Failure to Complete PASARR and Notify State Authority After Significant Change in Mental Illness
Summary
The deficiency involves the facility’s failure to complete required PASARR screenings and notify the state authority of significant changes in mental illness for a resident with a 30‑day PASARR exemption. The facility’s policy, revised 1/26, states that all applicants will be screened for serious mental disorders or intellectual disabilities per state Medicaid rules, that residents remaining beyond a 30‑day exemption must receive a Level 1 PASARR and be referred for Level 2 evaluation when indicated, and that any resident with newly evident or possible serious mental disorder or related condition will be referred to the state authority for a Level 2 resident review. The policy also assigns responsibility to the Social Services Director to track each resident’s PASARR status and make referrals. Despite this, a resident admitted with a PASARR dated 10/15/25 and a 30‑day exemption remained in the facility without a new Level 1 PASARR being completed before the exemption expired. Record review showed that the resident’s mental health status changed significantly after admission. A quarterly MDS dated 1/21/26 documented a BIMS score of 3, indicating severely impaired daily decision‑making skills, and a PHQ‑9 score of 13, indicating moderate depressive symptoms. The resident was diagnosed with Unspecified Mood Affective Disorder on 12/9/25 and Adjustment Disorder with Depressed Mood on 2/27/26, and was started on Paroxetine for anger and sexual inappropriateness on 1/8/26, with Depakote Sprinkles and PRN Ativan ordered on 3/27/26 for behaviors. Despite these new psychiatric diagnoses and psychotropic medication changes, the facility did not initiate a new PASARR process or notify the state authority of the significant change in mental illness. During interviews, the Social Services Director stated having nothing to do with processing PASARRs and not knowing who completes new Level 1 PASARRs when residents remain past 30 days or when new diagnoses and medications are added, and the DON confirmed that a new Level 1 PASARR had not been completed when the diagnoses and medications were initiated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
The facility failed to resubmit PASRRs for two residents after changes in their mental health conditions. One resident, admitted with paranoid schizophrenia, later received new diagnoses of anxiety, PTSD, and unspecified psychosis and was started on Zyprexa, but no repeat PASRR was completed. Another resident, admitted with anxiety and unspecified psychosis, later had a care plan update for psychosocial needs related to anxiety and was started on Trazadone, but no new PASRR was initiated. The MDSC acknowledged the repeat PASRRs were not done after the residents’ mental condition changes.
Failure to Update PASARR After Significant Change: A resident with dementia, schizophrenia, and hospice services had a significant change when admitted to hospice, but the MDS Nurse did not find or complete a new level 1 PASARR screening. The resident was observed restless and unable to answer questions appropriately, and both the MDS Nurse and DON acknowledged that a new PASARR assessment should have been completed for the hospice-related change.
A resident with anxiety, bipolar disorder, and severe depression with psychotic features had a psychiatric hospitalization for worsening symptoms and suicidal ideation, then returned with new psychotropic medication orders. The facility completed PASARR only on admission and did not complete a new PASARR after the resident’s significant change in mental condition and medication changes, despite ongoing depression, suicidal thoughts, and psychotic symptoms.
The facility failed to request Level II PASRR reevaluations for two residents with serious mental illness after significant changes in condition were identified on MDS significant change assessments. Both residents had existing Level II PASRR determinations with no expiration date and were receiving psychotropic medications, yet NC MUST records showed no reevaluation requests following the documented changes. The SW, who was responsible for PASRR submissions, reported being unaware that a significant change in condition required a Level II PASRR reevaluation, and the Administrator confirmed that the SW was designated to review diagnoses and request reevaluations per regulatory guidelines.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Failure to Resubmit PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a PASRR for two sampled residents after changes in their mental health conditions. Resident 5 was admitted with a diagnosis of paranoid schizophrenia and had a level I PASRR completed before admission, with no level II required. After admission, Resident 5 was diagnosed with anxiety, PTSD, and unspecified psychosis, and the order summary showed Zyprexa was started. A repeat PASRR was not resubmitted after these new mental illness diagnoses. Resident 45 was admitted with diagnoses that included anxiety and unspecified psychosis and had a level I PASRR completed before admission, with no level II required. The resident’s care plan was later updated for psychosocial wellbeing problems/needs related to anxiety, and the order summary showed Trazadone was started. A new PASRR was not initiated after the care plan update or after the medication change. During interview, the MDS Coordinator stated PASRRs are resubmitted when there is a significant change in mental status or cognitive decline, but acknowledged that these residents did not have repeat PASRRs after changes in their mental conditions.
Failure to Update PASARR After Significant Change
Penalty
Summary
The facility failed to complete a level 1 PASARR screening and notify the state mental health authority or state intellectual disability authority promptly after a significant change in condition for one resident. Resident 36 was admitted with diagnoses including palliative care, dementia, and schizophrenia, and the record also showed admission to hospice care under a primary diagnosis of Alzheimer's dementia. During the initial tour, the resident was observed sitting at the edge of the bed, watching TV, calling for assistance, and appearing restless and unable to answer questions appropriately. During interview and record review, the MDS Nurse stated she began completing PASARR assessments in January 2026 and that she completes a new PASARR assessment for significant changes such as admission to or discharge from hospice care. She reviewed Resident 36's record and stated she did not find a PASARR level 1 completed when the resident was admitted under hospice care, and acknowledged that she should have completed one. The DON stated the MDS Nurse was responsible for creating PASARR assessments for significant changes and agreed that a new level 1 PASARR assessment should have been completed when the resident was admitted under hospice care. Facility documents and the DHCS PASARR reference indicated PASARR information should be provided on admission and updated when clinically indicated, including after significant changes in condition.
Failure to Complete New PASARR After Significant Mental Status Change
Penalty
Summary
The facility did not ensure it notified the state mental health authority promptly for a resident review after a significant change in mental condition for one resident reviewed for PASARR. The resident had diagnoses including generalized anxiety disorder, bipolar disorder, and current episode of depression, severe, with psychotic features, and the quarterly MDS showed a BIMS score of 14 with no behavior concerns and use of antipsychotic, antianxiety, and antidepressant medications. After readmission in June 2025 following a psychiatric hospitalization for high anxiety, panic attacks, decreased appetite, and significant depression with suicidal ideation, the resident returned with medication changes including monthly Invega injections, Depakote three times daily, and trazodone at bedtime. The record also documented ongoing psychiatric follow-up with worsening depression, suicidal thoughts, and concern about saving medications to overdose, and a later psychiatric evaluation described severe depressive symptoms with psychotic features, chronic suicidal thoughts, delusional thoughts, and visual and auditory hallucinations. During interview, the Social Services Designee stated PASARRs were done only on admission and that only one PASARR had been completed for the resident, with no new PASARR completed after readmission and medication changes.
Failure to Request PASRR Level II Reevaluations After Significant Changes in Condition
Penalty
Summary
The facility failed to request Level II PASRR reevaluations after significant changes in condition for residents already determined to have Level II PASRR status. One resident with schizoaffective disorder, bipolar type, and anxiety disorder had a Level II PASRR determination with no expiration date and was identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and schizophrenia, and receiving antipsychotic and antidepressant medications. Despite this significant change assessment, a review of the NC Medicaid Uniform Screening Tool (NC MUST) showed that no PASRR reevaluation request had been submitted following the significant change. Another resident with major depressive disorder and anxiety disorder also had a Level II PASRR determination with no expiration date and was similarly identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and depression and receiving antianxiety and antidepressant medications. NC MUST records again showed no PASRR reevaluation request after the significant change assessment. During interviews, the Social Worker, who was responsible for submitting Level II PASRR reevaluation requests, stated she was still learning the PASRR process and was not aware that a reevaluation request was required when a resident had a significant change in condition. The Administrator confirmed that the Social Worker was responsible for reviewing diagnoses and requesting Level II PASRR reevaluations when residents experienced significant changes in condition per regulatory guidelines.
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