Failure to Implement PASARR Level II Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident with intellectual/developmental disabilities and mental illness. The PASARR Level II report specified that the resident required an intensive, continuous treatment program called specialized services, including a thorough assessment by a qualified intellectual disabilities professional (QIDP), physical/occupational therapy, monitoring for nonverbal communication, and person-centered interventions to address behavioral disturbances. Despite these recommendations, the facility's care plan did not reflect the specific person-centered interventions or specialized services outlined in the PASARR report. The resident had a complex medical history, including autistic disorder, intellectual disabilities, epilepsy, mood and anxiety disorders, and required a gastrostomy. The care plan included some general interventions for behaviors and mood but did not address the specialized services or recommendations from the PASARR Level II, such as involvement of a QIDP, targeted therapies, or specific behavioral supports. Staff interviews revealed a lack of awareness and training regarding specialized services, and key personnel, including the psychologist, occupational therapist, and social workers, were not involved in developing or implementing a specialized care plan for the resident. Additionally, the facility did not consistently monitor or document the resident's behaviors in relation to psychotropic medication use, and there was no evidence of ongoing psychiatric evaluation or review after the initial assessment. Staff reported challenges in managing the resident's behaviors, frequent disruptive incidents, and a lack of clear guidance or interventions. The absence of a coordinated, person-centered approach as recommended by the PASARR Level II report contributed to ongoing behavioral issues and a chaotic environment on the unit.