Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual Minimum Data Set (MDS) assessments within the required timeframe for 35 out of 79 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, annual MDS assessments must be completed no later than 14 calendar days after the assessment reference date (ARD). However, the facility did not adhere to this guideline, resulting in delayed assessments for numerous residents. Specific examples include Resident 4, whose annual MDS assessment was completed 25 days after the ARD, and Resident 6, whose assessment was completed 24 days after the ARD. Additionally, Resident 8's admission MDS assessment was completed 24 days after the ARD, and Resident 11's assessment was completed 16 days after the ARD. These delays were confirmed through a review of clinical records and staff interviews, indicating a systemic issue in meeting the required assessment timelines. The Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed that the comprehensive MDS assessments were not completed within the required timeframe. This deficiency was identified during a survey, and it highlights the facility's failure to comply with the regulatory requirements for timely resident assessments, as mandated by the RAI User's Manual and 28 Pa. Code 211.5(f) regarding clinical records.
Plan Of Correction
1. A comprehensive Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. 2. 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. 3. 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. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of five random 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. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.