Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for seven residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in late assessments for several residents. For instance, Resident 19's assessment was completed 18 days late, while Resident 54's assessment was 17 days late. The deficiency was confirmed through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the quarterly MDS assessments for the identified residents were not completed within the required timeframes. This non-compliance with the 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, highlights a lapse in the facility's adherence to mandated assessment schedules.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action. F638 1. The dates of submission for residents 19, 33, 35, 38, 43, 54, and 62 cannot be altered. The residents suffered no harm from this action. 2. Any other Minimum Data Set submission has potential to be submitted late. 3. An evaluation of the scheduling and planning process was conducted to determine measures that could be implemented to prevent this deficient practice from recurring. The scheduling target was shortened to fall within required parameters. Education was done with the interdisciplinary team, and dates are being reviewed weekly. 4. A Performance Improvement Plan was started to review timely submissions for 3 months until new process is secured. An audit of submission dates will be done weekly x 4 and then monthly x 2 and reported to the quality assessment team for review. Administrator or designee will monitor.