Failure to Complete Timely Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required regulatory timeframes for several residents. Specifically, one resident's admission MDS was completed 15 days past the required timeframe, while two other residents' admission MDS assessments were completed five and 15 days late, respectively. These delays were identified through interviews and record reviews, which showed that the assessments were not finalized within the 14-day period mandated by the Resident Assessment Instrument (RAI) Manual. The manual requires that an admission MDS be completed by the end of day 14, counting the date of admission as day one, and that annual MDS assessments be completed no later than 14 days after the Assessment Reference Date (ARD). The MDS Coordinator confirmed during an interview that timely completion of comprehensive assessments is essential for resident care and facility reimbursement. The Coordinator also stated that when they began working at the facility, there was no MDS Coordinator in place, and the facility was already behind on completing residents' MDS assessments. This lack of timely assessment completion hindered the care planning process necessary to provide appropriate care and services to the residents.