F0644

D

Failure to Integrate PASARR Level II Findings and Timely Submit Specialized Services Request

Katy, Texas Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to incorporate PASARR Level II recommendations and evaluation findings into a resident’s assessment, care planning, and transitions of care, and failure to timely and accurately submit a request for nursing facility specialized services (NFSS). The resident was an adult female with Down Syndrome, Type 2 Diabetes Mellitus, cognitive communication deficit, disorganized schizophrenia, bipolar disorder, and a history of developmental delay and seizures. Her care plan identified her as PASRR positive related to ID/DD and noted communication problems related to Down Syndrome, with interventions such as anticipating and meeting needs and referring her to speech therapy. Her Quarterly MDS documented that she was rarely or never understood, did not complete the BIMS, and was totally dependent on staff for all ADLs. However, there was no Level II PASARR assessment uploaded in her medical record, and the facility did not demonstrate that Level II recommendations were integrated into her comprehensive assessment or care plan.

Record review showed that the resident had been admitted to the hospital with developmental delay and seizures and then transferred to the facility. A PASARR Level I dated 01/16/2025 scored 0, indicating a negative Level I screen at that time. The baseline care plan coded her as understanding staff but not able to easily communicate with staff and included physical, occupational, and speech therapy to improve functional status. Despite her PASRR-positive status later identified in the care plan, the facility’s records lacked the Level II PASARR documentation and did not show that the Level II determination and evaluation report were used to guide her ongoing assessment, care planning, or transitions of care. When surveyors requested the Level II assessment from the Administrator, no documents were provided by the time of exit.

The facility also failed to submit a complete and accurate NFSS request within required timeframes. An IDT meeting on 03/24/2025 identified needs for a support mattress, PT, OT, ST, wheelchair service, and a positioning wedge. The state received an NFSS request on 04/25/2025 for PT, OT, and ST, and records indicated the resident was approved for a positioning wedge on 03/25/2025 but that the NFSS request for that item was not submitted. NFSS forms for therapy and equipment showed therapist, physician, and Administrator signatures dated in late June, July, and August 2025, and another NFSS form for a mattress was fully signed on 08/29/2025. The Director of Rehabilitation reported learning of the resident’s PASARR services from the MDS department but could not recall who informed her, and the MDS staff member responsible earlier in the timeline was unavailable for interview. The facility’s policy on post-admission notification of significant change did not address submission deadlines, and the Administrator stated he was not aware that the NFSS documents were not submitted in a timely manner.