Failure to Complete and Sign Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months and signed as complete within 14 days of the Assessment Reference Dates (ARDs) for multiple residents. According to the CMS Long-Term Care RAI 3.0 User's Manual, quarterly assessments must be completed every 92 days following the previous OBRA assessment, and the MDS must be signed as complete within 14 days of the ARD. The survey found that for seven residents reviewed, these requirements were not met, with assessments either completed late, left incomplete, or not signed within the required timeframe. Specific examples included residents with complex medical histories such as sequelae of cerebral infarction, congestive heart failure, senile degeneration of the brain, hemiplegia, chronic kidney disease, and other significant diagnoses. For these residents, MDS assessments were either not completed within the mandated 92-day interval, not signed as complete within 14 days of the ARD, or left in progress well past the required deadlines. In some cases, sections of the MDS were completed weeks after the ARD, and in others, the assessments remained incomplete with no signature to indicate completion. Interviews with facility staff, including the DON, MDS Manager, and MDS Assistant, revealed that the MDS department was behind on assessments, with staff acknowledging delays and incomplete work. The MDS Assistant was relatively new to the role, and the facility had experienced staffing challenges, leading to a backlog of MDS assessments. The Administrator confirmed awareness of the issue and stated expectations for timely completion in accordance with the RAI manual, but the deficiency persisted at the time of the survey.