Failure to complete a required PAS/ARR for a resident with mental illness and an intellectual disability-related condition after the 30-day Hospital Exemption. The resident had diagnoses including Asperger's Syndrome, autistic disorder, PTSD, and depression, and the PASARR Level I Screening showed mental illness treatment and recent antipsychotic or antidepressant use. The SW confirmed the screening was overlooked and should have been completed after the exemption period.
Failure to complete a required PASARR Level II evaluation for a resident with bipolar disorder. The resident had a prior PASARR II that required a new Level II evaluation if the resident remained in the facility, but the evaluation was not completed. The DON said an RN was responsible for monitoring PASARR requests, and the RN acknowledged it was her responsibility and that she had not thought about the PASARR system because the resident was already seeing Behavioral Care Solutions.
Failure to Complete Annual PASARR Evaluation: A resident admitted with schizophrenia, dementia, bi-polar disease, and PTSD did not have the required annual OBRA Level I PASARR evaluation completed to determine whether a Level II eval or exemption was needed. The record contained a PAS/ARR document noting dementia and recent psychotropic use, but no other PASARR documentation was found. The SW Director stated residents should be screened annually and/or with a significant change, and no PASARR policy was provided.
Failure to Complete and Update PASARR Reviews: The facility did not timely complete or update PASARR Level I/II reviews for multiple residents with diagnoses including MI, dementia, PTSD, bipolar disorder, and depression. Records showed several residents had outdated or missing PASARR documentation, including cases where Level II reviews were not updated, not submitted, or still waiting for physician signature, despite residents having impaired cognition and qualifying diagnoses.
PASARR screening was not completed before admission for a resident with anxiety disorder, depression, bipolar disorder, and schizophrenia. The MDS showed a BIMS score of 15/15, and review of the EMR confirmed the PASARR was completed only after admission. The DON acknowledged PASARRs are supposed to be completed at admission and confirmed this one was missed.
Annual PASARR reviews were not completed for 4 of 8 residents reviewed. The residents had prior Level II PASARR screenings and diagnoses including dementia, depression, bipolar disorder, Alzheimer's disease, anxiety, CVA, CAD, CHF, COPD, and other chronic conditions. Social services staff acknowledged the overdue PASARRs and stated the facility did not have a PASARR policy, relying instead on a state PowerPoint for guidance.
A resident with PTSD, anxiety disorder, depression, and non-Alzheimer's dementia was admitted without a PASARR completed before admission. An RN stated the only PASARR on file was completed later and that a new or updated PASARR was needed. Facility policy states PASARR Level 1 pre-screening is completed prior to admission.
A resident with paranoid schizophrenia, dementia, and cognitive communication deficit had a care plan addressing behavioral concerns and the need for behavioral health interventions, but required PASRR Level I and Level II evaluations were not completed on time. A prior Level II determination allowed continued NF residence with potential specialized MH/DD services and specified a due date for the next Level II, which was not met. The SSD reported not having the current Level II and was unsure if the OBRA evaluator had assessed the resident, and the NHA confirmed that while a Level I and Level II had been completed the previous year, there was no Level I documented for the current year, resulting in noncompliance with PASRR requirements.
Failure to complete required PASARR Level II screening for a resident with anxiety disorder, delusional disorders, and vascular dementia. The resident had severe cognitive impairment on BIMS, and the record showed a Level I review with Yes responses in Section II, but no DCH-3878/Level II screening was found. The SW said PASARR was handled by a third-party MDS group, and the MDS nurse could not locate the Level II form.
A resident admitted with bipolar disorder and receiving Abilify had no evidence of a current Level I PASARR screening in the record. The SW first provided an older PASARR from a prior admission, then confirmed that a new screening should have been completed but was not done. The Administrator stated the facility did not have a PASARR policy.
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