Failure to Complete and Submit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes for all 11 residents reviewed. According to the findings, MDS assessments, including quarterly, annual, significant change, admission, and discharge assessments, were not completed or submitted within the 14-day period mandated after the assessment reference date (ARD) or relevant event, such as admission or discharge. In several cases, the Care Area Assessments (CAAs) associated with the MDS were also not completed within the required timeframe. Record reviews for each resident showed that the assessments were delayed, sometimes by several weeks beyond the required period. For example, one resident's quarterly MDS with an ARD of 12/31/24 was not completed until 02/13/25, and another resident's annual MDS with an ARD of 01/30/25 was not completed until 03/06/25. These delays were consistently verified through interviews with the MDS Coordinator, who acknowledged that the assessments and CAAs were not completed or submitted on time. The residents affected had a range of medical conditions, including Parkinsonism, dementia, diabetes mellitus, COPD, chronic pain syndrome, hypertensive heart disease, epilepsy, and metabolic encephalopathy. The facility's policy, revised in March 2022, required comprehensive assessments to be conducted in accordance with the Resident Assessment Instrument (RAI) User Manual, including completion by day 14 for admission assessments. Despite this policy, the facility did not adhere to the required assessment and submission timeframes for the residents reviewed.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, 62, 70, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29, 62, and 70 assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. All resident MDS assessments were reviewed by MDS on 5/22/25. Admin provided MDS Coordinator education on MDS Assessment policy and timely submission on 5/21/25. Random weekly audits of comprehensive care plans are to be completed by the DON/Designee within 4 weeks. Results are to be reviewed in QAPI.