Incomplete Data Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

  • All residents who are missing or have duplicates of one of the following:

    • No recorded Primary Care Physician

    • Double admissions in PCC census 

    • Missing MDS Entry Assessment

    • Missing MDS Discharge Assessment

    • Double MDS Entry Assessments

    • Double MDS Discharge Assessments


Business Rules

Tasks:

  1. Remove Double Admission - Census duplicate admission is removed. (Q2601)

    1. Location in PCC:

      1. Census

    2.  Business Rule:

      1. IF a resident has two consecutive admissions without an intervening discharge in their Census record on PCC,
        THEN either the duplicate admission must be removed,
        OR an intervening discharge record added.

    3. Due Date:

      1. 24 Hour after the duplicate census record

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged

  2. Duplicate MDS Discharge - Duplicate MDS Discharge is removed. (Q2602)

    1. Location in PCC:

      1. MDS

    2.  Business Rule:

      1. IF a resident has two consecutive MDS discharge assessments without an intervening MDS admission assessment in their MDS record,
        THEN either the duplicate MDS discharge assessment must be removed,
        OR an intervening MDS admission assessment added.

    3. Due Date:

      1. 24 Hour after the duplicate MDS discharge assessment

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged

  3. Duplicate MDS Entry- Duplicate MDS Entry is removed. (Q2603)

    1. Location in PCC:

      1. MDS

    2.  Business Rule:

      1. IF a resident has two consecutive MDS entry assessments without an intervening MDS discharge assessment in their MDS record,
        THEN either the duplicate MDS entry assessment must be removed,
        OR an intervening MDS discharge assessment added.

    3. Due Date:

      1. 24 Hours after the duplicate MDS entry assessment

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged

  4. Missing MDS Discharge - Missing MDS Discharge must be added. (Q2604)

    1. Location in PCC:

      1. MDS

    2.  Business Rule:

      1. IF a resident is missing an MDS discharge assessment from their MDS record,
        THEN an MDS discharge assessment must be added.

    3. Due Date:

      1. 24 Hours after the incorrect MDS assessment was added

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged

  5. Missing MDS Entry - Missing MDS Discharge must be added. (Q2605)

    1. Location in PCC:

      1. MDS

    2.  Business Rule:

      1. IF a resident is missing an MDS entry assessment from their MDS record,
        THEN an MDS entry assessment must be added.

    3. Due Date:

      1. 24 Hours after the incorrect MDS assessment was added

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged

  6. Missing Primary Care Physician - Missing PCP must be added. (Q2606)

    1. Location in PCC:

      1. Profile

    2.  Business Rule:

      1. IF a resident is missing a Primary Care Physician on PCC
        THEN a PCP must be added to the resident’s PCC record.

    3. Due Date:

      1. 24 Hours after the resident’s admission

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

      1. If the resident has been discharged