Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for 10 of 24 residents reviewed. Record review showed that multiple residents had quarterly MDS assessments with established ARDs that remained in an “in progress” status and were not completed. Specifically, residents identified in the report had quarterly MDS assessments with ARDs ranging from mid-January through late February that were not finalized within the required timeframe. Each cited resident’s quarterly assessment was initiated and assigned an ARD, but the documentation showed the assessments were left incomplete beyond the regulatory deadline. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the cited assessments were incomplete. One MDS Coordinator explained that the assessments were not finished due to transitioning from previous job duties. In a separate interview, the DON and the Administrator each acknowledged awareness that some MDS assessments were behind or past due, and both stated their expectation that MDS assessments be completed timely to meet federal regulations. The report does not provide additional clinical details or medical histories for the affected residents beyond their admission dates and the status of their quarterly MDS assessments.
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