Inaccurate MDS Coding for Residents With Level II PASRR Determinations
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents who had Level II Preadmission Screening and Resident Review (PASRR) determinations documented in their records. One resident was admitted with diagnoses including intellectual disabilities, schizophreniform disorder, depression, anxiety, and dementia. The resident’s electronic health record showed a Level II PASRR determination with no end date completed prior to admission. However, the admission MDS did not code the resident as having a Level II PASRR determination, even though the MDS listed multiple psychiatric and cognitive diagnoses. In an interview, the MDS nurse acknowledged that the resident should have been coded for a Level II PASRR and stated the omission was an oversight. The second resident was admitted with diagnoses including depression, schizoaffective disorder, dementia, and psychosis. This resident’s electronic health record also contained a Level II PASRR determination with no end date. The resident’s care plan included a plan for Level II PASRR recommendations related to serious mental illness, with a goal that the resident would receive recommended care and services and interventions such as ADL support and therapy services as needed. Despite this, the resident’s annual MDS did not code the resident as having a Level II PASRR determination, although it documented several psychiatric diagnoses. In an interview, the MDS nurse confirmed that this resident also should have been coded for a Level II PASRR determination and again described the error as an oversight.
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