Failure to Timely Submit PASRR NFSS Documentation
Penalty
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 for one resident reviewed for PASRR services. 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 by policy. This lapse was identified through interviews and record reviews, which showed that although the resident continued to receive habilitation services such as speech, occupational, and physical therapy, the necessary documentation and portal submissions were not completed in a timely manner. The resident involved was a male with multiple diagnoses, including intellectual disabilities, schizophrenia, Parkinson's disease, and severe cognitive impairment, requiring significant assistance with activities of daily living. The care plan indicated that the resident was PASRR positive and required ongoing coordination of PASRR services, including quarterly care plan meetings and individualized service plans. Despite these documented needs and ongoing therapy services, the facility did not ensure that the NFSS forms were submitted within the required timeframe following IDT meetings, particularly during a period of change of ownership when access to the portal was disrupted. Interviews with facility staff, including the Director of Rehabilitation (DOR), MDS nurse, and Administrator, confirmed that while habilitation services were continuously provided, there was a breakdown in the administrative process for submitting required documentation. The MDS nurse and Administrator both acknowledged issues with portal access during the change of ownership and admitted that no one contacted the appropriate parties to resolve the issue at the time. As a result, the facility did not meet the regulatory requirement to submit the NFSS form within 20 business days of the IDT meeting, as outlined in their own policy.