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F0641
D

Inaccurate PASRR Coding on MDS Assessments

Wilmington, North Carolina Survey Completed on 06-23-2025

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 in the area of Preadmission Screening and Resident Review (PASRR) for two residents. For one resident with diagnoses of anxiety, depression, and bipolar disorder, the electronic health record showed a completed Level II PASRR, and the care plan included interventions and goals based on this status. However, the annual MDS assessment did not reflect the resident's Level II PASRR status. The social worker, responsible for coding PASRR status on the MDS, stated she had a list of Level II PASRR residents but could not explain why the resident was not coded correctly, attributing it to an oversight. The administrator confirmed the expectation that MDS assessments, including PASRR coding, be completed accurately. Similarly, another resident with diagnoses of psychosis and hallucinations had a completed Level II PASRR and a care plan addressing the associated needs and interventions. Despite this, the annual MDS assessment did not indicate the resident's Level II PASRR status. The social worker again acknowledged responsibility for coding but could not account for the omission, stating it was likely missed. The administrator reiterated the expectation for accurate completion of MDS assessments, including PASRR status.

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