cms_GA: 2052
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2052 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 640 | B | 1 | 1 | RFJ511 | > Based on record reviews and staff interviews the facility failed to ensure that Minimum Data Sets (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for six (6) rsidents (R#1, R#2, R#3, R#4, R#5 and R#7). The sample size was 32. Findings include: 1. Review of R#1's completed and transmitted MDS records revealed that a Discharge Part A was due on 8/31/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 2. Review of R#2's completed and transmitted MDS records revealed a Discharge Part A dated 9/13/19 with submission date of 9/19/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 3. Review of R#3's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed 12/21/18 and submitted on 2/21/19 which should have been submitted by 2/1/19. 4. Review of R#4's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 3/21/19. 5. Review of R#5's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/2/19 and submitted on 4/1/19 which should have been submitted by 3/21/19. 6. Review of R#7's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 4/17/19. Interview with the MDS Coordinator on 1/29/2020 at 2:45 p.m. revealed that she has been employed at the facility since May 2019 as the MDS Coordinator. She further stated that when she first came to the facility the Interim MDS Coordinator, who had been at the facility since January 2019, explained to her that OBRA assessments from February 2019 had not been completed but that all Medicare Part A assessments were complete. She further stated that she completed the February and May 2019 assessments together. Also stated she received a call from the MDS Automation Coordinator for the State on 1/13/2020 and both residents (R#1 and R#2) were on a missing assessment report. However, she stated she completed a discharge from Part A services but not an OBRA Discharge Assessment. She stated she has opened both assessments and completed the wrong assessment on R#2 that she completed an admission assessment instead of a discharge assessment. She also confirmed she needed to complete both discharge assessments on R#1 and R#2. She further stated when she opens an assessment and set an ARD date, there is about a week turn around to complete the MDS and then she transmits after that. Stated she tries to transmit every Friday. She went on to confirm that R#3, R#4, R#5 and R#7's assessments were completed but transmitted late. She confirmed that R#2 and R#1 tracking asssessments were not completed. She further stated that after transmitting the MDS Assessment to QIES, she will export the file on the computer so that it can be used for billing. | 2020-09-01 |