Failure to Complete PASRR for Residents Initiated on Hospice Services
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASRR) for two residents who began receiving hospice services. Both residents had significant medical histories, including dementia, anxiety, and other chronic conditions, and were dependent on staff for most or all activities of daily living. Despite these changes in their care needs, there was no evidence that a PASRR was completed or updated when hospice services were initiated for either resident. Record reviews confirmed that neither resident had a PASRR completed at the time of their significant change in status, specifically when they were admitted to hospice care. This was further verified through an interview with the Social Service Designee, who acknowledged the absence of PASRR documentation for both residents during this transition. The deficiency was identified during a review of residents receiving hospice services, affecting two out of two residents reviewed in this category.
Plan Of Correction
F644 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure that PASRR were completed for residents #14 and #3 regarding significant changes in condition and hospice enrollment. Step 1: Social Services promptly completed PASRRs on residents #14 and #3 for their significant change in condition. Completed on 6/12/25. Step 2: Social Services to complete an audit on all residents in the last year who have significant changes and admitted to hospice services. Completed on 6/26/25. Step 3: LNHA to provide education to IDT on process of discussing residents with significant change and possible hospice admission at morning clinical meeting, weekly resident review, and weekly PASRR meeting. Education completed by 6/30/25. Step 4: To monitor and maintain ongoing compliance, LNHA will audit PASRR weekly log and MDS Sig Changes assessments weekly x4, then monthly x2 to ensure PASRRs are being completed for residents with Sig Changes and admissions to hospice. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F0657 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents #29 and #39 received routine care conferences. Step 2: NHA will audit the care conference schedule and compare to Comprehensive assessments and make adjustments to the care conference schedule as necessary by 6/30/25. Step 3: Social Services will be educated by LNHA on process of scheduling care conferences timely in accordance with Comprehensive assessment schedule. Education completed by 6/30/25. Step 4: Administrator will monitor compliance by auditing Care Conference completion weekly x4 weeks, then monthly x2 months. The results of the audits will be submitted to the QAPI committee for further review.
Penalty
Resources
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A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
A resident with schizoaffective disorder, bipolar disorder, anxiety, severe cognitive impairment, and behavior issues had a PASRR Level 1 that did not reflect her mental health diagnoses. The DON, Regional MDS Nurse, and ADM stated that a new PASRR review should be completed when a new MI diagnosis is identified, but the facility did not complete a new PL1 when the resident’s diagnoses were documented.
A resident with diagnoses including disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy had a PASARR level two referral that was not acted upon. The resident’s care plan did not identify level two recommendations, and the DON confirmed the level two screening was not in the EMR. An OBRA Level 1 screening had identified serious mental illness and referred the resident for level two screening.
The facility failed to ensure accurate PASRR Level I screenings and appropriate PASRR referrals for two residents with documented mental illness diagnoses. One resident’s records showed schizoaffective disorder, depression, generalized anxiety disorder, and schizophrenia, yet the PASRR Level I from the referring hospital indicated no mental illness. Another resident had depression, vascular dementia with psychotic disturbance and anxiety, and later a new diagnosis of schizophrenia, but her PASRR Level I also showed no mental illness and she was not referred for a PASRR Level II after the new schizophrenia diagnosis. The MDS Coordinator acknowledged that the PASRR for one resident should have been positive and corrected, and that she was unaware of the other resident’s new schizophrenia diagnosis and had not notified the local authority, while the DON and Administrator confirmed the MDS Coordinator’s responsibility for PASRR accuracy and follow‑through.
A resident with multiple diagnoses, including a right femur fracture and schizophrenia, was not properly identified for PASRR Level II evaluation because the schizophrenia diagnosis was omitted from the Level I PASRR. Review of records showed the Level I PASRR did not list the schizophrenia diagnosis despite its established onset, and the DON acknowledged it should have been documented. As a result, the required referral for further evaluation by the state-designated authority for major mental illness, intellectual disability, or related conditions was not made.
PASARR services were not properly coordinated or documented for one resident with schizophrenia, anxiety, and bipolar disorder. The PASARR care plan called for group therapy, individual therapy, and routine case management, but the chart lacked documentation of those services, and staff said there was no consistent system to track PASARR visits or records. The facility also did not complete a PASARR Level II reassessment for another resident after a new diagnosis of major depressive disorder was added, even though the MDS nurse said a Form 1012 should have been completed.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Coordinate PASRR Review for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for one resident who had schizoaffective disorder, bipolar disorder, and anxiety disorder. Record review showed the resident’s quarterly MDS assessment reflected severe cognitive impairment with a BIMS score of 13, and the care plan documented behavior problems related to delusions, hallucinations, and false allegations toward others. The resident’s PASRR Level 1 screening dated 06/18/25 indicated she did not have a mental illness, even though the record also reflected mental illness diagnoses of schizoaffective disorder, bipolar disorder, and anxiety. During interview, the DON stated that if a resident received a new diagnosis, a new PASRR evaluation should be completed, and the Regional MDS Nurse stated the same. The Regional MDS Nurse reviewed the chart and stated the resident did not have a dementia diagnosis and had diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder, but the PASRR Level 1 was negative and did not reflect those mental health diagnoses. She stated she was unable to explain why a new PASRR Level 1 had not been completed when the new diagnoses were found. The ADM stated it was her expectation that the MDS Nurse ensure residents had a PASRR completed prior to admission and that if any resident received a new MI or developmental disability diagnosis while in the facility, the MDS Nurse was responsible for creating a PL1 to submit to the local authorities. Facility policy stated that if a resident had a qualifying MI or ID diagnosis and the nursing facility felt the resident should be positive, the referring entity should be contacted to correct the PL1 or complete the 1012, and that the facility must not accept admission from a hospital without a PL1.
PASARR Level Two Referral Not Acted Upon
Penalty
Summary
The facility failed to ensure a PASARR level two screening referral was acted upon for 1 of 1 resident reviewed for the PASARR screening process. The resident’s quarterly MDS identified diagnoses of disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy. The resident’s care plan did not identify PASARR level two recommendations. During interview, the DON confirmed a level two screening was not in the resident’s electronic medical record and stated it was important to identify what services were needed. An OBRA Level 1 screening identified serious mental illness and a referral to level two screening with the Hennepin County preadmission screening team, but a policy regarding the PAS process was requested and not received.
Failure to Ensure Accurate PASRR Screenings and Required Referrals for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PASRR Level I screenings accurately reflected residents’ mental health status and to coordinate necessary PASRR referrals. For one male resident, the face sheet and MDS documented diagnoses including schizoaffective disorder, depression, generalized anxiety disorder, and insomnia, with an MDS BIMS score indicating no cognitive impairment. His active diagnoses on the MDS included anxiety, depression, and schizophrenia. However, the PASRR Level I screening completed by the referring hospital indicated no primary diagnosis of dementia and no indicator of mental illness, despite the documented schizophrenia diagnosis present on admission. For a female resident, the face sheet and MDS documented diagnoses including depression, vascular dementia with psychotic disturbance, and vascular dementia with anxiety, with an MDS BIMS score indicating no cognitive impairment. Her active diagnoses on the MDS included non‑Alzheimer’s dementia, depression, and schizophrenia. The PASRR Level I screening completed by the referring hospital indicated no indicator of mental illness, and the resident reported she had not received PASRR services. The resident was newly diagnosed with schizophrenia on a later date, but this new diagnosis was not followed by a PASRR Level II referral. Interviews with facility staff confirmed that the PASRR information was inaccurate and that required follow‑up had not occurred. The MDS Coordinator acknowledged that the male resident’s mental illness diagnosis should have resulted in a positive PASRR Level I and that a corrected screening should have been completed and sent to the local authority. The MDS Coordinator also stated she was unaware of the female resident’s new schizophrenia diagnosis and had not notified the local authority as required. The DON and Administrator both stated that the MDS Coordinator was responsible for PASRR accuracy and follow‑through, and that inaccurate PASRR screenings could result in residents not receiving needed services or benefits.
Failure to Document Schizophrenia Diagnosis on PASRR and Refer for Level II Evaluation
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program by not ensuring a resident with a major mental illness was properly identified and referred for further evaluation. Record review showed that one resident, who had multiple diagnoses including a right femur fracture and schizophrenia, had a Level I PASRR dated 3/23/26 that did not document the schizophrenia diagnosis, which had an onset date of 3/21/22. Staff interview on 4/30/26 at 8:45 AM with the DON confirmed that the schizophrenia diagnosis should have been documented on the Level I PASRR but was not, and the resident was therefore not referred for a Level II PASRR evaluation as required for individuals with major mental illness, intellectual disability, or related conditions. This deficient practice was identified for 1 of 3 residents reviewed for Level II PASARR evaluations and was cited as having the potential to cause harm if the resident’s specialized services for mental health needs were not evaluated by the appropriate state-designated authority.
PASARR services and reassessment were not coordinated or documented
Penalty
Summary
The facility failed to coordinate and document PASARR-related services for a resident with serious mental illness. Resident #102 was admitted with schizophrenia, anxiety, and bipolar disorder, had a BIMS score of 15, and his care plan identified a need for specialized services due to mental illness. The PASARR Comprehensive Service Plan meeting documented recommendations for group therapy, individual therapy, and routine case management, but the resident’s electronic record did not contain documentation of those services through the date reviewed. During interviews, the PASARR Case Manager stated she visited the facility monthly to obtain a report from the resident and follow up with nurses, but she did not leave documentation of the visits. The MDS Coordinator stated she was responsible for ensuring PASARR Case Manager visits were conducted, was not aware when the skill trainer visited, and did not coordinate with them after visits. The DON stated he and the corporate nurse would try to obtain evidence of services provided, and the Administrator stated he did not know what services the resident was receiving until surveyor intervention and that there was no system in place to monitor MDS Coordinator oversight of needs. The facility also failed to complete a PASARR Level II assessment for another resident after a new diagnosis of Major Depressive Disorder was added after admission. Resident #86 had diagnoses including hemiplegia/hemiparesis following cerebral infarction, anxiety disorder, and insomnia, and later had Major Depressive Disorder documented on the face sheet. The annual MDS indicated no serious mental illness, and the electronic record did not show a Form 1012 had been completed for the new diagnosis. The MDS Nurse stated she should have completed a Form 1012 for the diagnosis and that she received psychiatric notes by email.
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