Failure to Accurately Capture SMI in PASRR
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) accurately captured an admission diagnosis of a serious mental illness (SMI). Specifically, the PASRR for a resident admitted on November 1, 2024, did not reflect their diagnosis of unspecified psychosis, which was part of their medical history. The facility's policy required participation in or completion of a Level I screen for all potential admissions to determine if the individual met the criteria for mental disorder, intellectual disability, or related condition. However, the resident's PASRR Level I Screening, dated October 15, 2024, incorrectly indicated that the resident did not have an SMI. Interviews with facility staff revealed that the PASRR process should have started on admission, and any discrepancies should have been addressed by resubmitting the PASRR to the hospital for correction. The Director of Nursing acknowledged that if a resident had an SMI diagnosis not captured by their PASRR, a new resident review should have been conducted. The deficiency was identified during a survey, prompting the facility to resubmit the PASRR on March 5, 2025, to accurately reflect the resident's diagnosis of unspecified psychosis.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Pre-Admission Screening and Resident Review (PASRR) for Resident #64 was promptly reviewed and updated. Upon further examination, it was determined that a correction was necessary, and a revised PASRR was resubmitted on March 5, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents within the facility have the potential to be affected by the deficient practice. Medical Records did a facility-wide audit of current residents' PASRR for accuracy on 3/21/25 and no additional deficient practice was noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A thorough audit of residents' PASRR was conducted by medical records to identify individuals who may have experienced any adverse effects on 3/21/2025, no additional issues were found. On 3/19/2025, an in-service was given by the Director of Nursing to all those involved in the PASRR screening process, including the medical records team, nursing management team, and admissions team. The purpose of this in-service was to reeducate those involved on the process and importance of PASRR screening regarding patient care and facility protocol. To ensure compliance with regulations, the facility will implement a system-wide change to improve the review process for all Pre-Admission Screening and Resident Review (PASRR) assessments. Going forward, the clinical team, including nurses, MDS, and other relevant healthcare professionals, will conduct a thorough review of the PASRR assessment upon each resident's admission to the facility. This review will verify that each resident's needs, including any mental health or specialized care requirements, are accurately identified and addressed in their individualized care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: Upon admission, the admissions team will verify that a Pre-Admission Screening and Resident Review (PASRR) has been received, preferably via file exchange or, if necessary, as a paper copy. In cases where follow-up is required for file exchange completion, the clinical team will notify the hospital for review or a new PASRR. As part of the verification process, the clinical team immediately reviews the PASRR and checks for accuracy. A secondary screening will be performed before the PASRR is officially uploaded to the patient's chart by the medical records team. Additionally, the medical records department will review the PASRR for accuracy to ensure compliance with regulatory requirements. Furthermore, the unit manager will reassess any PASRRs requiring follow-up, with all follow-up actions being systematically tracked through the Interdisciplinary Plan of Care (IPOC) by medical records. To maintain accountability and ensure accuracy, the medical records department will conduct regular audits of PASRR. Additionally, when the facility does the resident review for new admits, if an inaccuracy is noted, a new PASRR/resident review assessment will be created to ensure the residents' PASRR is accurate according to their needs. This process will be monitored by and reported to our Quality Assurance and Performance Improvement (QAPI) monthly meeting. This will stay on our QAPI for 90 days and/or 3 QAPI meetings. Include dates when corrective actions will be completed: March 21st, 2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with a diagnosis of PTSD and severe cognitive deficits had an admission MDS and an Interim History and Physical documenting PTSD, but the Idaho PASRR Level I form incorrectly indicated no major mental illness, even though PTSD is listed on the form as a major mental illness. The SSD stated he reviewed hospital records and the chart but missed the PTSD diagnosis and did not mark it on the PASARR, contrary to facility expectations and policy requiring accurate pre-admission screening for serious mental disorders and appropriate follow-up evaluation when a Level I screen is positive.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
A resident with documented major depressive disorder, schizoaffective disorder, and a history of schizophrenia and bipolar disorder was incorrectly coded as having no MI on the PASARR PL 1 Screening. The chart also included psychiatric notes describing delusions, hallucinations, depression, and prior suicidal ideation, along with an antipsychotic order for schizoaffective disorder. During survey, the ADON described the resident as depressed and paranoid, and the MDS Coordinator acknowledged the PL 1 was inaccurate.
Incorrect PASRR Screening for Residents with Mental Health Diagnoses: The facility failed to complete PASRR screening correctly for two residents with documented MH diagnoses. One resident had bipolar disorder and psychotropic medication use, and another had bipolar disorder, MDD, schizophrenia, anxiety, and depression with psychotropic medication use. In both cases, the PASRR marked mental illness as no, and the MDS Coordinator stated both residents should have been marked positive.
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
Failure to Update PASARR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to ensure that a PASARR Level I screen was accurately completed and updated to reflect a major mental illness diagnosis for one resident. The resident’s admission MDS, with an ARD of 03/30/26, showed a diagnosis of Post-Traumatic Stress Disorder (PTSD) and a BIMS score of 3/15, indicating severe cognitive deficits. An Interim History and Physical dated 03/25/26 also documented PTSD as a diagnosis. However, the Idaho PASRR Level I form dated 03/19/26 indicated “No” under the section asking whether the individual had any major mental illnesses, despite PTSD being listed on the form as a qualifying major mental illness and despite the resident having that diagnosis. The Social Services Director reported that he reviewed hospital records and the resident’s chart to ensure that diagnoses on the admitting PASARR matched the resident’s conditions, and he confirmed the resident was admitted with PTSD. He acknowledged that he missed the PTSD diagnosis and that it should have been marked on the PASARR. During an interview, the DON and Administrator stated the expectation that all PASARRs be correct and that, if not correct at admission, a new PASARR should be submitted. The facility’s PASRR policy specified that potential admissions are to be screened for serious mental disorders or intellectual disabilities prior to admission and that a positive Level I screen requires a Level II evaluation by the state-designated authority prior to admission unless otherwise authorized.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Inaccurate PASARR Level 1 Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure accurate PASARR Level 1 screening for a resident with documented mental illness on admission. Resident #6’s record showed diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and schizoaffective disorder. The admission MDS reflected intact cognition, no behavioral symptoms, and active depression with antipsychotic and antidepressant use, but the PL 1 Screening dated 03/31/2026 was coded “No” for Mental Illness even though the resident was documented as having a mental illness. The resident’s record also contained multiple references to schizophrenia, bipolar disorder, and schizoaffective disorder from hospital and psychiatric records. Psychiatry documentation described a history of schizoaffective disorder, depressive type, prior suicidal ideation and depression, and later noted delusions and hallucinations. An order summary showed Secuado transdermal patch prescribed for schizoaffective disorder. The care plan included psych services to evaluate and treat as needed, but did not document bipolar or schizoaffective disorder as active diagnoses. During survey, the resident was observed standing at his doorway, appropriately dressed and groomed, and he stated he did not want to go to activities because he felt “funky.” The ADON stated the resident gets depressed and is paranoid. The MDS Coordinator stated she was responsible for ensuring the PASRR Level 1 Screening was accurate when received and acknowledged that the resident’s PL 1 Screening was inaccurate and that a new PL 1 Screening and PASRR evaluation would need to be submitted.
Incorrect PASRR Screening for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR screening was completed correctly for two newly admitted residents with mental health diagnoses. Resident #35 was admitted with diagnoses including bipolar disorder, stroke, dysphagia, hypertension, and need for assistance with personal care. His admission MDS documented a BIMS score of 99, indicating the interview could not be completed, and also listed bipolar disorder as an active diagnosis. His care plan noted use of psychotropic medications related to behavior management for bipolar disorder and psychosis. However, the PASRR dated 03/13/2026 marked mental illness as no. Resident #65 was admitted with diagnoses including bipolar disorder, major depressive disorder, schizophrenia, dysphagia, hypertension, and stroke. His admission MDS documented a BIMS score of 13 and listed bipolar disorder, schizophrenia, anxiety disorder, and depression as active diagnoses. His care plan also noted use of psychotropic medications related to schizophrenia and bipolar disorder. Despite these documented mental health diagnoses, the PASRR dated 04/09/2026 marked mental illness as no. During interviews, the MDS Coordinator stated she was responsible for ensuring PASRRs were correct and said both residents should have been marked positive for mental illness. She also stated the DON and ADM monitored PASRR accuracy, and the ADM said the MDS Nurse was responsible for ensuring the PASRR was correct and sending referrals to the state designated authority. The facility’s PASRR policy stated the program is intended to identify residents with mental illness, intellectual disability, or developmental disability and ensure they receive the services they require.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
