Failure to Complete MDS Assessments Within Regulatory Timeframes
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required regulatory timeframes for 17 out of 24 residents reviewed for assessments. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, MDS assessments must be completed no later than the 14th calendar day after the Assessment Reference Date (ARD). The survey found that multiple types of MDS assessments, including quarterly, annual, admission, discharge, and death assessments, remained incomplete and in progress beyond the required 14-day period. Record reviews revealed that for each of the identified residents, the MDS assessments had ARDs set and corresponding required completion dates, but the assessments were not finalized within the mandated timeframe. The types of assessments affected included quarterly, annual, admission, discharge, and death assessments. For example, one resident had both quarterly and discharge assessments that were not completed on time, while another had both annual and death assessments outstanding. This pattern was consistent across all 17 residents cited in the deficiency. During an interview and records review with the staff member responsible for MDS (S5MDS), it was confirmed that each of the cited assessments remained open and incomplete past the 14-day requirement. The staff member acknowledged that the assessments should have been completed within the specified timeframe, as required by regulation, but this was not done for the residents identified in the survey.