Failure to Complete and Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe for six out of eleven residents reviewed. According to the 2024 Resident Assessment Instrument (RAI) Manual, the MDS Completion Date must be no later than the 14th calendar day after a resident's admission. In multiple cases, the MDS assessments were completed and signed well beyond this 14-day window, with completion dates ranging from day 16 to day 26 of the residents' stays. The clinical records for these residents showed that the required comprehensive assessments were not finalized in accordance with federal guidelines. Interviews with facility staff revealed that the Director of Nursing (DON), who is responsible for signing the MDS assessments, does not possess detailed knowledge of MDS regulations and relies on the MDS Coordinator, an LPN, to inform her when assessments are ready for signature. The DON stated that she typically signs the assessments on the same day she is notified, but there is no formal policy in place regarding the MDS assessment process. The facility administrator confirmed that there is no written policy and that the facility follows the RAI Manual guidelines.