Failure to Provide and Document Specialized PASRR Services and Equipment
Penalty
Summary
The facility failed to provide specialized habilitation services and did not obtain specialized durable medical equipment for a resident identified as needing such services through the PASRR (Preadmission Screening Resident Review) process. The resident, a male with multiple diagnoses including intellectual disability, cognitive communication deficit, and developmental disorder, was admitted with a PASRR positive status. His care plan indicated the need for specialized services, including a customized wheelchair and mattress, as determined by the IDT (Interdisciplinary Team) meeting. However, the IDT meetings did not address the use of a supportive mattress, and the facility did not request a customized mattress within the required 20 business days after the IDT meeting. Interviews with facility staff revealed that although the need for a customized mattress was discussed, it was not documented in the resident's records or in the facility's portal profile. The Director of Rehabilitation (DOR) acknowledged that the mattress was not ordered due to safety concerns related to another resident, but this rationale was not documented. The PASRR Program Specialist confirmed that the facility did not submit the necessary forms within the required timeframe and failed to document the reasons for the delay, which is required for compliance. The facility's own PASRR policy and procedure require coordination with the local authority, timely documentation, and provision of specialized services as recommended in the Level II evaluation. In this case, the facility did not document the provision or delay of the specialized mattress, nor did it ensure that all recommended services were addressed and provided within the mandated timeframe, resulting in a deficiency.