Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for one of four residents. Specifically, the deficiency was identified for Resident R83, whose discharge tracking records were not completed and transmitted as required. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, mandates that discharge tracking records must be completed and transmitted within 14 days of the Event Date. Upon review of Resident R83's records, it was found that the discharge date was recorded as 11/25/24, but there was no Discharge MDS completed. This oversight was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E9, who acknowledged the failure to ensure timely transmission of MDS assessments for Resident R83. This lapse in protocol highlights a specific instance where the facility did not adhere to the required timelines for data submission, as outlined by CMS guidelines.
Plan Of Correction
The completion dates for the discharge assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required discharge MDS assessment for residents who have discharged in the last 30 days. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting discharge assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents who have discharged to ensure compliance with F640 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.