Penalty

Fine: $26,68557 days payment denial

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 maintain documentation of a Level I preadmission screening and resident review (PASRR) assessment for a resident with serious mental illness and intellectual disability diagnoses. Record review showed that the resident had diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, traumatic brain injury (TBI), Alzheimer's disease, and paranoid schizophrenia. Despite these diagnoses, there was no evidence in the resident's medical record of a completed PASRR Level I or Level II screening prior to admission, nor was there a current PASRR assessment available. The care plan referenced a completed PASRR and outlined interventions for managing the resident's mental health needs, but the actual PASRR documentation was not provided by the facility. Additionally, the facility did not have a policy related to PASRR screenings. During an interview, a Central Office Medical Review Unit (COMRU) nurse confirmed that a Level II screening had been completed in the past, but stated that a replacement application would be required since the previous screening was over a year old. The absence of current and accessible PASRR documentation in the resident's record constituted a deficiency in ensuring the resident's behavioral health needs were properly identified and addressed.