Inaccurate MDS Coding of PASRR Level II Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident’s Preadmission Screening and Resident Review (PASRR) status. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder. A PASRR Level II Determination Notification letter dated 11/14/23 documented that the resident had a PASRR number ending in the letter H, indicating a halted PASRR Level II determination due to a primary diagnosis of dementia. Despite this, the resident’s most recent comprehensive significant change MDS assessment reported that the resident was not determined to have a PASRR Level II status. During an interview, the MDS nurse reviewed this assessment and confirmed it was incorrect and should have indicated a PASRR Level II status, and the DON stated she would expect residents’ MDS assessments to be accurate. This inaccurate coding of the PASRR Level II status on the MDS, despite existing documentation of the resident’s PASRR determination and diagnoses, constitutes the cited deficiency.
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