Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including bipolar disorder, dementia, and mood disorder, the clinical record showed a PASARR Level II determination for serious mental illness. However, the annual MDS assessment did not indicate the resident as PASARR Level II, as section A1500 was incorrectly marked 'no.' The Clinical Reimbursement Director confirmed this was an error and acknowledged the absence of a specific MDS assessment coding policy, relying instead on the Resident Assessment Instrument (RAI) manual. For another resident with diagnoses including heart disease, chronic respiratory failure with hypoxia, and dementia, the clinical record indicated the resident was receiving hospice services. Despite this, the quarterly MDS assessment did not reflect hospice care in section O0110. The Clinical Reimbursement Director confirmed that hospice services were being provided during the assessment period and that the MDS should have been marked accordingly. Both deficiencies were identified through record review and staff interview, with reference to the RAI manual for correct coding procedures.