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Based on record review and staff interview, it was determined that the facility failed to provide an appropriate discharge plan related to completion of the PASRR screen for 1 (# 11) of 11 sampled patients.


Findings include:


42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASRR) be completed prior to the patient's being transferred to the Skilled Nursing Facility (SNF) to ensure appropriate placement. Review of the medical record for patient (#11) revealed that the patient would be transferred to a SNF for continuing care. The PASRR in the medical record that was completed for this patient is dated 11/19/10. The new PASRR form that came into effect 11/14/11 was not utilized. The findings were confirmed by the Case Manager (CM). An interview was conducted with the patient's CM who stated that this is the current form that she was instructed to utilize. The CM discharge planning note entry, dated 12/5/11 11:41 a.m., reads: Printed out PASRR Level 1 from previous admission in October 2010.
An interview was conducted with the Director of Performance Improvement, Infection Control & Patient Safety Officer on 12/6/11 at approximately 12:50 p.m. She was made aware of the findings and she confirmed that there is no policy on completion of the PASRR screen.