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F0641
D

Inaccurate Coding of MDS Assessments for Hospice and PASRR Status

Black Mountain, North Carolina Survey Completed on 05-30-2025

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 accurately code Minimum Data Set (MDS) assessments for three residents in the areas of hospice care and PASRR (Preadmission Screening and Resident Review) status. For one resident with diabetes mellitus who was certified for hospice care, the quarterly MDS assessment did not indicate that the resident was receiving hospice services, despite documentation and staff confirmation that hospice care was being provided. The MDS Coordinator acknowledged the oversight and stated that hospice care should have been reflected in the assessment. For two other residents with diagnoses including schizoaffective disorder, bipolar disorder, delusional disorder, anxiety disorder, and major depressive disorder, both had valid Level II PASRR determinations indicating serious mental illness. However, their respective MDS assessments failed to indicate their Level II PASRR status. The MDS Coordinator confirmed these omissions and noted that the assessments were completed by a previous coordinator who was no longer employed. The Administrator confirmed that MDS assessments are expected to be coded correctly.

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