Failure to Implement PASRR Recommendations and Complete NFSS Submission
Penalty
Summary
The deficiency involves the facility’s failure to incorporate PASRR evaluation recommendations into a resident’s assessment, care planning, and transition of care, and to submit a complete and accurate NFSS request in the LTC online portal within the required timeframe. The resident was an adult male with cerebral palsy, depression, and chronic kidney disease, with a BIMS score indicating moderate cognitive impairment, who used a wheelchair for mobility and was able to understand and be understood by others. His care plan documented that he was PASRR positive related to a developmental disability and that he would participate in quarterly care plan meetings with a PASRR representative, with coordination of PASRR services and development of an Individual Service Plan by the PASRR representative. At a quarterly IDT meeting, attended by the PASRR Habilitation Coordinator, the MDS Coordinator, and the resident, several NFSS items were identified and confirmed as pending, including a customized manual wheelchair, a gait trainer, and orthotic devices. The PASRR Habilitation Coordinator reported that these items had been requested for almost a year without completion. Observation showed the resident propelling himself in his wheelchair down the hall by pulling on the handrails rather than pushing the wheels, although he was able to reach his destination independently. The resident stated he had been waiting approximately a year for the customized wheelchair, gait trainer, and orthotics, that a representative had measured him and shown him a chair, and that he understood the paperwork from the facility had not been approved. He also reported being told by the Physical Therapist that his current chair was too big, though he denied experiencing negative outcomes. The MDS Coordinator stated it was her responsibility to enter the NFSS form into the LTC online portal and that she had repeatedly attempted to submit the information but received error messages, which she reported to the PASRR Habilitation Coordinator. She indicated she had sought assistance from the DME company’s Lead PASRR specialist and from the Simple LTC portal but did not receive effective help, and she reported having worked at the facility for seven years without receiving PASRR training. The Administrator acknowledged that the process had been problematic on multiple levels, was unaware of the MDS Coordinator’s lack of PASRR training, and had assumed the paperwork issues were resolved. The DON stated he was unaware that the PASRR process for this resident had not been completed, was not aware of complications, and reported that neither he nor the MDS Coordinator had PASRR training. The physician stated the resident had not had a decline and that any mobility decline would be expected from cerebral palsy rather than from lack of the recommended equipment. When the surveyor requested a PASRR policy, the facility did not provide one prior to exit.
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