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F0641
D

Inaccurate MDS Coding for PASRR Status

Emmett, Idaho Survey Completed on 08-08-2025

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 ensure the accuracy of a resident's Minimum Data Set (MDS) assessment, specifically in Section A1500 regarding PASRR (Preadmission Screening and Resident Review) status. A resident admitted with diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence had a PASRR Level II documented in the electronic medical record. However, the admission MDS assessment incorrectly indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This inaccuracy was confirmed by the Director of Clinical Services, who acknowledged the MDS was coded incorrectly. The deficiency was identified through review of the RAI Manual, record review, and staff interview, and was found to be true for one of three residents whose records were reviewed for assessment accuracy.

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