A resident with multiple mental health and medical diagnoses was not re-screened for mental disorders with a PASARR Level 1 after a 30-day exemption expired, despite continued residence in the facility. The initial PASARR indicated a major mental disorder and the exemption, but no follow-up screening was completed as required by facility policy.
The facility did not complete required PASARR Level II screenings for four residents with major mental disorders who remained in the facility beyond the 30-day hospital discharge exemption period. Each resident was admitted with diagnoses such as major depressive disorder and prescribed psychotropic medications, but the necessary follow-up screenings were not performed due to lapses in staff responsibility and oversight.
A resident with a diagnosis of major depressive disorder and prescribed mirtazapine was admitted without an accurate PASRR Level I Screen, which failed to note the mental health diagnosis and medication. This omission resulted in the required PASRR Level II evaluation not being completed to determine the need for specialized services.
A resident with a diagnosis of depression was admitted without a completed PASARR Level 1 screen prior to admission, and although the Level 1 screen was later completed and indicated a major mental disorder, the required Level 2 PASARR screening was not performed as mandated by facility policy.
Surveyors found that two residents were not properly screened for serious mental disorders or intellectual disabilities as required by PASARR regulations. One resident did not have a follow-up PASARR Level 1 submitted after a 30-day hospital exemption expired, and another resident's PASARR Level 1 failed to document diagnoses of anxiety disorder and unspecified psychosis, which would have triggered a Level 2 evaluation.
The facility did not ensure timely and accurate completion of PASRR Level I and Level II screenings or obtain required county exemption forms for three residents with mental illness diagnoses and/or prescribed psychotropic medications. PASRR documentation was not updated to reflect medication changes, and necessary screenings were not submitted when residents remained in the facility beyond 30 days.
The facility did not complete or maintain required PASRR Level I and Level II screenings for two residents with mental health diagnoses. For one resident, no PASRR Level I was found, and for another, a PASRR Level II was missing despite a Level I with a 30-day exemption. The social worker and DON confirmed the absence of necessary documentation and acknowledged that PASRRs should be completed and kept in the medical record.
Two residents with suspected serious mental illness were granted 30-day hospital exemptions on their PASRR Level I Screens, but the facility did not submit the required PASRR Level II Screens after the exemptions expired. One resident had anxiety disorder and was not cognitively impaired, while the other had multiple mental health diagnoses and moderate cognitive impairment. The Admissions Coordinator confirmed the oversight.
The facility did not ensure PASRR requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. Both residents' records lacked the required County exemption form and timely PASRR Level II Screens, with documentation only submitted after surveyor inquiry.
A resident with diagnoses of anxiety disorder and PTSD was admitted from another facility without a PASRR Level II Screen, despite policy and regulatory requirements. Staff interviews confirmed that these conditions are mental illnesses and that a Level II Screen should have been completed, but staff were unaware of the requirement and no screening was performed.
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