cms_ND: 12
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12 | THE MEADOWS ON UNIVERSITY | 355024 | 1315 S UNIVERSITY DR | FARGO | ND | 58103 | 2019-05-16 | 640 | E | 1 | 1 | FA2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), the facility failed to ensure timely electronic data submission of required Minimum Data Sets (MDS) assessments for 9 of 20 sampled residents (Resident #1, #12, #13, #16, #20, #35, #38, #40, and #54) and 2 of 3 closed resident records reviewed (Resident #64 and #65). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: Review of Resident #1, #12, #13, #16, #20, #35, #38, #40, and #54's medical records occurred on all days of survey. Review of Resident #64 and #65's medical records occurred on 05/16/19. The MDSs showed the following: ENTRY TRACKING: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-36 stated, the entry tracking record, . Must be completed within 7 days after the admission/reentry. Must be submitted no later than the 14th calendar day after the entry (entry date (A1600) + 14 calendar days). Review of Resident #20's medical record identified an admission date of [DATE]. The entry tracking record was submitted to the Centers for Medicare and Medicaid Services (CMS) on 02/04/19, 10 days late. ADMISSION: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-21 regarding completion dates stated, . The MDS completion date (Item Z0500B) must be no later than day 14 (the admitted counts as day one). This date may be earlier than or the same as the CAA(s) (Care Area Assessment Summary) completion date, but not later . The CAA(s) completion date (Item V0200B2) must be no later than day 14 (the admitted counts as day one). -Review of Resident #12's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated items V0200B2 and Z0500B 12/18/18, 15 days late. -Review of Resident #13's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated items V0200B2 and Z0500B 12/07/18, three days late. -Review of Resident #16's medical record identified an admission date of [DATE]. The admission MDS, dated [DATE], showed the facility dated item V0200B2 09/14/18, one day late. -Review of Resident #35's medical record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 11/16/18, three days late. -Review of Resident #64's closed record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 02/19/18, two days late. -Review of Resident #65's closed record identified an admission date of [DATE]. The admission and 5-day PPS MDS, dated [DATE], showed the facility dated V0200B2 and Z0500B 02/10/19, three days late. ANNUAL: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-22 stated, . The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) completion date, but not later . Review of Resident #40's annual MDS with an ARD of 01/04/19, showed the facility dated V0200B2 and Z0500B 02/09/19, 22 days late. QUARTERLY: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-33 stated, . The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). Review of Resident #54's quarterly MDS with an ARD of 01/25/19, showed the facility dated Z0500B 02/19/19, 11 days late. OBRA DISCHARGE: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-37 stated, Discharge Assessment-Return Not Anticipated . Must be completed (Item Z0500B within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). Review of Resident #1's medical record identified a discharge date of [DATE]. The facility failed to complete a discharge assessment and submit it to CMS. MEDICARE PPS DISCHARGE: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), page 2-46 stated, . Part A PPS Discharge Assessment (A0310H=1) . Must be submitted within 14 days after completion of the MDS completion date (Z0500B + 14 calendar days). Review of Resident #38's Medicare Part A PPS discharge assessment, dated 01/16/19, showed the facility dated Z0500B 01/19/19 and submitted the assessment to CMS 02/04/19, two days late. | 2020-09-01 |