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F0645
D

Failure to Complete PASRR Requirements for Residents with Mental Illness

Weyauwega, Wisconsin Survey Completed on 04-17-2025

Penalty

5 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. For one resident with a diagnosis of bipolar disorder and moderate cognitive impairment, the medical record included a PASRR Level I Screen indicating a major mental disorder and a 30-day exemption, but did not contain the required County form F-20822 or a PASRR Level II Screen. The Social Services Director reported submitting the exemption request but did not receive confirmation, and the Level II Screen was only submitted after the surveyor's inquiry. Similarly, another resident with adjustment disorder and depression, who was receiving duloxetine, had a PASRR Level I Screen indicating mental illness and a 30-day exemption, but the medical record lacked both the required exemption form and a PASRR Level II Screen. The Social Services Director also stated that the exemption request was submitted without confirmation and the Level II Screen was not obtained until prompted by the surveyor. These omissions resulted in the facility not meeting federal and state PASRR requirements for residents with mental illness.

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