Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
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.
Penalty
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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.
A resident with severe cognitive impairment, positive PASRR status, and a need for a manual wheelchair was identified by the IDT and PCSP as requiring a customized manual wheelchair (CMWC). Facility records and the PASRR Compliance Call Report showed that the NF was required to submit an NFSS request for this specialized service in the LTC Online Portal within 20 business days of the IDT meeting, but the Simple LTC PASRR NFSS Activity Portal History and staff interviews confirmed the request was not submitted until well after the required timeframe. The Director of Therapy, identified by the DON and Administrator as responsible for meeting this deadline, acknowledged the late submission as an oversight, resulting in noncompliance with the facility’s PASRR policy and regulatory timeframes for specialized services authorization.
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.
Failure to Timely Submit PASRR NFSS Request for Customized Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to timely coordinate a PASRR Nursing Facility Specialized Services (NFSS) request for a customized manual wheelchair (CMWC) for a resident with intellectual and developmental disabilities. The resident was an adult male with diagnoses including cerebral infarction, convulsions, and a cognitive communication deficit, and his quarterly MDS showed severe cognitive impairment with a BIMS score of 00 and a need for a manual wheelchair. His care plan documented a positive PASRR status and the expectation that he would receive specialized services recommended by the local authority. A PASRR IDT meeting and Person-Centered Service Plan (PCSP) were completed on 08/18/2025, identifying the need for a new CMWC. The PASRR Compliance Call Report indicated that, based on this IDT date, the NF was required to submit the NFSS form for therapies, including the CMWC, in the LTC Online Portal by 09/12/2025 (within 20 business days of the IDT meeting). Record review of the Simple LTC PASRR NFSS Activity Portal History showed that the NFSS request for the CMWC was not submitted within the required 20 business days. The Director of Therapy stated in interview that the NFSS request for the custom wheelchair was actually submitted on 11/07/2025, which was past the 20-business-day requirement, and described this as an oversight. The DON and the Administrator both stated in interviews that the Director of Therapy was responsible for ensuring the NFSS deadline was met and acknowledged that the deadline had been missed. During observation, the resident was seen seated on a couch with his CMWC next to him, but he was non-verbal and could not be interviewed. The facility’s PASRR policy stated that, after the IDT meeting, the NF must submit information from the IDT meeting on the LTC Online Portal and must submit prior authorization requests for NF specialized services via the NFSS form, which did not occur within the required timeframe for this resident’s CMWC request.
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