Failure to Complete MDS Assessment for Deceased Resident
Penalty
Summary
Tremont Health and Rehabilitation Center was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the encoding and transmitting of resident assessments. The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who was discharged from the facility. This deficiency was identified during a survey that included a review of clinical records and staff interviews. The specific incident involved a resident who passed away in the facility. The clinical record review revealed that there was no documented evidence of an MDS assessment being completed to reflect the discharge status of the resident upon their death. During an interview, the facility's Administrator confirmed that the MDS had not been completed for the resident's discharge, which occurred on the date of the resident's passing.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. MDS for resident # 109 was completed and transmitted at time of survey. 2. To identify like residents that have the potential to be affected, the MDS Nurse/designee will complete a 14-day look back of section Z0500 to ensure completion and transmission. 3. To prevent this from happening again, the Regional Reimbursement coordinator/designee will educate the RNAC on timely completion and transmission of section Z0500. 4. To monitor and maintain ongoing compliance, the RNAC will review 5 MDS weekly x 4 then monthly x 2 to ensure that Section Z0500 is completed and transmitted timely. Results of audits will be submitted to the QAPI committee for further review and recommendation. Allegation of Compliance date: 4/8/2025