Inaccurate Coding of MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for one of 17 residents reviewed for MDS accuracy. According to the facility's policy, all assigned disciplines are required to participate in the completion of the MDS assessment and verify the accuracy of their respective sections. In this case, a resident had a physician's order for hospice admission, but the corresponding MDS assessment did not indicate that the resident was receiving hospice services in Section O, which covers special treatments, procedures, and programs. The MDS Coordinator confirmed that the assessment was inaccurately coded and should have reflected the resident's hospice status. This deficiency was identified through record review and staff interview, specifically noting the discrepancy between the physician's order and the information documented in the MDS assessment.