Inaccurate Coding of MDS Assessments and PASARR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect the conditions and services of several residents. Specifically, for six residents with diagnoses including bipolar disorder, major depressive disorder, schizoaffective disorder, and PTSD, the most recent comprehensive or admission MDS assessments did not accurately code their Pre-Admission Screen and Resident Review (PASARR) Level II status, despite documentation indicating the presence of major mental illness. In one case, there was no PASARR Level I or II on file for a resident with a relevant diagnosis. The Regional MDS Consultant attributed these errors to a transition in the Social Service Director position, during which several items were incorrectly coded. Additionally, another resident with diagnoses such as senile degeneration of the brain and falls, who had an active hospice order and was receiving hospice services, was not coded as receiving hospice care on the MDS assessment. The MDS consultant confirmed that hospice services had started prior to the assessment, but the MDS did not reflect this status. Facility policy requires the RAI process to be used in accordance with specified formats and timeframes to ensure comprehensive and accurate assessments, but this was not followed in these instances.