Inaccurate MDS Coding for Pneumococcal Vaccination Status
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) assessments related to pneumococcal vaccination status and cognitive assessment for three residents. For one resident admitted in 2016, a quarterly MDS with an Assessment Reference Date (ARD) in December 2025 documented that staff could not determine the resident’s Brief Interview for Mental Status (BIMS) score and indicated the resident was up to date on pneumococcal vaccination. However, the electronic medical record (EMR) immunization section showed only a PPSV23 vaccine given in 2019, with no evidence that the resident or representative had been offered PCV13 before age 55 or PCV20/PCV21 after age 55, as referenced in CDC guidance. For another resident admitted in 2018, the EMR showed a PPSV23 vaccine given in 2015, but there was no evidence in the record that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. The quarterly MDS for this resident, with an ARD in October 2025 and a BIMS score of 12 (moderate cognitive impairment), left blank the section that identifies whether the resident was offered or was up to date on pneumococcal vaccination. A third resident, admitted in 2008, had an EMR immunization record showing PPSV23 administration in 2015, with no evidence that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. Despite this, the quarterly MDS with an ARD in December 2025, which documented a BIMS score of 9 (moderate cognitive impairment), indicated that the resident was up to date on pneumococcal vaccination. During an interview, the MDS Coordinators stated they obtained pneumococcal vaccine information from the clinical record and relied on its accuracy, noting that influenza vaccine information was easier to locate because it appeared on the Medication Administration Record. One MDS Coordinator acknowledged not being familiar with CDC recommendations for pneumococcal vaccination. These findings, combined with the RAI Manual and CDC guidance cited in the report, demonstrate that the facility failed to ensure accurate MDS coding for pneumococcal vaccination status for the three residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.