Inaccurate MDS Coding for PASRR Level II Status and Hospice Services
Penalty
Summary
The facility failed to accurately code the MDS assessment for a resident with a documented PASRR Level II status. The resident’s EMR contained a PASRR Level II Determination Notification letter issued on 11/22/23 with no expiration date, and the resident’s diagnoses included schizophrenia and major depressive disorder. The resident’s care plan included a focus area indicating a Level II PASRR status related to serious mental illness due to schizophrenia, initiated on 3/25/25. Despite this, the resident’s most recent annual MDS dated 11/15/25 was coded to indicate that the resident was not considered by the state Level II PASRR process to have a serious mental illness or related condition. During interviews, the DON stated she believed a corporate MDS nurse had completed the assessment, and the social worker confirmed upon review that the resident did have a PASRR Level II status. The facility also failed to accurately code hospice services on the MDS for another resident. This resident was admitted with a diagnosis of cerebrovascular disease and had a care plan, last updated on 06/14/2024, that documented a terminal prognosis related to cerebrovascular disease and enrollment in hospice services. Physician orders dated 06/12/2024 confirmed hospice admission, and a hospice recertification dated 10/27/2025 documented a certification period from 11/25/2025 to 01/23/2026, with a corresponding hospice physician order reflecting the same certification period. However, the resident’s quarterly MDS assessment dated 11/02/2025 did not reflect hospice services. In an interview, the DON verified that the resident was receiving hospice care and that the MDS should have been coded to reflect hospice services.
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