Repeated Deficiency in MDS Assessment Accuracy
Penalty
Summary
The facility failed to implement effective action plans to correct previously identified quality deficiencies related to the accuracy of Minimum Data Set (MDS) assessments. During a recertification survey, surveyors found that the facility inaccurately coded the MDS for two out of four residents reviewed, specifically failing to code an indwelling urinary catheter under section H for one resident. Despite the existence of a Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee that meets monthly and includes all required interdisciplinary team members, the same deficiency was cited again during a subsequent survey, indicating that the issue of inaccurate MDS coding persisted. The facility's policy states that it maintains a comprehensive, data-driven QAPI program focused on care outcomes and quality of life, but the repeated deficiency demonstrates that the identified problem with MDS coding was not effectively addressed.