Inaccurate PASRR Level II Coding on MDS Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASRR) Level II assessment was accurately coded on the Minimum Data Set (MDS) assessment. The resident, who had diagnoses of post-traumatic stress disorder (PTSD) and bipolar 2 disorder and was receiving medications for these conditions, had a PASRR Level II assessment completed as required. However, interviews with facility staff revealed that the PASRR Level II information was not properly documented in the MDS assessments. The social worker designee stated that while she completed the PASRR Level II assessments for her assigned unit, she did not document them in the MDS, leaving this responsibility to the RN coordinator. The RN coordinator confirmed that the resident's most recent comprehensive and quarterly MDS assessments were inaccurately marked and did not reflect the required PASRR Level II information, despite the resident having a qualifying diagnosis. Further review of facility policies indicated that all staff completing any portion of the MDS must sign to attest to its accuracy, and the assessment coordinator is responsible for ensuring accurate and complete MDS data is transmitted to CMS. The director of nursing confirmed the expectation for accurate MDS documentation. The facility's PASRR policy also requires individualized screening and appropriate documentation for residents with mental illness or intellectual disabilities. The failure to accurately code the PASRR Level II assessment on the MDS resulted in incomplete and inaccurate resident assessment documentation.