Inaccurate MDS Coding for Hemodialysis Treatment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for one resident. Specifically, a review of the resident's Admission MDS assessment showed that the section for Special Treatments, Procedures, and Programs did not indicate that the resident was receiving hemodialysis. However, a physician's order dated prior to the assessment confirmed that the resident was scheduled for hemodialysis three times a week at a contracted dialysis facility. During interviews, the MDS Coordinator acknowledged that the MDS assessment was coded incorrectly and verified the omission. The Director of Nursing (DON) was also informed and acknowledged the findings. The facility's policy required that all assessments accurately reflect the resident's status at the time of assessment, but this was not followed in this instance, potentially impacting the development of individualized care plans for the resident.
Plan Of Correction
F641 - Accuracy of Assessments How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On 6/18/2025, The MDS Coordinator modified the Admission/5-day MDS assessment with ARD of 6/6/2025 to reflect the dialysis status for Resident 399. How the Facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents that are on Dialysis could be affected by the deficient practice. On 6/18/2025, the MDS Coordinator conducted an audit of the MDS assessments of all residents that have dialysis to ensure that the MDS assessments are coded accurately to reflect resident's dialysis status. Out of 2 residents, 1 was modified and transmitted to reflect accurate coding in resident's dialysis status and the other 1 MDS assessment was coded accurately. What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur: On 6/18/2025, the MDS Consultant provided an In-service to the MDS Coordinator and MDS staff regarding dialysis and MDS coding per RAI Manual. MDS coding accuracy per RAI Manual was emphasized during the In-service. How the Facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficient practice will not recur: The MDS Coordinator will conduct quarterly and annual audits of residents who have dialysis to ensure that MDS assessments accurately reflect the resident's dialysis status. Any findings will be corrected and reported to the Director of Nursing (DON) and will be presented at the Monthly facility Quality Assurance meeting for further discussion and action plans as appropriate.