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 Assessment (CAA) processes within the required time frames for 11 out of 65 residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAA completion dates must be no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records, the CMS MDS validation report, and staff interviews confirmed that multiple MDS assessments were completed several days past the required deadlines for the identified residents. Specific examples include assessments being completed between 1 and 15 days late for various residents. The Registered Nurse Assessment Coordinator (RNAC) confirmed during an interview that these comprehensive MDS assessments were not completed within the mandated time frames. This deficiency was identified through review of clinical documentation and staff interviews, as well as validation against regulatory requirements.