Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required 14 days after completion for two residents. Resident #129's Quarterly MDS, with an assessment reference date of November 15, 2024, and a completion date of November 20, 2024, was not submitted until January 24, 2025. Similarly, Resident #225's Quarterly MDS, with an assessment reference date of November 18, 2024, and a completion date of November 27, 2024, was also submitted on January 24, 2025. During an interview, the MDS Coordinator acknowledged that the assessments were completed but not transmitted due to a change in status in the medical record to 'do not transmit' to the Centers for Medicare Services, though the reason for this change was unknown. The Director of Nursing was unaware of the delay and stated that the MDS Coordinator was responsible for submitting the assessments.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: The two residents who are affected with the deficient practice are scheduled for a new MDS schedule. Resident #129 next MDS schedule 2/14/25, and resident #225 2/17/25. The status of submission will be monitored with the use of the Monthly MDS schedule, starting with their new schedule. There was no negative outcome from the late submission. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the potential to be affected by this deficient practice. An audit was complete to review all MDS completed over the last 90 days and found that all were submitted timely. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? To ensure full compliance with the MDS schedules, an audit tool/checklist will be utilized to monitor full compliance to the timely CMS submission. "Facilities are required to electronically transmit MDS data to the CMS system for each resident in the facility." An audit tool was developed to ensure all submissions are submitted timely. A monthly MDS schedule that is derived from the PCC scheduler that the facility has been using was modified to include three columns: "PREVIOUS MDS/ARD/TRANSMISSION STATUS," "EXPORT READY," and "ACCEPTED." The MDS schedule of the next month is completed in the middle of the current month and modified ad lib. The RAUM Manager and/or designee checks her own assigned unit every week to ensure that MDSs are completed, locked with "EXPORT READY" status, and checks the said column in the MDS schedule. The Director of the Clinical Compliance and/or designee will transmit the "EXPORT READY" status MDSs to CMS. Upon completion of the transmission process in PCC, the RAUM Manager and/or designee checks the "ACCEPTED" column. A meeting with RAUM Managers and in-service regarding the transmission process will be conducted, and this audit will be done bi-weekly for two months, then bi-weekly for one month, and then monthly thereafter. This process will be monitored by the Director of MDS and/or designee. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? The MDS Schedule, the MDS report in PCC, and the IQIES report on MDS 3.0 Missing assessments will be utilized to complete the audit tool. The audit will be done by the Director of MDS or designee bi-weekly for one month, then monthly for three months. Results of the audits will be submitted to the Administrator, and results of the audits will be reported to the QAPI meeting monthly for three months for action as appropriate.