and anxiety, no PASARR 1 or PASARR 2 was completed. The Level I PASARR in the record was marked as a hospital discharge exemption with a 30-day maximum, and the nursing home administrator acknowledged that a PASARR should have been completed.
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