Delayed MDS Submissions Due to Staffing and Process Gaps
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days after completion for several residents. The report highlights that multiple residents had their MDS assessments completed but not submitted in a timely manner, with delays ranging from 20 to 39 days past the completion date. This issue affected at least nine residents, including Residents #31, #79, and #88, among others. The delays in submission were attributed to staffing changes and gaps in the MDS Coordinator role. The MDS Nurse, who started at the facility in late January 2025, was still undergoing training and was responsible for managing both current and overdue assessments. The Director of Nursing (DON) was not initially aware of the need to sign and lock assessments completed before the new MDS Nurse's tenure, which contributed to the delays. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument Manual require timely submission of MDS assessments, which was not adhered to in these cases. Interviews with the MDS Nurse and the DON revealed a lack of clear communication and understanding of the submission process. The MDS Nurse was relying on electronic medical record software for scheduling, while the DON was new to the process and learning alongside the MDS Nurse. The Administrator expected timely transmission of MDS assessments within 14 days, as per the facility's policy and federal guidelines, but this expectation was not met due to the aforementioned issues.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Failure to Transmit Discharge MDS Assessments to CMS: The facility failed to transmit a DRA MDS for one resident and a DRNA MDS for another resident to CMS. Both assessments were completed, but the submit section indicated not to submit to CMS, and the MDS coordinator confirmed neither assessment had been sent. One resident was discharged to the ED after a fall, and the other was discharged with family to an ILF.
The facility failed to ensure an MDS 3.0 Discharge Return Not Anticipated assessment for a resident with a fractured back, major depressive disorder, and insomnia was transmitted to CMS within the required timeframe. The assessment was completed but not sent as required, and the MDS nurse verified the late transmission issue during interview.
Late MDS Submission After Discharge: A resident with Alzheimer’s disease and HTN was discharged, but the PPS discharge MDS was completed late and then mistakenly set to “do not send” instead of being transmitted to CMS/QIES ASAP. The MDS Nurse stated the wrong submission option was selected during the sending process, and the RAI manual requires the discharge assessment to be completed and submitted within the specified timeframe.
The facility failed to complete and transmit required MDS assessments for three residents. One resident with moderate cognitive impairment left after dialysis and had no discharge assessment completed, while two other residents had hospital/ER transfers and returns without the required discharge return anticipated, reentry, or entry assessments. The MDS coordinators acknowledged the missing assessments and stated some were missed or overdue.
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.
Failure to Transmit Discharge MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that a discharge return anticipated (DRA) MDS for one resident and a discharge return not anticipated (DRNA) MDS for another resident were transmitted to CMS. For one resident, the admission MDS indicated the resident had a discharge-return anticipated status and that the discharge was unplanned, but the assessment was marked completed without showing that it had been submitted to CMS. The resident’s census listing showed the resident was admitted to the nursing home and later changed to STOP BILLING, and a progress note documented discharge to the emergency department after a fall. For the second resident, the DRNA MDS indicated the assessment was completed but did not show submission to CMS, and the submit section stated not to submit to CMS. The resident’s census listing showed admission to the nursing home and later a STOP BILLING status, and a progress note documented discharge with family to an ILF. During interview, the MDS coordinator confirmed that both assessments had been completed but never sent to CMS. The facility policy stated that MDS forms are completed on the facility computer and signed and dated after review for accuracy, but it did not include the expected time frame for submitting DRA or DRNA MDSs to CMS.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to ensure that MDS 3.0 assessments were transmitted to CMS within fourteen days of completion as required. Record review for Resident #18 showed an admission date of 12/24/25 with diagnoses including fractured back, major depressive disorder, and insomnia, and the resident discharged back to the community with his spouse on 02/03/26. Review of the MDS assessment records showed a Discharge Return Not Anticipated assessment that was completed but not transmitted directly to CMS as required. An interview with the MDS Nurse on 05/19/26 at 10:00 A.M. verified that the assessment was not transmitted to CMS within fourteen days of completion.
Late MDS Submission After Discharge
Penalty
Summary
The facility failed to submit and transmit Resident 2’s discharge MDS assessment to CMS within the required timeframe after the assessment was completed. Resident 2’s record showed a discharge from the facility on 2/23/2026, and the MDS summary identified that date as the target date for the assessment. The MDS itself was completed on 3/10/2026, which was later than the discharge target date, and the assessment was not transmitted as required. During interview and record review, the MDS Nurse stated that while sending the assessment, the wrong option was selected and “do not send” was triggered instead of sending it to CMS. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions, and the admission record showed diagnoses including Alzheimer’s disease and hypertension. The facility’s Administrator stated the facility followed RAI rules and regulations regarding MDS, and the RAI manual reviewed by surveyors stated that the Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay and submitted within 14 days after the MDS completion date.
Missed and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure resident assessments were encoded and transmitted to the State within the required timeframes for three residents. For Resident #25, who had a BIMS score of 11 indicating moderate cognitive impairment, a nurse’s progress note documented that the resident refused to enter the facility after returning from dialysis, and another note stated the resident left the facility without a proper discharge or medications. The last assessment completed and transmitted was an entry tracking record, and there was no discharge assessment showing the resident had left the facility. The MDS Coordinator stated the discharge assessment should have been completed but was missed. For Resident #54, progress notes showed the resident left the facility with EMSA for the ER, was later readmitted, then hospitalized and readmitted again, and later left with EMSA to the ER once more. There were no discharge return anticipated or reentry admission assessments completed for these returns. For Resident #81, a discharge return anticipated entry assessment showed the resident was discharged and transferred to the hospital, and a later progress note showed the resident returned from the hospital, but there was no MDS entry assessment documenting the return. The MDS Coordinator stated the missing entry assessments should have been done and that the facility was behind on MDS assessments.
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