Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents. For one resident, the Electronic Health Record showed an admission date followed by a series of MDS assessments with Assessment Reference Dates (ARDs) including quarterly and annual assessments. Review of these ARDs revealed that the interval between the quarterly assessment dated 12/21/2024 and the subsequent quarterly assessment dated 3/25/2025 was 94 days, which exceeded the 92-day regulatory limit for OBRA-required assessments. This delay meant the quarterly assessment was not completed within the timeframe specified by regulation and the facility’s own policy. During interviews, the RN Vice President of Clinical Reimbursement confirmed that the quarterly assessments were late by two days, acknowledging there were 94 days between the ARDs instead of the required maximum of 92 days. The Administrator and the National Director of Risk Management stated that the facility’s expectation is that assessments are completed on time and referenced the potential negative outcomes of failing to meet regulatory requirements and ensuring appropriate care planning within required timeframes. Review of the facility’s policy titled “MDS 3.0 Completion” showed that annual assessments must use an ARD no more than 366 days from the most recent comprehensive assessment and no more than 92 days from the most recent quarterly assessment, and that quarterly assessments must use an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, confirming that the 94-day interval was out of compliance.
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