Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frame for six out of 24 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, several residents had their MDS assessments completed beyond this timeframe, with some not completed at all by the time of the survey. Specifically, Resident R67, R147, R148, R153, R248, and R249 were affected, with completion dates ranging from January 5, 2025, to January 13, 2025, or not completed at all by January 13, 2025. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E9, who acknowledged the failure to complete the assessments timely.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. A comprehensive Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next annual MDS assessment or admission MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting comprehensive assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' annual and admission MDS assessments to ensure compliance with F636 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.