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F0645
D

Failure to Ensure Timely and Accurate PASRR Screening and Documentation

Oshkosh, Wisconsin Survey Completed on 05-14-2025

Penalty

No penalty information released
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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 compliance with Pre-admission Screening and Resident Review (PASRR) requirements for three residents with mental illness (MI) diagnoses and/or prescribed psychotropic medications. For these residents, the facility did not update PASRR Level I Screens to reflect changes in prescribed medications and did not submit timely PASRR Level II Screens when the residents remained in the facility beyond 30 days. Additionally, the facility did not obtain required county exemption forms (DHS form F-20822) upon admission for these residents. One resident with major depressive disorder and moderate dementia was admitted with a PASRR Level I Screen indicating MI and psychotropic medication use, but the screen was not updated when medications changed, and a Level II Screen was not submitted in a timely manner. Another resident, admitted with a diagnosis of acute respiratory failure but prescribed psychotropic medications for depression and anxiety, had a PASRR Level I Screen marked for MI and a 30-day hospital exemption, but the Level II Screen was not submitted until after the resident remained in the facility past 30 days. The required county exemption form was also not provided at admission. A third resident with a history of depression and OCD with skin picking was prescribed multiple psychotropic medications, but the PASRR Level I Screen did not reflect all current medications or MI diagnoses. The facility did not update the Level I Screen with new medications, did not submit a Level II Screen, and did not provide the county exemption form. Throughout the survey, the facility was unable to provide complete PASRR documentation or exemption forms for these residents despite multiple requests.

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