Inaccurate MDS Coding for Hospice and PASRR Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code Minimum Data Set (MDS) assessments for hospice status and PASRR Level II determinations for four residents. One resident who had been initially admitted to hospice and recertified for continued hospice services did not have hospice services reflected on a quarterly MDS assessment. Another resident, admitted to hospice several months earlier and recertified for hospice services, had a quarterly MDS that did not indicate a condition or chronic disease with a life expectancy of less than six months and did not show that hospice care was being received. A third resident elected hospice services, as documented in a hospice agreement, and a significant change MDS was completed due to this election; however, the MDS did not indicate that the resident was receiving hospice care. The facility also failed to accurately code PASRR information for a fourth resident. This resident had a Level II PASRR determination letter with no expiration date, but the annual MDS assessment did not reflect that the resident was currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. In interviews, the Regional MDS Consultant, MDS Coordinator, and MDS RN acknowledged that each of these MDS assessments should have reflected the residents’ hospice status or Level II PASRR status and characterized the errors as oversights. The DON and Administrator each stated they expected MDS assessments to be coded accurately.
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