Late Submission of Resident Assessments
Summary
The facility failed to ensure timely submission of completed resident assessments to the Quality Improvement Evaluation Assessment Submission and Processing system. During the recertification survey conducted from August 12 to August 16, 2024, it was found that four out of six Minimum Data Set (MDS) submissions reviewed were not submitted to the Centers for Medicare and Medicaid Services (CMS) system within the required 14 days of completion. The specific residents affected were Resident #66, Resident #6, Resident #95, and Resident #9, whose assessments were completed between June 1 and June 4, 2024, but were only submitted on August 14, 2024. Interviews with facility staff revealed that the Director of Minimum Data Set and the Controller were responsible for the oversight. The Director stated that they follow the Resident Assessment Instrument manual for assessment completion and submission, and the Controller receives daily reports from Sigma Care listing MDS assessments needing submission. Both acknowledged the late submissions as an oversight, with the Controller unaware of the delay until the survey. This deficiency was documented under 10 NYCRR 415.11.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple complex medical conditions was discharged to a hospital with the intention of going home on hospice, but the facility failed to accurately code the discharge status on the MDS 3.0 assessment and did not submit a timely correction to reflect the true discharge disposition.
The facility did not complete or submit MDS assessments and associated CAAs within the required 14-day timeframes for multiple residents with various medical conditions, as verified by record review and staff interviews. These delays occurred despite facility policy requiring timely completion in accordance with the RAI User Manual.
A resident with aphasia, dementia, and atrial fibrillation did not have their MDS assessments completed or transmitted within the required timeframe. Both the January and April assessments were completed and submitted late, as confirmed by the MDS Coordinator.
Two residents did not have their MDS assessments completed and transmitted to the State within the required 14-day period. One resident with multiple medical conditions had both discharge-related MDS assessments left in progress and unsubmitted after leaving and returning to the facility, then being discharged home. Another resident with neurological and psychiatric diagnoses also had quarterly and discharge MDS assessments that were not finalized or transmitted on time. An LPN confirmed these delays in assessment completion and transmission.
A facility failed to timely complete and submit a discharge MDS 3.0 assessment for a resident with multiple diagnoses, including spinal stenosis and chronic heart failure. The assessment was finalized but not submitted, with all sections completed on a later date. The resident had returned from a leave of absence and reported not returning to the facility. The DON confirmed the assessment was missed and completed late.
The facility failed to complete discharge MDS assessments in a timely manner for two residents, affecting compliance with regulatory requirements. One resident with multiple diagnoses, including COPD and acute kidney failure, was discharged without a completed assessment. Another resident with conditions such as spinal fusion and cognitive communication deficit was also discharged without a timely assessment. An MDS nurse confirmed the delay in completing these assessments.
Failure to Accurately Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that the discharge Minimum Data Set (MDS) 3.0 assessment for one resident was completed accurately and that a correction was submitted in a timely manner to reflect the resident's actual discharge disposition. The resident, who had multiple diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, GERD, benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder, was admitted on 06/17/19. On 03/02/25, the resident was transported to a local hospital by critical transport, and the power of attorney was notified. The discharge MDS assessment completed on the same day was coded as 'discharge - return anticipated' and marked as an unplanned discharge. However, documentation indicated that the resident was discharged to the hospital with the intention of going home on hospice services, meaning the discharge should have been coded as 'return not anticipated.' No correction to the MDS assessment was completed at the time to accurately reflect this disposition.
Failure to Complete and Submit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes for all 11 residents reviewed. According to the findings, MDS assessments, including quarterly, annual, significant change, admission, and discharge assessments, were not completed or submitted within the 14-day period mandated after the assessment reference date (ARD) or relevant event, such as admission or discharge. In several cases, the Care Area Assessments (CAAs) associated with the MDS were also not completed within the required timeframe. Record reviews for each resident showed that the assessments were delayed, sometimes by several weeks beyond the required period. For example, one resident's quarterly MDS with an ARD of 12/31/24 was not completed until 02/13/25, and another resident's annual MDS with an ARD of 01/30/25 was not completed until 03/06/25. These delays were consistently verified through interviews with the MDS Coordinator, who acknowledged that the assessments and CAAs were not completed or submitted on time. The residents affected had a range of medical conditions, including Parkinsonism, dementia, diabetes mellitus, COPD, chronic pain syndrome, hypertensive heart disease, epilepsy, and metabolic encephalopathy. The facility's policy, revised in March 2022, required comprehensive assessments to be conducted in accordance with the Resident Assessment Instrument (RAI) User Manual, including completion by day 14 for admission assessments. Despite this policy, the facility did not adhere to the required assessment and submission timeframes for the residents reviewed.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, 62, 70, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29, 62, and 70 assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. All resident MDS assessments were reviewed by MDS on 5/22/25. Admin provided MDS Coordinator education on MDS Assessment policy and timely submission on 5/21/25. Random weekly audits of comprehensive care plans are to be completed by the DON/Designee within 4 weeks. Results are to be reviewed in QAPI.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to submit Minimum Data Set (MDS) assessments in a timely manner for one resident out of 17 reviewed. The resident, who had diagnoses including aphasia, dementia, and atrial fibrillation, was admitted on 10/03/23. Review of the medical record showed that the MDS assessment for January had a target date of 01/06/25 but was not completed until 01/27/25, and the April assessment had a target date of 04/07/25 but was not completed until 04/29/25. Staff interview with the MDS Coordinator confirmed that both assessments were completed late and were not transmitted within the required 14-day timeframe.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted to the State within the required 14-day timeframe for two residents. For one resident with a history of cellulitis, asthma, and type 2 diabetes, the admission MDS was completed, but both the discharge return anticipated (DRA) MDS assessments dated 04/19/25 and 04/21/25 remained in progress and were not transmitted as required. This resident had left the facility for the emergency room and later returned, before ultimately being discharged home, but the necessary MDS documentation was not finalized or sent within the mandated period. Similarly, another resident with diagnoses including cerebral infarction, generalized anxiety disorder, and major depressive disorder had an admission MDS completed, but both the quarterly and DRA MDS assessments were still in progress and had not been transmitted within 14 days. Staff interviews confirmed that these assessments were not completed and transmitted as required by regulation, affecting the facility's compliance with timely MDS data submission.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for a resident, affecting one of six closed records reviewed. The resident, who had diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia, was admitted and later discharged from the facility. The discharge MDS assessment was finalized but not submitted, with all sections completed on March 12, 2025. A progress note indicated that the resident returned from a leave of absence on December 27, 2025, and reported they would not be returning to the facility. An interview with the Director of Nursing confirmed that the MDS assessment was missed and not completed until March 12, 2025.
Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner for two residents, affecting their compliance with regulatory requirements. Resident #63, who had multiple diagnoses including chronic obstructive pulmonary disease and acute kidney failure, was discharged to home on 10/09/24 without a completed discharge MDS assessment. Similarly, Resident #82, with conditions such as spinal fusion and cognitive communication deficit, was discharged to home on 10/23/24, also without a completed discharge MDS assessment. An interview with MDS Nurse #495 confirmed that the discharge MDS assessments for both residents were not completed on time, indicating a lapse in the facility's assessment processes.
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