Inaccurate MDS Documentation of PASARR Level II Determinations
Penalty
Summary
The facility failed to ensure that residents' Minimum Data Set (MDS) assessments accurately reflected the presence of a PASARR (Preadmission Screening and Resident Review) level II determination for serious mental illness, as required by the Resident Assessment Instrument (RAI). Specifically, two residents with documented PASARR level II determinations in their medical records had their MDS assessments incorrectly marked as 'no' in section A1500, which should have been marked 'yes' according to the RAI guidelines. One resident had a diagnosis of bipolar disorder and a completed PASARR level II, while another had multiple diagnoses including dementia, anxiety, and depression, and also had a PASARR level II on file. The MDS Coordinator stated that she was unaware that the presence of a PASARR level II required marking 'yes' at A1500, leading to the inaccurate documentation for both residents.