Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
The facility failed to accurately code the MDS assessment for hospice care for one resident. The resident was admitted with chronic ischemic heart disease and COPD, and the electronic medical record showed that the responsible party signed a Hospice Admission Agreement and the resident transitioned to hospice services on 09/08/2025. On the same date, the resident’s care plan was revised to reflect a focus that the resident required hospice care and would be kept comfortable. However, review of the resident’s quarterly MDS assessment dated [DATE] showed hospice services were not indicated. The responsible party reported that the resident had been receiving hospice care since the previous fall and received weekly updates from the hospice nurse. The MDS Coordinator confirmed, upon review of the quarterly MDS, that hospice services had not been captured and stated the MDS was coded incorrectly and should have indicated the resident was receiving hospice services. The Administrator stated her expectation was that all MDS assessments be completed accurately based on the resident’s clinical condition.
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