Failure to Accurately Complete PASRR Screenings and Level II Referrals for Multiple Residents With Mental Disorders
Summary
The deficiency involves the facility’s failure to ensure accurate completion, updating, and referral of PASRR Level I screenings and Level II evaluations for multiple residents with serious mental illness (SMI) or other mental disorders. For one resident with borderline personality disorder, PTSD, recurrent depression, anxiety disorders, and factitious disorder, hospital-generated PASRRs repeatedly documented “no” history of SMI, mental disorders, or psychotropic medications, despite extensive behavioral health diagnoses and active psychotropic orders. The facility did not correct these PASRRs or complete a Level I PASRR after the 30‑day convalescent period ended, even though the resident’s MDS assessments, psychiatric notes, care plans, and social services assessments consistently documented anxiety, depression, PTSD, borderline personality disorder, and ongoing psychiatric treatment. Another resident with PTSD, depression, generalized anxiety disorder, bipolar disorder, polysubstance abuse, and recent inpatient psychiatric hospitalization for suicidal ideation had a PASRR Level I that omitted major depression and bipolar disorder and incorrectly indicated no recent psychiatric hospitalization or suicidal ideation. A subsequent PASRR Level I, completed after re‑admission, documented bipolar disorder and anxiety disorder but again indicated no recent psychiatric hospitalization or suicidal ideation and concluded that no Level II referral was necessary. The clinical record showed no evidence of any PASRR Level II referral for this resident. A separate resident with diabetes, depression, and later‑added bipolar disorder exhibited altered mental status and psychotic‑like behavior, prompting a psychiatric consult. However, the quarterly MDS did not list bipolar disorder as an active diagnosis, and the PASRR Level I documented major and mild/situational depression but stated the resident did not have bipolar disorder and did not require a Level II referral, with no Level II referral found in the record. For another resident admitted and re‑admitted with anxiety disorder, schizophrenia, recurrent depressive disorder, chronic PTSD, and polysubstance abuse in remission, multiple PASRR Level I tools were inconsistent with the clinical record. One hospital PASRR identified bipolar disorder and personality disorder and psychotropic use but did not document whether a Level II referral was needed. A subsequent facility PASRR Level I documented schizophrenia and anxiety disorder but stated the resident was not prescribed psychotropic medications, despite the admission MDS showing active anxiety, depression, schizophrenia, and use of antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. A later PASRR Level I listed schizophrenia only, omitted depression, anxiety, and other mental disorders, and left the Level II referral determination section blank, even though the same form listed multiple psychotropic medications for depression, anxiety, and schizophrenia. No Level II referral was present in the record. Additional residents with multiple psychiatric diagnoses and psychotropic treatment also lacked accurate PASRR documentation and appropriate Level II referrals. One resident with anxiety disorder, bipolar disorder (current episode depressed), and schizophrenia had a PASRR Level I that correctly listed these diagnoses and related psychotropic medications but indicated no Level II referral; a later PASRR for the same resident omitted all mental illness diagnoses and psychotropic medications, again indicating no Level II referral, despite MDS documentation of anxiety disorder, bipolar disorder, schizophrenia, and use of antipsychotics and antidepressants. Another resident with aphasia, anxiety disorder, recurrent depressive disorder, mood disorder, personality and behavioral disorder due to physiological condition, and adjustment disorder had an initial PASRR listing anxiety and depression with no Level II referral, followed by a second PASRR that omitted all diagnoses and psychotropic medications, again indicating no Level II referral, despite orders and care plans for Depakote and anticonvulsant therapy for mood disorder. In interviews, the Director of Social Services acknowledged that PASRRs were inaccurate or incomplete, that required Level II referrals had not been submitted for several residents, that the facility was responsible for ensuring PASRR accuracy, and that she was uncertain about PASRR update requirements and tracking for residents needing Level II evaluations. The Director of Social Services further stated that the facility’s process for identifying residents with mental disorders or intellectual disabilities involved review of diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia, and review of psychiatric medications, and that residents with more than one or two psychiatric diagnoses and stays longer than 30 days should automatically have a Level II PASRR referral submitted. She confirmed that she was responsible for completing Level I PASRRs and submitting Level II referrals, that PASRR resource reviews were infrequent and random, and that she had not received formal performance evaluation or sufficient training to identify knowledge gaps. She also stated that inaccurate or incomplete PASRR screening and referral processes could result in residents not receiving the services they need, and that accurate PASRR completion is critical to resident safety and quality of care.
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.
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