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F0644
D

Failure to Coordinate and Initiate PASRR Habilitative Therapy Services

Webster, Texas Survey Completed on 04-19-2025

Penalty

Fine: $34,385
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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 coordinate with the Pre-Admission Screening and Resident Review (PASRR) program and did not initiate habilitative therapy services within the required timeframe for a resident with intellectual and developmental disabilities. Despite an interdisciplinary team (IDT) meeting where the need for specialized assessments and services in physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was agreed upon, the facility did not complete or submit the necessary therapy evaluations and NFSS forms within 30 days as required. As a result, requests for these services were denied due to missing or late documentation, and the resident did not receive timely habilitative therapies as outlined in the PASRR service plan. The resident involved was an adult male with diagnoses including intellectual disabilities, Down syndrome, diabetes mellitus type II, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. At the time of the deficiency, he had moderate cognitive impairment and required assistance with all activities of daily living. He had undergone multiple surgeries resulting in the loss of all toes on his right foot, which left him unable to walk and reliant on a wheelchair for mobility. The resident expressed a desire to regain the ability to walk, but was not receiving the agreed-upon therapy services due to the facility's failure to complete the necessary PASRR processes. Interviews with facility staff revealed that there had been a change in facility ownership and staff turnover, resulting in incomplete records and a lack of continuity in care coordination. The current Director of Rehabilitation and MDS Coordinator were unable to account for the actions or documentation of previous staff, and there was no evidence that the required therapy assessments or service initiation had occurred within the mandated timeframe. Facility policy required that all specialized services identified by the Local Authority be added to the care plan and initiated within 25 days, but this was not followed in this case.

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