cms_UT: 41
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 41 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 636 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined that for 4 of 43 sample residents, that the facility did not conduct initially and periodically a comprehensive Minimum Data Set (MDS) Assessments within the timeframes prescribed. Specifically, multiple MDS Assessments were documented as accepted with warnings for being submitted late. Residents identifiers: 22, 37, 38, and 45. Findings include: 1. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 22's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS assessment records dated 2/6/18 and 9/3/17 were pulled for review. The MDS record dated 9/3/17 revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS Assessment had a target date of 9/3/17 and was due to be submitted to the Center for Medicare and Medicaid Services (CMS) on 9/16/17. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 10/2/17. 2. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 45's medical record was reviewed. According to the medical record, the MDS assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS Assessment records dated 12/17/17 and 3/17/18 were pulled for review. The MDS record dated 12/17/17 revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS Assessment that had a target date of 12/17/17 and was due to be submitted to the Center for Medicare and Medicaid Services (CMS) on 12/30/17. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 1/2/18. The MDS Coordinator stated that the MDS assessment dated [DATE] was due to be submitted to CMS on 3/30/18. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 4/3/18. 3. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warningindicator by their dates. Two MDS Assessment records dated 4/26/17 and 3/10/18 were pulled for review. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 5/10/17 but was submitted late on 5/17/17. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 3/24/18 but was submitted late on 3/26/18. 4. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 38's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warningindicator by their dates. Two MDS Assessment records dated 9/8/17 and 3/11/18 were pulled for review. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 9/22/17 but was submitted late on 10/9/17. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 3/25/18 but was submitted late on 3/27/18. On 4/30/18 at 3:48 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that the warning indicator for the MDS assessments could be for a misspelled name or for a change for resident. The facility MDS Coordinator stated that the reason for the warning could be a validation report and could apply to residents transfers, acceptances, rejections, admissions, discharges, etc. The facility MDS Coordinator stated that she was busy, overwhelmed and that she submitted multiple MDS Assessments as well as care plans later than normal. The facility MDS Coordinator stated that each MDS Assessment would last 3-4 hours and that with a building the size of the facility, it was impossible for her to complete the MDS Assessments on time. The facility MDS Coordinator stated that she would have one facility member to help her for a few hours per week, but that lately that person had been pulled to do other things in the facility so she was working on the MDS Assessments herself. | 2020-09-01 |