Inaccurate MDS Assessments for PASRR and Hospice Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with cerebral palsy and a developmental disability, the Comprehensive MDS assessment did not indicate her Level II PASRR status, despite documentation in her care plan and PASRR evaluation confirming she was PASRR positive. For another resident with chronic obstructive pulmonary disease and generalized anxiety disorder, the Quarterly MDS assessment did not reflect that he was receiving hospice services, even though his order summary, care plan, and hospice documents all indicated he had been admitted to hospice care. Interviews with the MDS Coordinator revealed that these inaccuracies were due to data entry errors and oversight, with the Coordinator acknowledging awareness of the correct statuses but failing to code them properly. The facility relied on spot checks and audits for oversight, but not every MDS assessment was reviewed. The Administrator confirmed that the MDS Coordinator was responsible for accurate completion of assessments and that errors in coding could affect residents' function and diagnoses. The Regional Compliance Nurse stated there was no specific policy for MDS accuracy, and that the facility followed the RAI manual.