Failure to Timely Submit MDS Assessments
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Death in Facility MDS: The facility failed to complete a Death in Facility MDS for a resident who expired and had been receiving hospice care. The EHR showed only the Entry and Admission MDS assessments, and the DON acknowledged the Death in Facility MDS had not been completed when reviewed. The MDS Coordinator stated she had forgotten to complete it after the resident passed away, despite the RAI manual requiring completion within 7 calendar days.
Late MDS Transmission for Two Residents: The facility failed to transmit required MDS data to IQIES within the required timeframe for two residents. One resident with dementia, osteoarthritis, and HTN had a quarterly MDS submitted late, and another resident with pancreatic neoplasm, DM, and HTN had a discharge MDS completed and submitted late. The MDSN and DON both stated that MDS assessments are used for resident care, billing, and compliance, and must be submitted within 14 days of the due date.
The facility failed to complete and submit required MDS assessments on time for two residents. One resident’s death/discharge tracking MDS was not started or completed after the resident died, and another resident’s quarterly MDS was completed but not transmitted by the required deadline. The MDS Coordinator acknowledged the missed and late submissions, and the DON stated she expected all MDS records to be completed and submitted timely.
Failure to transmit completed discharge MDS: A resident with COPD, AFib, CHF, Type II DM, and HTN had a discharge MDS marked complete, but it was not submitted to CMS within the required timeframe. Record review showed no batch was created, and interviews confirmed the discharge assessment should have been transmitted within 14 days of completion.
Failure to Complete and Transmit Discharge MDS: A resident admitted with fractures and other diagnoses was discharged the same day as admission, but the facility completed only an entry MDS and did not complete, encode, or transmit a discharge MDS. The DON and MDS Coordinator both stated a discharge MDS should have been completed, and the MDS Coordinator said the omission was an oversight.
Discharge MDS Not Completed or Transmitted Timely: A resident with multiple chronic conditions, including DM2, HLD, anxiety, PVD, depression, chronic pain, and HTN, was transferred to an acute care hospital, but no discharge MDS was completed or transmitted to CMS within the required timeframe. The DON and Administrator stated the MDS nurse, who was working remotely, missed the discharge assessment and that it should have been initiated the day the resident left or the next day.
Failure to Complete Death in Facility MDS
Penalty
Summary
The facility failed to complete a Death in Facility MDS assessment for one of three discharged residents who expired. Resident #2 had been admitted from the hospital and had received hospice care. The admission MDS documented diagnoses including palliative care, cancer, coronary artery disease, heart failure, thyroid disorder, and genetic related intellectual disability. A progress note documented that the resident's POA called the nurse to the room stating the resident had expired, and the time of death was recorded as 12:52 PM. An Admission/Discharge To/From Report later listed the resident as expired. Review of the resident's EHR showed that only an Entry assessment and an Admission assessment had been completed and accepted, and the MDS tab did not contain a Death in Facility MDS assessment. The DON stated MDS assessments were completed collaboratively and acknowledged the Death in Facility MDS had not been completed, stating it should be completed within the following day. The MDS Coordinator later stated she had just completed the Death in Facility MDS and acknowledged she had forgotten to complete it after the resident passed away. The RAI 3.0 User's Manual states a Death in Facility assessment should be completed no later than 7 calendar days after death.
Late MDS Transmission for Two Residents
Penalty
Summary
The facility failed to ensure that resident-specific assessment information for payment and quality measures was electronically transmitted to IQIES/ASAP within the required timeframe for two sampled residents. Resident 17 was admitted on 10/29/2025 with diagnoses including dementia, osteoarthritis, and HTN, and a later MDS showed the resident was cognitively impaired and dependent on staff for ADL care. Resident 87 was admitted on 1/8/2026, readmitted on 2/6/2026, and discharged on 2/11/2026; diagnoses included neoplasm of the head of pancreas, DM, and HTN, and the MDS indicated the resident was cognitively intact and dependent on staff for ADL care. During a concurrent interview and record review, the MDSN stated that MDS assessments are completed on admission, quarterly, annually, and with significant changes in condition, and then submitted in IQIES within 14 days of completion. The MDSN stated that Resident 17’s quarterly assessment was due for submission on 6/9/2026 but was not submitted until 6/16/2026. The MDSN also stated that Resident 87 required a discharge MDS on 2/11/2026, but the discharge MDS was completed and submitted on 3/3/2026. The DON stated that MDS assessments are used to guide resident care and for billing purposes, and that they need to be submitted within 14 days of their due date. The facility’s RAI process policy stated that MDS assessments are to be transmitted according to the facility’s assessment reporting schedules, and the CMS RAI Manual stated that required MDS data records must be transmitted to IQIES, with completion no later than 14 days after the ARD for non-admission OBRA and PPS assessments.
Late and Missing MDS Assessments
Penalty
Summary
The facility failed to complete and submit MDS assessments within the required timeframes for 2 of 2 sampled residents, Resident #15 and Resident #3. Review of the EHR for Resident #15 showed that the facility did not start or complete a Death in Facility Tracking MDS after the resident was admitted and later died on 3/17/26. During an interview, the MDS Coordinator stated she missed the discharge tracking record for Resident #15 and acknowledged that a discharge MDS should have been completed for 3/17/26 and submitted within the required timeframe. Review of Resident #3’s EHR showed a Quarterly MDS with an ARD of 05/14/2026, a completion date of 05/15/2026, and an acceptance date of 6/3/26. The MDS Coordinator confirmed the assessment was completed on 05/15/2026 but not submitted until 06/03/2026, which was later than the required deadline of 05/29/2026. The DON stated she expected all MDS records to be completed and submitted on time, and the Administrator stated the facility used the MDS RAI Manual for MDS completion.
Failure to Transmit Completed Discharge MDS
Penalty
Summary
The facility failed to transmit a completed discharge MDS that accurately reflected Resident #40’s status within the required timeframe. Resident #40 was an [AGE]-year-old female with diagnoses including COPD, atrial fibrillation, CHF, Type II DM, and hypertension. Her record showed she was admitted to the facility on [DATE] and discharged on 01/30/2026. The electronic medical record MDS tab showed a Discharge Return Not Anticipated MDS with a status of complete, but the assessment history indicated the Discharge MDS had not been submitted and no batch had been created. The Discharge MDS for Resident #40 was documented as a completed assessment with A0310F coded as discharge assessment - return not anticipated, A2000 showing the discharge date, and A2300 showing the assessment reference date as 01/30/2026. During interview, the Clinical Reimbursement Coordinator stated the Discharge MDS should have been submitted to CMS and that all discharge MDSs should be transmitted within 14 days of completion, but this one had not been transmitted because the box remained checked. The ADM stated he was not aware the Discharge MDS had not been transmitted until the day of the interview and confirmed the 14-day submission timeframe.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS system, including a required assessment upon a resident's transfer, reentry, discharge, and death, for one resident reviewed for completed MDS data. Resident #83 was admitted with diagnoses including other nondisplaced fracture of the upper end of the right humerus, hyperlipidemia, and a nondisplaced fracture of the shaft of the right clavicle. The resident's closed clinical record showed an entry MDS was completed on 01/12/2026, and a signed AMA form dated the same day indicated the resident discharged from the facility on the day of admission. Further review of the closed clinical record showed that a discharge MDS was not completed, encoded, or transmitted for Resident #83. During interview, the DON stated a discharge MDS should have been completed, encoded, and transmitted upon the resident's discharge. The MDS Coordinator also stated a discharge MDS should have been completed, encoded, and transmitted and said the omission was an oversight. The facility policy on MDS Assessment Data Accuracy stated that federal regulations require the assessment to accurately reflect the resident's status.
Discharge MDS Not Completed or Transmitted Timely
Penalty
Summary
The facility failed to ensure an encoded, accurate, and complete discharge MDS was electronically completed and transmitted to the CMS system within 14 days after completion for one resident reviewed for discharge MDS assessments. Resident #2 was a male with diagnoses including type 2 diabetes mellitus, hyperlipidemia, anxiety disorder, peripheral vascular disease, depression, chronic pain, and hypertension. Record review showed he had a transfer to an acute care hospital and a stop billing/discharge date of 05/24/2026, but as of 06/11/2026 there was no evidence that a discharge MDS had been completed or transmitted to CMS. The resident’s electronic MDS record showed a Quarterly MDS Assessment with an ARD of 04/10/2026, but no discharge MDS was present. During interview, the DON and Administrator stated the MDS nurse was not in the facility and was usually working remotely, and that the discharge MDS should have been initiated the day the resident left or the day after. They stated it was the MDS nurse’s responsibility to complete and transmit the discharge MDS and that she missed it. The Administrator also stated that timely completion of MDS assessments was important so the facility knew how to care for residents.
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