Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for 15 out of 65 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly MDS assessment must have an assessment reference date (ARD) no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 calendar days after the ARD. Review of clinical records revealed that for multiple residents, either the quarterly or comprehensive MDS assessments were not completed within these mandated time frames. Specific examples included assessments with ARDs that were not followed by timely completion, as well as instances where no prior assessment was completed within the required 92-day period. Interviews with the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the identified residents were not completed as required. The deficiency was identified through review of the RAI Manual, clinical records, and staff interviews, and it was determined that the facility did not comply with the regulatory requirements for timely completion of resident assessments as outlined in 28 Pa. Code 211.5(f) regarding clinical records.