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F0644
D

Failure to Incorporate PASRR Recommendations and Submit NFSS Request

Richmond, Texas Survey Completed on 12-23-2025

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 (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transition of care. Specifically, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting, as required. This omission was identified for one resident who was PASRR positive for intellectual disability and had a recommendation for a prosthetic device documented in the Person-Centered Service Plan (PCSP). Record review showed that the resident had multiple complex diagnoses, including profound intellectual disabilities, cerebral palsy, contractures, and was totally dependent on activities of daily living. The resident's care plan acknowledged the PASRR assessment and the need for specialized services, but there was no evidence in the clinical record that the NFSS form was completed or submitted. Interviews with facility staff revealed a lack of awareness and communication regarding the PCSP recommendation for a prosthetic device, with the MDS coordinator and RN both stating they were not aware of the recommendation at the time of the meeting. The physical therapist also indicated that no device was recommended during the PASRR meeting. The facility's policy requires that all residents be properly screened using PASRR and that referrals for specialized services be made to the appropriate state agencies. However, in this case, the process was not followed, and the required documentation and referral for specialized services were not completed. Staff interviews confirmed that the failure to submit the NFSS could prevent residents from receiving necessary services for their wellbeing.

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