Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was accurately coded to reflect the presence of a Preadmission Screening and Resident Review (PASRR) Level II. According to the CMS Long-Term Care Resident Instrument 3.0 Manual, residents with a PASRR Level II determination for serious mental illness or intellectual disability must be coded accordingly on the MDS. The resident in question was admitted with diagnoses including depression, adjustment disorder, and psychotic disorder, and was later diagnosed with schizophrenia. A PASRR Level II Service Determination completed for the resident indicated a diagnosis of serious mental illness, specifically schizophrenia. Despite this, the resident's annual MDS assessment was marked as 'No' for the question regarding current PASRR Level II status. During an interview, a social services staff member confirmed that the resident was indeed a Level II as of the PASRR determination date and acknowledged that the MDS should have been coded to reflect this status. The staff member also noted the importance of accurate coding for tracking and ensuring appropriate mental health services for residents with such diagnoses.