Inaccurate MDS Coding for PASARR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding serious mental illness and intellectual or developmental disability. A review of the resident's medical records showed an admission with multiple psychiatric diagnoses, including severe depression with psychotic features, major depressive disorder, persistent mood disorder, borderline personality disorder, anxiety, and bipolar disorder. The resident's Pre-admission Screening and Resident Review (PASARR) indicated a Level II determination, confirming that the individual met state criteria for intellectual/developmental disability. Despite this, multiple MDS assessments for the resident, conducted on three separate dates, were coded as 'no' in section A1500, indicating the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability. This discrepancy was confirmed during an interview with an LPN, who acknowledged that the PASARR information was incorrectly coded and did not accurately reflect the resident's status as determined by the state process.