The facility failed to request Level II PASRR evaluations for two residents after new serious mental illness conditions were identified. One resident with a prior Level I PASRR later developed nighttime hallucinations requiring antipsychotic therapy, yet no PASRR reevaluation was submitted in NC MUST. Another resident with a Level I PASRR was subsequently diagnosed with PTSD and depression and started on prazosin and sertraline, with these diagnoses reflected on the MDS, but no Level II PASRR request was made. The SW reported being responsible for Level II PASRR submissions but stated she was not always informed of new mental health diagnoses and acknowledged these omissions as oversights, which the administrator confirmed as residents being overlooked during PASRR reviews.
A resident was admitted with documented bipolar disorder, dementia, and other medical conditions, and was prescribed multiple antidepressant and psychotropic medications. A Level I PASRR completed before admission instructed that paperwork be resubmitted for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change, and the admission MDS listed bipolar disorder as an active diagnosis. Psychiatry notes and the care plan reflected ongoing treatment and monitoring for bipolar disorder, yet the SW Director only submitted Level I PASRR paperwork and did not include supporting psychiatric or medical documentation. No Level II PASRR request was ever submitted, and facility leadership later acknowledged that a Level II PASRR evaluation should have been completed but was not.
Surveyors found that the facility did not request a PASRR Level II evaluation after a resident with a prior Level I status was later diagnosed with major depressive disorder and PTSD and was receiving antidepressant therapy, despite PASRR guidance requiring further screening when new mental illness diagnoses or treatment changes occur. In addition, for another resident with severe cognitive impairment, multiple serious mental illness diagnoses, and a documented PASRR Level II determination specifying specialized services such as psychological testing and psychiatric evaluation, the facility’s comprehensive care plan did not address or incorporate these Level II PASRR recommendations, which staff acknowledged as an oversight.
A resident admitted with diabetes and a history of Guillain-Barre Syndrome later had a diagnosis of intellectual disability added by the Medical Director based on family report and prior records, but no Level II PASRR request was submitted. The diagnosis was documented in the medical record and reflected in the facility’s processes, yet the Social Worker lacked a clear system to track PASRR needs or new diagnoses, and the DON acknowledged that the MDS nurse’s communication of new diagnoses should have triggered a PASRR referral. The Medical Director and Administrator both recognized that an intellectual disability diagnosis requires a Level II PASRR, but the evaluation was never initiated.
The facility failed to submit required Level II PASRR evaluations for several residents who developed new or additional mental health diagnoses after admission or readmission. Each affected resident had a prior Level I PASRR indicating that paperwork should be resubmitted for Level II if new mental health conditions or significant changes occurred. Despite subsequent diagnoses such as PTSD, major depressive disorder, anxiety disorder, and psychotic disorders, documented as active on the MDS and in some cases treated with antidepressant and antipsychotic medications, there was no evidence that Level II PASRR requests were made. The SW and administrator confirmed the SW was responsible for PASRR submissions and acknowledged that Level II evaluations should have been completed for these residents based on their documented mental health conditions.
A resident was admitted with a completed Level I PASRR that instructed the facility to resubmit for a Level II PASRR if a new mental health diagnosis or significant change in condition occurred. After admission, the resident exhibited a history of hallucinations, paranoia, and prior aggressive behavior in the hospital, was treated with multiple antipsychotics and anti-anxiety medications, and was later diagnosed in the facility with paranoid schizophrenia. The MDS reflected schizophrenia and psychotropic use but still indicated only a Level I PASRR. Although the MDS Coordinator recognized the new diagnosis and reported it to a former SW, neither the MDS Coordinator nor the SW had access to submit Level II PASRR requests, and the Assistant Business Office Manager reported never receiving a referral request. No Level II PASRR evaluation was requested for the resident despite the documented new mental health diagnosis and the Administrator’s understanding that such referrals should be made when new mental health diagnoses are identified.
A resident admitted with multiple mental health diagnoses, including schizoaffective disorder, anxiety, depression, bipolar disorder, schizophrenia, OCD, and insomnia, and receiving antianxiety medications, did not receive a requested Level II PASRR evaluation. The admission MDS reflected active psychiatric/mood disorder diagnoses, and psychiatric NP notes documented ongoing treatment for anxiety, depression, and bipolar disorder. The SW reported that her usual practice was to review diagnoses and medications and submit PASRR requests through NCMUST for residents with mental health diagnoses, but acknowledged that this resident was overlooked during an audit. The Administrator stated that the expectation was for the SW to review all residents admitted with a Level I PASRR and mental health diagnoses and submit them for Level II re-evaluation, which did not occur in this case.
A resident was admitted with a Level I PASRR that directed resubmission for Level II if a new mental health diagnosis or significant change in condition occurred. Later, the resident developed panic attacks, and after discussion with family, the psychiatrist diagnosed PTSD, documented it in the EMR, adjusted medications, and changed caregiver assignments. The SW, who is responsible for PASRR paperwork, acknowledged knowing about the new PTSD diagnosis and the requirement to request a Level II PASRR for new mental health diagnoses but did not submit the request. The administrator stated awareness that Level II PASRR must be completed when a resident has a change in condition or new mental health diagnosis.
The facility failed to request required Level II PASRR evaluations for four residents who developed new mental health diagnoses after admission. Each resident had a pre-admission Level I PASRR that directed the facility to resubmit paperwork for a Level II if new mental health conditions or significant changes occurred, yet subsequent MDS assessments documented new active diagnoses such as psychotic disorder, major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar type, and autism without any corresponding Level II PASRR requests. The SW reported she was responsible for PASRR paperwork but had not received training on when and how to complete and submit Level II requests and was unaware they were required for new mental health diagnoses or significant changes, while the Administrator confirmed the SW’s responsibility and acknowledged that Level II PASRR evaluations had not been completed as expected for these residents.
A resident was admitted with medical diagnoses and a Level I PASRR that showed no mental illness and did not trigger Level II criteria. Over time, the resident’s record was updated to include generalized anxiety disorder, depressive disorder, and later a psychiatrist-documented mood disorder with psychosis/bipolar, with Zyprexa prescribed and bipolar disorder coded on the MDS. Despite these new serious mental illness diagnoses, no Level II PASRR request was found in the record. The MDS Coordinator reported she did not notify the Business Office Manager (who is responsible for submitting Level II PASRR requests) when the new mental health diagnoses were added, and the Business Office Manager confirmed she was never informed of these diagnoses.
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