Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments and Care Area Assessments (CAA) within the required time frames for nine residents. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAAs must be completed no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records and the CMS MDS validation report revealed that for several residents, the MDS assessments were completed one to three days late. In one case, there was no MDS completed in the prior 366 days for a resident. Staff interviews, including with the Registered Nurse Assessment Coordinator Consultant, confirmed that the comprehensive MDS assessments for the identified residents were not completed within the required time frames. The findings were based on documentation and assessment dates in the residents' clinical records, as well as the facility's adherence to the regulatory requirements outlined in the RAI User's Manual and state code.