Failure to Coordinate PASRR Assessments and Timely Submission of NFSS
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program to the maximum extent practicable, resulting in the omission of PASRR Level II determination recommendations and evaluation reports from residents' assessments, care planning, and transitions of care. Specifically, for two residents with significant mental health and developmental diagnoses, the facility did not incorporate specialized services and recommendations identified during the PASRR process into their care plans. The records showed that both residents had complex conditions, including autistic disorder, bipolar disorder, anxiety disorder, dementia, moderate intellectual disabilities, and developmental disorders, yet the required coordination and documentation were not completed as mandated. Additionally, the facility did not submit complete and accurate requests for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meetings for both residents. Interviews with facility staff confirmed that the NFSS should be completed within the specified timeframe, and failure to do so would prevent verification that residents were receiving PASRR services. Review of facility policy also indicated that the IDT meetings and documentation in the portal were not performed according to regulatory requirements, contributing to the deficiency.