Health inspection·April 22, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to coordinate assessments in which a PE was not conducted after the pre-admission screening indicated a yes for intellectual disability and resident review (PASARR) program under Medicaid for 1 (Resident #1) of 3 residents reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting on 05/28/24. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet dated 4/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating her cognition was intact and diagnoses of cerebral palsy (a condition that affects muscle control, movement, and posture due to brain damage that usually happens before or during birth), non-Alzheimer's dementia (a type of memory loss or brain decline that isn't caused by Alzheimer's disease), hemiplegia (paralysis on one side of the body) and hemiparesis (with weakness on one side of the body), traumatic brain injury (a serious injury to the brain caused by a bump, blow, or jolt to the head), anxiety (feeling of constant worry, nervousness, or fear that doesn't go away), and depression (mood disorder that causes persistent sadness and loss of interest). Record review of Resident #1's PASRR Level 1 Screening Summary dated 3/5/24 revealed Primary Diagnosis of Dementia - Marked Yes under Section C, field C0900; Indicators of Intellectual Disability Marked Yes under C0200; Indicators of a Developmental Disability (Related Condition) - Marked Yes under C0300. Record review of Resident #1's PASRR Evaluation dated 03/06/2024 revealed she met the criteria for IDD. Local Authority Compliance Confirmation was completed 03/08/2024 with comment PASRR services to include participation in IDT meetings, habilitation services, and monitoring for transition to the community if appropriate. Record review of Resident #1' PCSP dated 5/28/24 revealed the team certified the need for habilitative therapies were discussed. Resident #1 was receiving OT services and was to be assessed for ST. Page 1 of 4 676468 676468 04/22/2025 Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 had expressed a desire to continue OT within the facility and preferred receiving services in her room, as she did not want to be away from her room or wheelchair for extended periods. The DOR and habilitation coordinator indicated the resident had been receiving therapy and would begin ST to support continued functioning. Record review of Resident #1's care plan revealed Resident #1 was identified as PASRR-positive due to an intellectual/developmental disability related to cerebral palsy. The care plan included maintaining the highest practicable level of wellbeing for the next 90 days. Interventions also included evaluating the need for habilitative services and/or durable medical equipment to support functional maintenance, and utilization of all available community resources. Record review of Resident's #1's visit details report with date range 3/1/24-6/30/24 revealed she received a total of 29 documented OT sessions between March 1, 2024, and May 29, 2024 with no documented missed or incomplete visits and was scheduled for 9 speech therapy sessions between May 28, 2024, and June 14, 2024, of the 9 scheduled sessions, 8 were completed and 1 session (June 14, 2024) was marked as missed. Record review of Resident #1's Occupational Therapy Discharge Summary with date of service range of 3/27/2024 - 5/29/2024 revealed she was discharged from services on 5/29/24 due to highest practical level achieved. She required continued support for ADLs but was appropriate for ongoing care at the LTC facility with 24-hour supervision and continued monitoring by nursing. Record review of Resident #1's Speech Therapy Discharge Summary with date of service range of 5/28/24-6/13/24 revealed she was discharged from services on 6/13/24 due to refused treatment. During an interview on 4/16/25 at 10:02 am, Resident #1 was alert and oriented ×4 but did not answer direct questions related to PASRR, OT, or ST. During an interview on 4/16/25 at 1:43 pm, the DON stated Resident #1 was identified as a potential PASRR-positive case following the submission of a PL1, which triggered a portal alert to Emergence. The DON stated Local Mental Health Authority contacted the facility requesting Resident #1's demographics, diagnosis, medication list, and face sheet in order to conduct a PASRR evaluation. The DON stated that following Emergence's assessment, Resident #1 was determined to be PASRR-positive, requiring an annual IDT meeting with Local Mental Health Authority present, per regulation. The DON stated during the IDT, the LIDDA representative recommended habilitative services, including OT and ST. The DON stated an NFSS form was initiated to request authorization for therapy services to be reimbursed under PASRR. The DON stated the NFSS forms for Resident #1 were left in draft status and never submitted, resulting in no official authorization for payment, despite Resident #1 receiving therapy services consistently from March 2024 to June 2024. The DON stated the current MDS and therapy staff, including the DOR and MDS Coordinator, were not employed at the time and were unaware of why the forms were not submitted. The DON stated it was discovered that former staff may have assumed Resident #1's refusal of services negated the need for NFSS submission. The DON stated during the care plan meeting, all service sections related to specialized therapies and durable medical equipment were left blank. The DON stated the habilitation coordinator documented Resident #1 was already receiving OT and would be assessed for ST. The DON stated Resident #1 expressed a desire to continue residing in the facility and participating in OT. The DON stated the IDT meeting notes indicated the continuation of services already in place, rather than the initiation of new habilitation therapies, which likely contributed to the decision not to submit the NFSS form at that time. The DON stated a signature from the LIDDA representative dated 03/25/24 confirmed Resident #1's participation in the IDT and 676468 Page 2 of 4 676468 04/22/2025 Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her request to continue OT, with ST to be initiated following that evaluation. The DON stated completion and submission of the NFSS form was a joint responsibility between the MDS Coordinator and therapy department. The DON stated the MDS Coordinator was responsible for completing the nursing section, while the respective therapy disciplines complete their sections based on IDT recommendations. The DON stated if only one therapy discipline was recommended, such as OT, only that section was completed before the form was submitted. The DON stated the NFSS was not submitted within the 20-day requirement; however, Resident #1 was already receiving therapy services as of March 2024. The DON stated there was no interruption in care and the failure to submit the NFSS did not pose a direct risk to Resident #1. During an interview on 4/16/25 at 2:49 pm, the MDS Coordinator stated the PASRR process begins at admission, and they are responsible for initiating PASRR entries. The MDS Coordinator stated the initial form determined whether a resident was PASRR-negative or PASRR-positive. The MDS Coordinator stated PASRR-positive determinations typically involved residents with major mental illness or IDD diagnoses and triggered involvement from external agencies such as Emergence. The MDS Coordinator stated for PASRR-positive residents, quarterly care plan meetings and annual IDT meetings were conducted to reassess therapy needs and care planning. The MDS Coordinator stated the NFSS was generally completed after the annual IDT meeting and must be submitted within 20 days. The MDS Coordinator stated they were responsible for initiating and submitting the NFSS, while the therapy department completed the therapy-specific sections based on the IDT recommendations. The MDS Coordinator stated although employed during the March 2024 timeframe, they were not part of the MDS team and were not involved in the handling of the NFSS form. The MDS Coordinator stated the NFSS form for Resident #1 was not submitted but stated Resident #1 continued to receive therapy services throughout that period. The MDS Coordinator stated the failure to submit the NFSS within the 20-day period was a compliance issue affecting documentation and potential reimbursement but did not impact Resident #1's care. During an interview on 4/16/25 at 3:46 pm, the DOR stated they were unaware of any NFSS submission delay following the May 2024 IDT meeting for Resident #1 and were unsure who was responsible at the time due to it being before her time working at the facility. The DOR stated Resident #1 received therapy services from 03/04/24 to 06/14/24, according to available documentation. The DOR stated that NFSS authorizations were typically approved for a six-month to one-year period and may be reviewed again during future IDT meetings. The DOR stated the NFSS was not submitted within the required 20-day timeframe following the May 2024 IDT meeting. The DOR stated there was no direct risk to Resident #1, as therapy services were habilitative in nature and aimed at maintaining her current level of functioning. The DOR stated Resident #1 received therapy throughout the identified period. The DOR stated the NFSS delay was a documentation compliance issue and did not impact care. The DOR stated ST services were discontinued on 06/14/24 due to refusals, and OT services were also discontinued at that time. During an interview on 4/16/25 at 4/22/25 at 9:42 am, the Administrator deferred the PASSR related questions to the DON. Record review if the facility's PASSR policy dated 06/2022 did not mention any 20-day deadline related to the NFSS (Nursing Facility Specialized Services) or submission timeframes for PASSR Level II evaluations or recommendations. Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-profession revealed: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, 676468 Page 3 of 4 676468 04/22/2025 Avir at Patriot 11490 Gateway North Blvd. El Paso, TX 79934

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures). 676468 Page 4 of 4