|§483.20 Resident Assessment |
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.
§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Based on clinical record review and staff interview, it was determined that the facility failed to complete comprehensive annual assessments timely for three of 22 clinical records reviewed (Resident R3, R1, and R4).
Review of Resident R3's Significant Change Minimum Data Set, (MDS- an assessment tool completed at specific intervals to determine resident care needs) revealed that the assessment was completed on August 12, 2020. The next annual MDS assessment was due on August 13, 2021. Further review of the resident's clinical record revealed the annual assessment due on August 13, 2021 had not been completed.
Review of Resident R1's Annual Minimum Data Set (MDS- assessment tool completed at specific intervals to determine resident care needs) revealed that the assessment was completed on November 27, 2020, with a quarterly MDS's completed on February 27, 2021, April 27, 2021, and May 18, 202. The next annual MDS was due on August 18, 2021. Further review of the resident's clinical record revealed the annual assessment of August 18, 2021 still had not been completed.
Review of Resident R4's Annual Minimum Data Set (MDS- assessment tool completed at specific intervals to determine resident care needs) completed on December 8, 2020, with a quarterly MDS's completed on March 10, 2021, April 5, 2021, and May 25, 2021. The next MDS was due on August 25, 2021. Further review of the resident's clinical record revealed the annual assessment of August 25, 2021 still had not been completed.
Interview with licensed nursing staff, Employee E4, October 21, at 2:35 p.m. confirmed that the above mentioned MDS assessments still had not been completed and were over due.
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| ||Plan of Correction - To be completed: 11/23/2021|
1. R1, R3, R4 have had their MDSs completed.
2. To identify others with the potential to be affected, an audit was conducted to identify other assessments that are outside of the 120 day completion date.
3. To prevent this from reoccurring, NHA has reeducated the Social Service Director on the timely completion of MDS.
4. Ongoing monitoring for compliance, RNAC will audit MDS timely completion 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 2 times a week for 4 weeks. RNAC will report during Clinical morning meeting any required MDSs.
5. Results will be provided to the QA Committee for review and revision as needed.