Failure to Complete Quarterly Assessments and Update IDT Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain comprehensive care plans in accordance with federal requirements. Record review showed that for 67 of 105 residents reviewed, quarterly assessments and corresponding care plan reviews and revisions had not been completed within the required three‑month interval. Minimum Data Set (MDS) records dated within the review period revealed that these residents had not had an updated quarterly care plan for longer than three months, with quarterly care plans not updated since August 2025. The deficiency relates to the requirement at 42 CFR 483.21(b) that comprehensive care plans be developed within 7 days of the comprehensive assessment and then reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both comprehensive and quarterly assessments. During interviews, the DON stated she expected the IDT to complete a new care plan for each newly admitted resident within 14 days of admission and to reassess each resident on a quarterly basis, and identified the Social Worker as responsible for coordinating quarterly care plan meetings. The DON acknowledged that the facility did not have a Social Worker at the time and confirmed that the 67 residents’ quarterly care plans had not been updated since August 2025. The MDS Case Manager confirmed that the IDT was expected to meet quarterly to initiate and complete quarterly care plan assessments and reiterated that the Social Worker was responsible for coordinating these meetings, noting that the facility had been without a Social Worker for most of 2025. The Administrator stated he expected the IDT to follow the RAI Manual regarding the frequency of care plan meetings and confirmed that care plan meetings should be held on a quarterly basis. Reference to the CMS RAI Manual and Appendix PP documented that, although quarterly MDS assessments do not require Care Area Assessments, the resident’s care plan must be reviewed and revised by the IDT after each assessment.
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