Inaccurate MDS Assessment Coding for Hospice Services
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident. Record review showed that the resident was admitted with diagnoses including unspecified dementia, cognitive communication deficit, and chronic obstructive pulmonary disease, and had a terminal prognosis with an active hospice order. However, the resident's quarterly MDS assessment was incorrectly coded to indicate that the resident was not receiving hospice services, despite documentation in the care plan and clinical record confirming hospice enrollment. The MDS Coordinator confirmed during interview that this was an oversight, and the Director of Nursing stated that all MDS assessments are expected to be correctly coded according to the RAI manual.