A resident with spina bifida, hydrocephalus, and cerebral palsy had PASRR II recommendations for a customized manual wheelchair plus OT and PT, but the facility’s NFSS submissions were denied because required signatures were missing, requests were not responded to, and assessments expired before authorization. Staff interviews showed the ADM had no PASRR policy and the MDS nurse was unsure how PASRR specialized services and timelines worked.
Two residents with cerebral palsy and cognitive impairment had PASRR-related IDT meetings that identified NFSS such as customized wheelchairs, DME, and specialized OT/PT/ST services, but the facility did not submit the NFSS requests in the LTC portal within the required timeframe. The MDS nurse and DOR both stated they were unfamiliar with the process, and the ADM said the late submissions may have been related to staffing changes.
A resident with PASRR positive IDD status and multiple medical diagnoses had an IDT meeting where specialized services, including CMWC and DME, were agreed upon, but the NF did not submit the NFSS request within the required timeframe. Email records showed HHSC PASRR notified the facility that it was out of compliance because the request had not been received, and staff interviews confirmed confusion after the MDSC who attended the meeting left the facility.
A resident with PASRR positive status, severe cognitive impairment, and mobility limitations did not have the recommended NFSS for a customized manual wheelchair timely submitted through the LTC Online Portal. The DOR and DON stated the request process began with an IDT meeting and therapy evaluation, but the form was incomplete and did not go through within the required timeframe, delaying the resident’s specialized service request.
Failure to Complete PASARR Specialized Service Referrals: The facility did not incorporate PASARR level II recommendations into the assessment, care plan, and care coordination for two PASARR-positive residents. One resident had Mild Intellectual Disabilities with a BIMS of 8 and was receiving therapy, while the other was rarely understood and could not complete a BIMS. The DOR and MDS nurse coordinator reported that therapy evaluations and portal referrals were not completed as expected after the IDT meeting, and one resident’s customized wheelchair process was delayed.
A resident with severe cognitive impairment, CP, and epilepsy was PASRR positive for ID/DD, and the IDT agreed to specialized services and a pressure-reducing mattress. However, the facility did not timely submit the PASRR NFSS request in the TMHP portal, and PASRR compliance staff documented that no request had been submitted despite the agreed-upon PT, OT, ST, and DME needs.
PASRR coordination failed for a resident with DD, ID, CP, aphasia, and severe cognitive impairment. The MDS nurse completed the PL1, PE, and IDT process, but the NFSS form was not submitted in the portal after the IDT meeting, and HHSC later notified the facility that the form had not been received. Staff reported the prior MDS nurse started the process but did not finish it, and the form was later uploaded but not submitted because it was not going through due to the resident's Medicaid-pending status.
PASRR specialized services were not properly incorporated into a resident’s assessment, care plan, and transitions of care. A resident with cerebral palsy, severe ID, and other chronic conditions had a PASRR Level II finding requiring specialized services, and the IDT identified PT/OT-related needs and DME. However, the NFSS request in the LTC portal was not completed within the required timeframe, the portal was reopened for resubmission, and the submission remained incomplete and not closed.
The facility failed to coordinate PASRR assessments and submit NFSS requests for two PASRR-positive residents with cognitive impairment and wheelchair needs. Their records showed care plans and HSPs noting specialized services and CMWC requests, but the DOR said the forms were not submitted because the DME vendor had not returned to finish measurements and she did not know the 20-business-day deadline. The vendor confirmed delays in completing the measurements, and the residents’ RP and HC said the wheelchair process was still pending.
PASARR screening was not completed accurately and timely for a resident with major depressive disorder and a history of TBI. The MDS Coordinator said the resident should have had a positive Level I and that PASARR should be done within 72 hours of admission, but the prior PASARR from the sending facility was incorrect and a new PL1 was generated later. The resident’s IDT also approved PT, OT, ST, and DME, but PASRR compliance records showed the facility had not requested specialized services within the required timeframe.
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