Failure to Provide Required Permanency Planning Services for a Resident Under 22
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically permanency planning services, to a resident under the age of 22 as required by Texas regulations. The resident was a young adult with a history of diffuse traumatic brain injury with loss of consciousness, ventilator dependence via tracheostomy, severe mobility limitations, GERD, generalized anxiety disorder, and depression. Her MDS reflected severe cognitive impairment, no speech, dependence on staff for all ADLs with two-person assist, risk for dehydration and shortness of breath, need for parenteral/IV feeding and feeding tube, risk for pressure ulcers, and multiple special treatments including oxygen, suctioning, tracheostomy care, invasive mechanical ventilation, and IV access. The care plan and MD orders documented extensive medical and nursing needs, including anticoagulant therapy, seizure disorder, bowel incontinence, enhanced barrier precautions, feeding tube management, and tracheostomy care. Despite the resident’s age and the Texas requirement that permanency planning be completed every six months for individuals under 22 residing in nursing facilities, the facility did not ensure that permanency planning was initiated or supported. The Permanency Planning Contractor (PPC) sent emails to the facility social worker (SW) on multiple dates with a provider letter explaining permanency planning requirements, a blank Form 2437 (Notification of Nursing Facility Admission of Person Under Age 22), and information that permanency planning is mandated under Texas Administrative Code. The PPC reported requesting records on several occasions and informing the SW that records were required within three days. The PPC also stated that a negative PASRR result would not prevent permanency planning services. However, the facility’s Clinical Director (CD) stated that permanency plans were only completed for PASRR-positive residents under age 22 and that, because the resident’s PASRR evaluation was negative, no further action was taken. The SW reported being unfamiliar with the term “permanency planning” and stated that when contacted by the PPC for the resident’s care files and related documents, she questioned the legitimacy of the request, was concerned about HIPAA and confidentiality, and did not feel comfortable providing information. She indicated that the PPC could not provide sufficient information about the resident’s relation and purpose of the request, and she did not document the contact, did not forward the emails to the DON or administrator, and did not contact HHSC, the PPC, or a PPC superior to verify the request. The SW initially denied receiving emails from the PPC, and it was only after the surveyor requested supporting documentation that the SW produced the email correspondence. Interviews also revealed that the DON and CD could not provide a facility policy on permanency planning, and both reported that no such policy existed. As a result of these actions and inactions—misunderstanding of PASRR’s role, failure to recognize and act on permanency planning requirements for a resident under 22, failure to respond to PPC requests, and lack of policy guidance—the facility did not provide the required medically related social services related to permanency planning for this resident. The resident remained non-interviewable during survey observations due to her traumatic brain injury, but she was observed awake in bed, ventilator-dependent, with clean equipment and environment, and able to visually track the surveyor. The record review confirmed that the resident had been in the facility for several months, and the SW’s own note documented initial contact from an individual stating the resident had been flagged by the state for permanency placement assistance due to age. The SW’s note also reflected her discomfort with the call, her belief that the caller’s identification as a state representative was questionable, and her decision not to proceed without consulting the family or administration, yet she did not follow through with leadership or regulatory contacts. The combination of the facility’s lack of a permanency planning policy, the SW’s lack of knowledge and failure to act on multiple PPC contacts, and the CD’s reliance on PASRR status instead of permanency planning regulations led directly to the failure to assist this under-22 resident in obtaining permanency planning resources and services as required. Additionally, the DON reported that she had completed the initial PASRR at admission, determined the resident was positive, and submitted the 2401 form to HHSC, after which a QIDP evaluation concluded the resident did not qualify for PASRR services. The DON stated that the family was informed of these PASRR results and agreed to services for the resident, and that the SW was assigned to contact the provider about the records request. However, the SW did not complete this assignment and did not engage with the PPC to move forward with permanency planning. The surveyor’s review of the SW’s personnel file showed that she had been hired earlier in the year at a sister facility and transferred to the current facility shortly before the PPC contacts, and there was no evidence that she had prior training on permanency planning before the in-service that occurred after the PPC’s initial outreach. The absence of a facility policy, combined with the SW’s inaction and the CD’s misunderstanding of regulatory triggers, resulted in the resident not receiving the medically related social services necessary to support permanency planning.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ESRD and thrombocytopenia had a physician-ordered oncology follow-up, but the referral for insurance authorization was not sent in a timely manner. SS and the CM described delays and a lack of follow-up communication, and the oncology appointment was not scheduled until much later after authorization was finally obtained.
A resident with dysphagia, COPD, depression, anxiety, a stage 2 sacral pressure ulcer, urinary retention, severe malnutrition, and cachexia had an incomplete discharge process. The SW did not complete a discharge note, and the discharge summary omitted key details such as transportation, follow-up care, pharmacy information, home health agencies, and needed DME like a wheelchair, oxygen, peg tube supplies, and foley catheter supplies. The care conference and discharge documentation also failed to accurately reflect the resident’s wounds, tube feeding needs, and urinary status.
Failure to Provide Timely Social Services After Neglect Incident: An LPN repeatedly left the unit without notifying staff and failed to administer ordered meds and tx, leading to a neglect event with multiple residents affected. Review of records for numerous residents with conditions such as DM, CHF, AFIB, seizures, dementia, chronic pain, and renal dialysis showed no social svc follow-up after the incident. Resident interviews described missed meds, late med pass, increased pain, sleep disruption, and a panic attack after omitted meds and blood sugar checks.
A facility failed to provide medically-related social services for two cognitively intact residents who were in an intimate relationship. Staff, including the SW, RCC, UM, and DA, were aware the residents were holding hands, spending private time together, and using the conference room for privacy, but neither resident had a completed Intimacy and Sexual History assessment or an intimate relationship care plan with person-centered interventions.
Failure to provide medically-related social services and psychosocial follow-up: one resident reported needing help with transition into the facility, retrieving mail and home paperwork, paying bills, and coordinating dental care, but staff were unaware of these needs after the initial admission period. Another resident was involved in a resident-to-resident altercation in which she was struck in the back, and there were no nursing or social services notes addressing her reaction or concerns afterward.
Failure to Send Requested Transfer Referrals: A resident with MDD, GAD, and chronic pain, who was cognitively intact, repeatedly asked to be transferred to a facility closer to her daughter. Social services notes showed the resident wanted referrals sent closer to home, but the requested referrals were not made for about 6 weeks. Staff interviews confirmed referrals were expected to be sent immediately or the same day if possible, and the delay was not considered acceptable.
Delayed Oncology Referral Authorization
Penalty
Summary
The facility failed to ensure a referral was sent in a timely manner to Resident 4’s insurance company for authorization to schedule an oncology appointment for thrombocytopenia. Resident 4 was admitted with end stage kidney disease and had a BIMS score of 15 out of 15, indicating intact cognition. A physician order dated February 23, 2026 directed follow-up with an oncologist for evaluation and management of thrombocytopenia, but the referral process was not completed promptly. During interviews, Social Services staff stated that when an appointment requires insurance authorization, Social Services or the Case Manager submits a referral form to the insurance company, and authorization is expected to take about three to four days. The Case Manager stated she was unsure of the exact date she sent the referral, but authorization was not received until April 23, 2026, and the oncology appointment was not scheduled until May 21, 2026. The Case Manager also stated there was a delay in requesting the authorization and that Social Services and Case Management did not have a process to follow up with each other regarding resident authorizations. The facility policy stated that Social Services personnel coordinate most resident referrals and collaborate with other disciplines to arrange physician-ordered services.
Incomplete discharge planning and social services support
Penalty
Summary
The facility failed to provide medically related social services to support the physical and psychosocial health of one resident and failed to provide advocacy for the resident’s rights during discharge planning. The resident had multiple diagnoses including dysphagia, COPD, depression, anxiety, emphysema, acquired absence of part of the stomach, a stage 2 sacral pressure ulcer, chronic pain, urinary retention, severe protein malnutrition, and cachexia. An order dated 6/11/26 indicated the resident was to discharge home with home health services for skilled nursing wound care, medication management, PT/OT, home health aide services, and DME including peg tube supplies, oxygen therapy, and a wheelchair. Record review showed no discharge note completed by the social worker and no medical provider discharge note. The care conference assessment completed on 6/3/26 did not include other disciplines, and several discharge-related items were incomplete or not checked, including tube feeding and foley catheter supplies, nutritional interventions, and resident/family education or follow-up. The nursing section also indicated the resident did not have any wounds, despite the documented stage 2 pressure ulcer. The discharge summary started on 6/1/26 was incomplete and did not document transportation, the primary provider, follow-up appointments, pharmacy information, or the agencies contacted for home care services. It selected only PT and OT for in-home care and indicated no medical equipment was needed at discharge, despite the listed need for a wheelchair, tube feeding supplies, and oxygen. It also identified the resident as continent even though the resident had a foley catheter, did not note skin integrity concerns, and did not select tube feeding as a nutritional consideration.
Failure to Provide Timely Social Services After Neglect Incident
Penalty
Summary
The facility failed to provide medically-related social services support timely after an alleged neglect event involving multiple residents. The report states that during the 3:00 PM to 11:00 PM shift, an LPN repeatedly left the assigned unit for long periods without notifying staff and did not ensure medications and treatments were administered per physician orders. Later that shift, staff found the LPN lethargic in an employee bathroom with suspected drug paraphernalia, EMS was called, the LPN was removed from the schedule pending investigation, and twenty-two residents were identified as having omitted medications and/or treatments. The event was classified as neglect. Review of social service notes from 5/21/26 through 5/27/26 for nineteen sampled residents failed to identify social worker interaction regarding the neglect incident and omitted medications. These residents included individuals with a wide range of diagnoses and care needs, such as diabetes, CHF, atrial fibrillation, seizures, dementia, depression, chronic pain, renal dialysis, and gastrostomy status. Several residents had impaired cognition, while others were documented as cognitively intact. The record review showed that the residents’ care plans included medication administration as ordered and monitoring for effectiveness, but the social service documentation did not reflect follow-up related to the incident. Resident interviews that were completed described missed medications and symptoms after the shift. One resident reported the LPN was consistently rude and called him/her crazy, leading the resident to avoid contact. Another resident reported increased pain and difficulty sleeping after not receiving medications. A resident with diabetes and insulin use reported not receiving blood sugar checks or medications, resulting in a panic attack and pain overnight. Other residents stated they could not recall whether medications were given, and several reported that when the LPN worked, medications were given very late or all at once. The DON and Regional Nurse stated that after neglect or abuse situations, all involved residents should be followed by social services daily for 3 days, and they noted there was no full-time social worker employed at the facility at that time.
Failure to Complete Intimacy Assessments and Care Plans for Two Residents in a Relationship
Penalty
Summary
The facility did not ensure medically-related social services were provided to help each resident achieve the highest possible quality of life for 2 of 4 sampled residents, R1 and R11. Both residents were cognitively intact, with BIMS scores of 15 on their annual MDS assessments, and both had diagnoses including anxiety disorder and depression for R1, and anemia, essential hypertension, and hypokalemia for R11. Survey observations and interviews showed that R1 and R11 were in an intimate relationship, were seen holding hands in R1's room and on the patio, and were using the conference room for privacy. Staff members including the RCC, UM, and DA were aware of the relationship, and the SW stated awareness that the residents had been spending more time together and getting closer. The SW also stated that intimacy and sexual history assessments were supposed to be completed on admission and that a care plan would be initiated based on the assessment outcome, but both R1 and R11 did not have completed Intimacy and Sexual History assessments. Survey review found that neither resident had a completed intimate relationship care plan with person-centered interventions. The facility's social services policy stated that the facility would provide medically-related social services to each resident and that the social worker would complete initial and quarterly assessments to identify any need for such services and document them in the medical record.
Failure to Provide Social Services and Psychosocial Follow-Up
Penalty
Summary
Medically-related social services were not provided for a resident who said he needed help transitioning into the facility and managing personal affairs. During an interview, the resident stated that after the first day or two of admission, no one had been in to help him, and he reported having no family or friends to assist him. He said he needed help getting to his home or having someone retrieve his mail, paying his insurance and household expenses, and obtaining paperwork and information from a dental appointment at home. He also stated that he had been told a tooth would be pulled and a partial plate made, and he wanted the partial denture so he could eat and chew more easily. A staff member reported only seeing the resident once shortly after admission and was unaware of the resident’s dental concerns or need for help retrieving items from home to pay bills. Psychosocial well-being was not assessed for another resident after a resident-to-resident physical altercation. Nursing documentation showed that the resident backed her wheelchair into another resident, and the other resident responded by hitting her in the back between the shoulder blades with a closed fist. A staff member stated he would talk to residents after such events only sometimes and said he was unaware that this resident had been involved in the altercation. He did not follow up with the resident regarding social service needs, and no nursing or social services notes addressing the resident’s reaction or concerns after the incident were provided by the end of the survey.
Failure to Send Requested Transfer Referrals
Penalty
Summary
The facility did not provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being when it failed to make requested transfer referrals. The resident was admitted with diagnoses including Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, and Chronic Pain Syndrome, and her MDS indicated a BIMS score of 15 out of 15, showing she was cognitively intact. She repeatedly requested to be transferred to a facility closer to her daughter, her only living relative, and stated she had asked facility management over and over, spoken with social work, and written a letter asking to move closer to family. Record review showed a Social Services note at baseline care plan meeting stating the resident wanted referrals sent closer to home, and another note indicating she requested referrals be sent out and would consider other options. The resident continued to report that her request had not been followed up on for about 6 weeks. Interviews with the SSA, NHA, DON, and CNO showed the facility expected social services to send referrals immediately or the same day if possible, and staff acknowledged that a 6-week delay was not acceptable. A later Social Services note documented that 4 referrals were faxed to skilled nursing facilities and that the facility was waiting to hear back.
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