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F0641
D

Failure to Accurately Code PASRR Level II Status on MDS Assessments

High Point, North Carolina Survey Completed on 07-24-2025

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 accurately code the Minimum Data Set (MDS) assessments regarding Preadmission Screening and Resident Review (PASRR) Level II status for two residents. For one resident with a diagnosis of major depressive disorder, a PASRR Level II Determination Notification letter indicated a Level II status with no expiration date. However, both the annual and most recent comprehensive MDS assessments incorrectly reported that the resident did not have a PASRR Level II status. The MDS nurse confirmed that the assessments did not reflect the correct PASRR status due to a misunderstanding of the authorization codes, specifically not recognizing codes ending in 'H' or 'B' as indicative of Level II status. Similarly, another resident with diagnoses including bipolar disorder, major depressive disorder, post-traumatic stress disorder, and dementia had a PASRR Level II Determination Notification letter indicating Level II status. The annual MDS assessment for this resident also failed to report the correct PASRR Level II status. The MDS nurse acknowledged that the facility's previous practice was not to report certain PASRR authorization codes as Level II, and was unaware that these codes should be reported as such on the MDS assessment. The administrator was made aware of the issue during the survey.

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