Inaccurate MDS Coding for PASRR Level II Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a Pre-Admission Screening and Resident Review (PASRR) Level II. Review of the resident's annual MDS indicated that Section A did not reflect that the resident had been evaluated by Level II PASRR and determined to have a serious mental illness or related condition, despite Section I documenting diagnoses such as anxiety disorder, depression, and bipolar disorder. Further review of the electronic medical record confirmed the resident's admission and a PASRR Level II approval date. During staff interview, the MDS Coordinator acknowledged being unaware of the PASRR Level II approval for the resident, resulting in the inaccurate coding on the MDS.