Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy and completeness of Level 1 PASRR screenings and did not submit required Level 2 PASRR evaluations for two residents with mental health diagnoses. For one resident admitted with anxiety disorder, major depressive disorder, and PTSD, the Level 1 PASRR did not accurately reflect the resident's history of suicidal ideation or prior psychiatric hospitalizations, and did not trigger a Level 2 PASRR evaluation. Additionally, after a new diagnosis of anxiety was made, the facility did not submit a new PASRR as required for a change in condition. For another resident admitted with multiple mental health diagnoses, including anxiety, dependent personality disorder, major depressive disorder, and bipolar disorder, the Level 1 PASRR failed to include all relevant diagnoses and did not prompt a Level 2 PASRR evaluation. The facility also did not submit a status change to the PASRR vendor after the resident was later diagnosed with unspecified dementia, as required by PASRR protocols. Interviews with facility staff revealed that the Level 1 PASRR forms were not coded correctly and that there was a lack of understanding or oversight regarding the need to update PASRR documentation following changes in residents' mental health diagnoses. The facility did not have a policy in place for PASRR, and the care plans for both residents did not include information related to PASRR requirements.