Failure to Complete Required Community Survival Skills Assessments per Policy
Penalty
Summary
The facility failed to follow its Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and additionally when residents request outside passes. During an interview, the Social Services staff member (V9) stated that these assessments are completed quarterly, annually, and when a resident requests an outside pass. However, review of the electronic medical records showed that for one resident (R10), the last documented community survival skills assessment was dated 3/31/25, and no subsequent assessments were present. V9 initially suggested that a more recent assessment might not be visible because it was not locked, but was informed that even in-progress assessments would appear in the record, confirming that no later assessment had been completed. Record review for three additional residents showed similar gaps in required assessments. R1’s last community skills assessment was dated 7/9/25, R17’s was dated 8/1/25, and R18’s was dated 9/8/25, with no evidence of quarterly assessments thereafter as required by the facility’s policy. The facility also produced a document titled “admission, quarterly, annual, and significant change assessments,” which indicated that community skills assessments are completed on admission, with significant change, and annually, a schedule that did not align with the written Community Access Determination policy. When asked if this document was a policy, the DON (V2) and ADON (V8) did not initially respond; after consulting with the Administrator (V1), V2 stated it was not a policy but a document listing assessments and their timing. The facility’s formal guidelines for community access determination, dated 2/8/23, specify that community skills assessments are to be completed by Social Services upon admission and quarterly for all residents, which was not followed for the four residents reviewed.
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