Failure to Complete Required PASRR Level II Screens: The facility did not complete required PASRR follow-up for 4 residents whose Level I 30-day hospital exemptions expired. Residents had diagnoses including depression, anxiety, dementia, intellectual disability, cerebral palsy, and other mental disorders, and records showed no Level II PASRR screening after the initial Level I screens. The SSD and VPS confirmed the missing PASRR Level II screens.
PASRR screening for mental disorders or ID was not completed for a resident with depression who had intact cognition and was his or her own decision maker. The chart contained multiple PASRR Level I screens, including a 30-day hospital exemption and later screens noting antidepressant use and a mental health disorder, but no PASRR Level II screen was completed after the exemption expired. The SSD stated he or she lacked formal PASRR training and was unaware another Level I screen was required when the resident remained in the facility.
A resident with bipolar disorder, generalized anxiety disorder, and ADD had a PASRR Level I Screen showing a 30-day exemption, but the facility did not complete a new Level I Screen or a Level II evaluation after the exemption expired. The SSD said the resident was expected to stay only 30 days for rehab and then discharge to ALF, and the NHA later acknowledged the required PASRR screens were not completed.
Failure to Complete PASRR Level II Screening: A resident admitted with schizoaffective disorder and receiving psychotropic meds, including Buspirone HCL, Clozapine, and Lorazepam, had a Level I PASRR indicating a major mental disorder and need for a Level II screen. Surveyor follow-up found the facility did not have a PASRR II on file, and the DON could not confirm that one had ever been completed.
PASRR screening requirements were not met for a resident with anxiety disorder and major depressive disorder. The resident had intact cognition and was responsible for healthcare decisions, but the record did not include a timely PASRR Level I Screen after admission, and the later Level I Screen did not indicate serious mental illness. The record also lacked a PASRR Level II Screen, and the SSD stated she was not aware of when to refer for Level II screening.
Missing Level II PASARR Screening: A resident admitted with major depressive disorder had a Level I PASARR indicating a Level II review was needed under a short-term hospital discharge exemption, but no Level II PASARR was found in the record. The SSD confirmed the review was not completed and stated the facility did not have a system to ensure PASARR II completion for residents who remained beyond the 30-day window.
A resident admitted for short-term rehab had a PASARR I indicating suspected serious mental illness and a 30-day hospital discharge exemption. The resident exceeded the exemption period without a PASRR II being completed, and the DON acknowledged the PASRR II was overdue.
A resident admitted with paranoid schizophrenia and receiving psychotropic medications had a Level I PASRR that identified serious mental illness and a hospital discharge exemption with a 30-day maximum stay. The resident remained beyond the exemption period, but no additional PASRR screening was completed, and SS staff later stated the follow-up screen should have been done.
PASARR screening was not completed correctly for a resident with major depressive disorder and antidepressant use. The admission PASRR Level I Screen failed to identify the mental illness and did not accurately list nortriptyline and mirtazapine as antidepressants, so a PASRR Level II Screen was not done to determine whether placement was appropriate and whether specialized services were needed.
PASRR screening was not completed for a resident with schizophrenia, anxiety disorder, and seizure disorder. The resident had severe cognitive impairment with a BIMS score of 0/10 and a court-ordered guardian, but the medical record contained no PASRR Level I or Level II screen. The SW verified the omission and stated they had not received training on PASRR requirements.
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