Delayed PASARR Level I Review After Significant Mental Status Change
Summary
The facility failed to promptly obtain a new PASARR Level I screen for a resident with a significant change in mental status after re-admission from the hospital. Resident #68 had a prior PASARR Level I review request in the record, and the resident’s diagnoses included altered mental status, unspecified, with a diagnosis date of 3/20/26. The resident also had a history of Bipolar II disorder, fetal alcohol syndrome, and PTSD. On 4/8/26, the resident reported hearing voices that were repeating “Knife, knife, and kill, kill, kill,” and stated she was frightened and afraid she might act on the hallucinations. The resident was transported by EMS to the Emergency Department for evaluation, where psychiatry documented severe depressed bipolar II disorder with psychotic features. A new PASARR Level I review request was not documented until 4/22/26. During interview, staff stated a new PASARR Level I review should have been requested when there was a new psychiatric or mental health diagnosis or when the resident was sent out for psych clearance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Request Level II PASRR Reevaluation After Significant Change: A resident with schizoaffective disorder, dementia with psychotic disturbance, and unspecified psychosis had a Level II PASRR with no expiration date, and a significant change MDS identified serious mental illness and/or ID-related conditions. The SW Assistant did not submit a Level II PASRR reevaluation request, stating she believed it was only needed if the change directly related to the mental illness and that the resident's mental status had not changed; the Administrator stated reevaluation requests should be made when a resident has a significant change in condition.
Failure to complete and update PASRR notifications for two residents with mental health and developmental needs. One resident was readmitted after hospitalization with new acute respiratory failure with hypoxia and sepsis following an incident involving ingestion of feces, but the record lacked historical PASRR documentation and the state mental health authority was not notified. Another resident had a significant change in condition with a newly diagnosed bipolar disorder, yet no updated PASRR was completed until the deficiency was identified.
A resident with dementia, schizophrenia, depression, and anxiety had an aggressive behavioral incident, was sent for psychiatric assessment, and was later discharged to a psychiatric facility. The record showed no new PASARR was completed after the significant change in mental status, and the SSD verified the omission.
A resident with a PASRR indicating SMI indicators but no level II need due to stability on psychotropic meds experienced worsening anxiety, including acute episodes requiring hydroxyzine and a later antidepressant cross-taper from venlafaxine to Zoloft. The facility did not document a new PASRR or request a level II evaluation after these mental status changes, and SS staff stated they only pursued a new PASRR if a new diagnosis was added.
A resident admitted under a 30‑day PASARR exemption remained in the facility without a required new Level 1 PASARR being completed after the exemption period ended, despite multiple new psychiatric diagnoses and psychotropic medication changes. The resident’s MDS documented severely impaired decision‑making and moderate depressive symptoms, and diagnoses of Unspecified Mood Affective Disorder and Adjustment Disorder with Depressed Mood were added, along with Paroxetine for anger and sexual inappropriateness and later Depakote Sprinkles and PRN Ativan for behaviors. Facility policy required screening of residents who stay beyond 30 days and referral to the state authority when serious mental disorder is present or newly evident, and assigned the Social Services Director responsibility for tracking PASARR status, but the PASARR process was not initiated and the state authority was not notified of the significant change in mental illness. The SSD reported not being involved with PASARR processing or knowing who completes new Level 1 screenings, and the DON confirmed that a new Level 1 PASARR had not been completed when the changes occurred.
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.
Failure to Request Level II PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to submit a request for a Level II PASRR reevaluation after a significant change in condition was identified for a resident previously determined to have a Level II PASRR. Resident #9 was admitted with diagnoses including schizoaffective disorder-bipolar type, moderate dementia with psychotic disturbance, and unspecified psychosis. The NC MUST inquiry dated 07/13/21 showed the resident had a Level II PASRR with no expiration date, and a significant change MDS assessment dated [DATE] identified the resident as having a serious mental illness and/or intellectual disability or other related conditions. The resident's active psychiatric and mood disorder diagnoses included psychotic disorder and schizophrenia, and she received antipsychotic medication during the MDS assessment period. Review of the medical record found no evidence that a request for a Level II PASRR reevaluation was submitted after the significant change MDS assessment. During interview, the SW Assistant stated she was responsible for submitting Level II PASRR reevaluation requests when needed, but believed a request was only required if the significant change directly related to the mental illness. She reported she did not submit a request because the resident's mental status did not change. The Administrator stated that requests for Level II PASRR reevaluations should be made when a resident had a significant change in condition per regulatory guidelines.
Failure to Complete and Update PASRR Notifications for Residents With Mental Health and Developmental Needs
Penalty
Summary
The facility failed to notify the state mental health authority when Resident #03 was readmitted after a hospitalization with new diagnoses of acute respiratory failure with hypoxia and sepsis following an incident in which he ingested his own feces. Resident #03 had a history that included paraplegia, type II diabetes mellitus, schizoaffective disorder, bipolar type, cognitive communication deficit, major depressive disorder, PTSD, generalized anxiety disorder, unspecified intellectual disabilities, chronic kidney disease, and dysphagia. The record showed a hospital exemption document but no PASRR documentation, and Social Services Director #269 stated she could not find a historical PASRR. A PASRR was later completed and submitted, and the result notice indicated the resident required a level II evaluation due to indications of serious mental illness and developmental disability. The facility also failed to complete an updated PASRR for Resident #16 after a significant change in condition that resulted in a newly diagnosed mental health condition. Resident #16 had diagnoses including bipolar disorder, severe vascular dementia with behavioral disturbance, and epilepsy. The record showed a newly identified diagnosis of bipolar disorder with an onset date and no PASRR reflecting the updated mental health diagnosis. Social Worker #269 stated the facility previously did not have access to PASRR documentation following corporate acquisition, and the newly diagnosed bipolar disorder was not captured on an updated PASRR. A PASRR was completed after the deficiency was identified, and the Administrator stated the facility had no policy on PASRR processes.
Failure to Complete PASARR After Significant Change in Mental Status
Penalty
Summary
The facility failed to ensure a new PASARR was completed when a resident had a significant change in condition. Resident #41 was admitted with diagnoses including dementia with behavioral disturbance, schizophrenia, depression, and anxiety. Nursing progress notes showed that the resident was involved in an aggressive incident in another resident's room, where she pushed a television and pushed the other resident to the ground. The physician was notified and nursing obtained an order to send her for psychiatric assessment. The resident was then discharged to a psychiatric facility, but the medical record contained no indication that a new PASARR was completed after the significant change in mental status. The Social Services Director verified that PASARR was not completed for the resident's psychiatric hospital admission and change in mental status.
Failure to Notify PASRR Coordinator After Significant Mental Status Change
Penalty
Summary
The facility failed to notify the State PASRR Coordinator after a significant change in mental condition for one resident who had been identified on PASRR as having indicators of serious mental illness but did not require a level two evaluation because the resident was stable on venlafaxine and buspar. The resident was admitted with diagnoses including Parkinson's disease, major depressive disorder, and anxiety. A psychiatric provider later documented that venlafaxine may have been contributing to the resident's anxiety and recommended changing the antidepressant. Subsequent records showed escalating anxiety-related events, including a one-time dose of hydroxyzine for an acute anxiety episode, a later PRN hydroxyzine order for increased anxiety, another episode of anxiety and panic requiring hydroxyzine for three days, and an order to cross-taper venlafaxine with Zoloft and discontinue venlafaxine. Review of progress notes from the period showed no documentation that a new PASRR was completed or that a level two evaluation was requested after these changes in mental status. In interview, Social Services staff stated they reviewed PASRRs quarterly for accuracy and would not complete a new PASRR or seek a level two evaluation for changes in psychotropic medications unless a new diagnosis was added.
Failure to Complete PASARR and Notify State Authority After Significant Change in Mental Illness
Penalty
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.
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.
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