Failure to Accurately Code Resident Discharge and Transmit Correction to CMS
Penalty
Summary
The facility failed to properly code a resident's discharge in accordance with its policy and federal requirements. Specifically, for one resident with multiple chronic conditions, the Minimum Data Set (MDS) was inaccurately coded as a discharge to a hospital when the resident had actually been discharged home. The facility's policy requires that discharge assessments be completed using the discharge date as the Assessment Reference Date (ARD) and that corrections be transmitted to CMS if errors are identified. However, no correction transmittal was sent to CMS for this resident, and the error was not identified or corrected in a timely manner. Interviews with the MDS Coordinator and Remote MDS Coordinator revealed uncertainty and oversight regarding the correct discharge coding for the resident. The MDS Coordinator was unsure why the resident was coded as a hospital discharge, and the Remote MDS Coordinator acknowledged that the discharge should have been coded as 'return not anticipated' and that a correction should have been made. The DON stated that she expected the MDS process to be checked and rechecked to ensure accuracy, but this did not occur in this instance.