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F0644
E

Failure to Incorporate PASRR Recommendations and Timely Submit NFSS Request

Odessa, Texas Survey Completed on 05-14-2025

Penalty

16 days payment denial
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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 incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into the assessment, care planning, and transition of care for a resident identified as needing specialized services. The resident, a male with multiple complex diagnoses including profound intellectual disabilities, cerebral palsy, epilepsy, hemiplegia, and significant mobility limitations, was admitted with a positive PASRR Level 1 screening for intellectual disability and was determined to require specialized services. Despite this, the facility did not ensure that the PASRR recommendations were fully integrated into the resident's care plan and assessment process. Record reviews showed that the resident's quarterly MDS assessment did not include a BIMS score and was marked as moderately impaired for cognitive skills. The PASRR evaluation confirmed the need for specialized services, and an IDT meeting was held to identify necessary services such as durable medical equipment. However, the facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the required LTC online portal within 20 days after the IDT meeting, as mandated by state policy. The initial NFSS submission was declined due to missing required assessments, and the resubmission was still pending at the time of the survey. Interviews with facility staff revealed gaps in communication and understanding of the PASRR process, with staff members unaware of the current status of equipment requests and the specific needs of the resident. The delay in submitting the NFSS form and the lack of integration of PASRR recommendations into the care plan resulted in the resident not receiving timely access to the specialized services identified as necessary for his care.

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