Failure to Complete Timely Admission Activities Evaluations
Penalty
Summary
Harmar Village Health & Rehab Center was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding comprehensive assessments and their timing. The facility failed to complete the required Admission Activities Evaluation for three residents within the specified timeframe. Resident R3, admitted on November 12, 2024, had an evaluation due by November 16, 2024, which was not completed. Similarly, Resident R1, admitted on November 27, 2024, had an evaluation due by November 31, 2024, and Resident R2, admitted on November 29, 2024, had an evaluation due by December 2, 2024. All these evaluations were overdue and not completed as required. The deficiency was confirmed during an interview with the Nursing Home Administrator on December 17, 2024, who acknowledged that the Admission Activities Evaluations were not completed as mandated. This failure to conduct timely comprehensive assessments is a violation of the federal regulations that require facilities to assess residents' needs, strengths, and preferences within 14 days of admission, excluding readmissions without significant changes in condition.
Plan Of Correction
R1, R2 and R3 previously dated late assessments were unable to be recreated. R1, R2 and R3 assessments have been completed to be current. A house audit will be completed by 12/25/24, to ensure active residents have a recent Activity Assessment. Assessments due will be reviewed in clinical meeting and followed up on per policy as appropriate. The new Activity Director was provided education on the Activity Assessments completion and policy by the Nursing Home Administrator/designee. The Registered Nurse Assessment Coordinator/designee, moving forward, will perform an audit of new admissions/due Activity Assessments 3 times per week for 4 weeks, then weekly for 2 weeks to ensure compliance. Any noted discrepancies will be addressed as appropriate, and results of auditing will be reviewed at the facility Quality Assurance Meeting.