Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and electronically submit encoded, accurate, and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for all 26 residents reviewed. Specifically, the MDS assessments for several residents were not submitted within 14 days after the assessment completion date, and others were not completed within 14 days following their Assessment Reference Date. This deficiency was identified during a standard survey conducted on February 13, 2025. The facility's policy, dated October 2019, requires that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, the facility did not adhere to these timeframes, resulting in significant delays. For instance, Resident #14's Quarterly MDS was due by December 31, 2024, but remained incomplete as of February 13, 2025, which was 44 days past the required completion date. Similarly, Resident #103's Annual MDS was due by December 30, 2024, and was 43 days overdue. Other residents also experienced delays in the submission of their MDS assessments. Interviews with facility staff revealed that the delays were attributed to staffing shortages, particularly in the social work department, and the need for additional training for a newly hired MDS Coordinator. The Registered Nurse responsible for MDS coordination acknowledged the late submissions and cited being busy and waiting on other departments to complete their sections as reasons for the delays. The Administrator and Regional Director of Clinical Reimbursement were aware of the overdue assessments and attributed the delays to staffing issues, indicating that they were doing what they could to manage the situation.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Resident #103/14/4/5/9/14/17/18/28/30/47/63/67/82/103/109/125/132 overdue MDS were completed on 3/3/25. Resident 6 and 78 were completed on 3/4/25. Resident 118 was completed on 3/5/25. Resident 110 was completed on 3/6/25. Resident #66 overdue MDS was completed on 2/25/25. Resident #122 was reviewed to ensure accuracy on 1/19/25. Resident #135 was reviewed to ensure accuracy on 2/28/25. All residents have the potential to be affected by this deficient practice. MDS(s) were reviewed for all residents related to compliance with MDS transmission timeframes. Areas identified will be assessed and corrected. The policy and procedure for MDS transmission was reviewed by the VP of Clinical Reimbursement and no changes were made. MDS Coordinator will be educated on RAI manual timeframes for transmission by the VP of Clinical Reimbursement. MDSC will review MDS assessment(s) for timely submission. Any identified will be submitted to QIES. MDS coordinator will review the MDS List “Completed,” “Export Ready” list within PCC twice a week for completed MDS(s) that are awaiting submission. Regional Director of Clinical Reimbursement will submit an audit related to MDS completion date and transmission on all residents including looking at the Assessment Reference Dates (ARD), completion date, submission due date for MDS weekly x4, biweekly x2, and monthly x3. All findings will be reported to the QAPI Committee for review and comment. Responsible party: DON