Failure to Implement PASARR Recommendations for Substance Abuse Support
Penalty
Summary
A deficiency occurred when the facility failed to implement Level II PASARR recommendations for a resident with a diagnosed substance abuse disorder. The resident was admitted with a history of alcohol dependence, anxiety disorder, and repeated falls, and had recently been hospitalized for alcohol withdrawal. Upon admission, the resident's smoking status was not assessed, and subsequent clinical records did not document any smoking assessments. Despite a physician's order for supervised smoking and care plan interventions for safety risk evaluations, the admission MDS did not identify current tobacco use, and there was no evidence that the recommended substance abuse support services were provided. The Level II PASARR identified that the resident required specific services, including participation in a support group for substance abuse recovery (such as Alcoholics Anonymous), group therapy with a trained therapist, and the appointment of a guardian conservator for health and safety decisions. While the care plan acknowledged these recommendations, the facility did not offer group counseling or substance abuse support programs. Interviews with facility staff confirmed that the recommended services were not available, and there was no documentation of the resident receiving these supports. During the resident's stay, multiple incidents occurred involving the possession and use of marijuana and smoking paraphernalia, as well as violations of the facility's smoking and safety policies. Room searches revealed marijuana, a smoking pipe, and a pocketknife in the resident's possession. Despite these findings and the clear recommendations from the PASARR, the facility did not provide the required substance abuse support services, contributing to ongoing behavioral and safety concerns.