Failure to Accurately Code PASRR Level II Status and Update Care Plan
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment regarding Preadmission Screening and Resident Review (PASRR) Level II status for two residents. Specifically, for one resident with a history of major depressive disorder, generalized anxiety disorder, and vascular dementia, the PASRR Level II Determination Notification initially indicated a need for specialized services and a 90-day placement approval. However, after a subsequent PASRR determination changed the authorization code from F to H, indicating no restrictions due to a primary diagnosis of dementia, the facility did not update the resident's care plan to reflect the new PASRR status or provide guidance for future care decisions related to PASRR. The care plan did not address the resident's current PASRR status or recommendations from the determination letter. Staff interviews revealed that the facility's practice was not to report residents with PASRR authorization codes of H or B as having a PASRR Level II status on the MDS assessment, which led to the omission of PASRR findings from the care plan. The MDS nurse and Director of Clinical Services confirmed that the resident's care plan was not updated after the PASRR code changed, and the Administrator acknowledged awareness of the issues related to both MDS reporting and care planning for PASRR Level II status.