Inaccurate MDS Coding of Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses listed an active diagnosis of viral hepatitis for a resident who had a history of Chronic Viral Hepatitis C but was not receiving any treatment or medication for this condition. Review of the resident's active orders confirmed there was no treatment in place for viral hepatitis. The MDS Coordinator acknowledged that the resident was admitted with a previous diagnosis but had not received any related treatment, and the Administrator confirmed that the diagnosis should not have been coded as active. According to the CMS LTCF RAI 3.0 User's Manual, only diagnoses with a direct relationship to the resident's current status or treatment should be coded as active.