Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within the required 14 days after completing the resident assessments. This deficiency was identified for two residents who had been discharged from the facility. Specifically, a discharge MDS assessment for one resident was completed on December 4, 2024, but had not been exported by January 15, 2025. Similarly, another resident's discharge MDS assessment was completed on December 11, 2024, and also had not been exported by January 15, 2025. During an interview on January 15, 2025, a registered nurse (RN1) confirmed that the discharge MDS assessments had not been exported and transmitted to the CMS system in a timely manner.
Plan Of Correction
The assessment for the two of two residents who had been discharged from the Facility have been completed and transmitted. (Residents 1, 3) Holy Redeemer TCU facility will assess all records in the system to assure all residents data is now completed and electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) immediately. The facility RNAC will electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after residents are discharged from the facility. The nurse manager and NHA or their designee will monitor MDS transmissions weekly to assure compliance. We complete this audit by running the MDS in progress list from PCC weekly to assure they are all up to date and submitted. We will also run all admissions and discharges list from the EHR and reconcile the two reports to assure no one is missed each week. The RNAC and the Unit Manager have been in serviced on the requirement and how to comply. MDS transmission compliance reports will be added to QAPI quarterly for next 6 months.