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F0644
D

Failure to Incorporate PASRR Recommendations and Submit Timely NFSS Request

Denver City, Texas Survey Completed on 06-16-2025

Penalty

No penalty information released
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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 evaluation report into the assessment, care planning, and transition of care for a resident identified as PASRR positive. Specifically, after an IDT meeting where the need for a new customized manual wheelchair (CMWC) was discussed and confirmed, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within the required 20-day timeframe. The process for obtaining the CMWC was not completed as outlined, and the necessary forms and documentation were not submitted as required by policy. Record review showed that the resident had multiple diagnoses, including muscle weakness, muscle wasting, lack of coordination, osteoarthritis, genetic-related intellectual disabilities, and obesity. The resident's care plan indicated participation in quarterly care plan meetings with PASRR representatives and coordination of PASRR services. Despite these documented needs and the identification of the CMWC as an ongoing requirement, the facility did not follow through with the necessary steps to secure the recommended equipment. Interviews with facility staff revealed confusion and lack of familiarity with the PASRR and NFSS processes. The MDS nurse, DOR, and other staff members indicated difficulties in completing the required paperwork and uncertainty about who was qualified to sign the necessary forms. The DME company evaluated the resident and determined that a new CMWC was not immediately needed, but repairs were required. Despite internal communications and attempts to clarify the process, the facility ultimately did not submit the NFSS form within the mandated timeframe, resulting in a failure to coordinate and provide the recommended PASRR services.

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