Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for three of eight residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, for Resident R44, the ARD was 12/5/24, and the MDS was completed on 1/7/25. For Resident R52, the ARD was 12/18/24, and the MDS was not completed as of 1/13/25. Similarly, Resident R76 had an ARD of 12/5/24, with the MDS completed on 1/7/25. During an interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility's failure to complete the MDS assessments within the required timeframe for these residents.
Plan Of Correction
A quarterly 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 quarterly 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 quarterly assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' quarterly MDS assessments to ensure compliance with F638 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.