Quarterly MDS Assessment Failed to Reflect Hospice Services
Penalty
Summary
The facility failed to accurately complete the Quarterly Minimum Data Set (MDS) assessment for one resident who was receiving hospice services. Review of the facility's policy on Maintaining Minimum Data Set (MDS) Assessments showed that it addressed record maintenance and retention but did not provide guidance to ensure accurate coding of services, such as hospice care, on Quarterly MDS assessments. The electronic medical record indicated that the resident was admitted to hospice services, but the corresponding Quarterly MDS assessment did not reflect this in section O, which covers Special Treatments, Procedures, and Programs. Staff interviews confirmed that hospice services were not coded on the assessment, and both the MDS RN and DON acknowledged the importance of accurate MDS coding for care planning.