Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with significant mental health diagnoses. Specifically, the MDS for a female resident with a history of bipolar disorder, schizophrenia, delusional disorder, and anxiety disorder was incorrectly coded in the PASRR (Preadmission Screening and Resident Review) section. The assessment marked that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation in the care plan indicating that the resident was PASRR positive and receiving habilitation coordination and independent living skills training. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Specialist, Regional Compliance Nurse, and Administrator, confirmed that the MDS should have been marked to reflect the resident's PASRR status. The Administrator acknowledged that monitoring of MDS accuracy was done through random audits or spot checks but could not recall the last audit performed. There was no specific policy or procedure in place regarding MDS assessment accuracy, and the facility relied on the RAI manual for guidance.