Failure to coordinate PASRR services and document required meetings affected three residents with IDD or related conditions. One resident with spina bifida and IDD had no documented annual PCSP meeting in the prior year, another resident with mild intellectual disabilities and mental health diagnoses had no documentation of quarterly PASRR PCSP meetings, and a third resident with IDD had no documentation of habilitation coordination or independent living skills training notes despite those services being recommended. Interviews confirmed the facility lacked a system to track the coordinator’s visits and required PASRR meeting documentation.
A resident who was PASRR positive related to IDD had a care plan calling for coordination of specialized services, but the facility did not incorporate PASRR recommendations into assessment, care planning, or transitions of care. A PCSP showed OT and PT were newly requested and agreed upon at a quarterly meeting, yet the LTC portal had no record of a specialized services request for therapy afterward. Staff interviews showed the MDS Coordinator, former MDS Coordinator, Habilitation Coordinator, and DON were unaware of or not trained on the PASRR requirements tied to the requested services.
Failure to Submit PASRR NFSS Request Within Required Timeframe: The facility failed to submit a complete and accurate NFSS request in the LTC portal within the required 20 business days after the PASRR IDT meeting for a resident with Down Syndrome, Alzheimer's disease, dementia, severe cognitive impairment, and mobility needs. The State PASSR Specialist and email correspondence confirmed the request was not submitted on time, and the DON stated another IDT meeting was held because the original deadline had passed.
Failure to coordinate PASRR screening for a resident with mental health diagnoses. A resident with bipolar disorder, anxiety disorder, and moderate cognitive impairment had a PASRR Level I screening that did not identify mental illness. The MDS Nurse, who served as the PASRR Coordinator, stated the screening was completed as negative and could not explain why a new PL1 was not drafted after the diagnoses were identified. The DON and ADM stated the MDS Nurse was responsible for reviewing PASRR accuracy and submitting a PL1 when a resident had a new MI.
A resident with bipolar disorder, major depressive disorder, and a PASRR Level I screening positive for Mental Illness did not have a PASRR Level II evaluation completed. The resident’s MDS also identified PASRR Serious Mental Illness, and the DON and MDS Coordinator stated the Level II review should have been completed, but it was not. The facility did not have a PASRR policy when requested.
A resident with Down syndrome, myasthenia gravis, dementia, and severe functional dependence was identified as PASARR positive and approved for a customized wheelchair at the IDT meeting, but the NFSS specialized service was not initiated within the required timeframe. Interviews showed the wheelchair was not ordered after the IDT decision, the MDS nurse was responsible for PASARR referrals, and no backup person was assigned to ensure PASARR II services were completed.
PASARR Level I screenings for two residents did not accurately reflect their mental health diagnoses. One resident had bipolar disorder and the other had major depressive disorder, but both PASARR screens stated there was no mental illness, and their MDSs and care plans did not address the mental illness. The MDS coordinator, DON, and ADM stated that a new PASARR screening should be completed when a resident has a new diagnosis.
Incorrect PASRR Screening for a Resident with Schizoaffective Disorder: A resident with anxiety, depression, schizoaffective disorder, and COPD had a PASRR Level 1 screening that incorrectly marked mental illness as absent, despite the diagnosis being present on admission. The resident’s care plan also addressed mood problems and psychotropic medication use, and the MDS C and DON stated the PASRR was incorrect and should have reflected the need for a PASRR Level 2 assessment.
PASARR screening was not updated for a resident with psychotic disorder and major depressive disorder. The resident’s MDS showed moderate cognitive impairment, and the care plan noted depression, anxiety, and psychotropic use. Staff relied on an older PASARR Level One Screening that was negative for MI/ID/DD and did not complete a new screening after learning of the resident’s mental illness diagnosis.
PASRR specialized services were not properly incorporated into a resident’s assessment and care planning, and the NFSS request was not submitted within the required timeframe after the IDT meeting. The resident had severe cognitive impairment, multiple neuropsychiatric and neurologic diagnoses, and was identified as PASARR positive with new needs for OT, PT, ST, and habilitation coordination. Interviews showed the MDS nurse, DON, Administrator, and Director of Rehabilitation were aware of the PASRR process, but the facility did not complete the portal request on time and there was confusion about the resident’s service status.
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