Delayed Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were transmitted to the Center for Medicare and Medicaid Services (CMS) within the required 14-day timeframe. This deficiency was identified during a recertification survey for a resident who had a significant change in condition. The resident, who had diagnoses including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Heart Failure, had a Significant Change MDS assessment completed on January 16, 2025. However, the assessment was not submitted to CMS until March 6, 2025, which was 35 days after completion. The delay in submission was attributed to the facility's reliance on a software system that tracks MDS assessment schedules. The system failed to generate a report listing the resident's assessment as due for transmission, leading to the oversight. Interviews with the MDS Director and Assistant Director revealed that they depended on the system to provide due dates for submissions, and the error was not identified until the survey. The facility's policy did not specify the timeframe for MDS completion and transmission, contributing to the oversight.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 I. The following actions were accomplished for the residents identified in the sample: The Minimum Data Set (MDS) for Resident #25 dated 1/10/25 and completed on 1/16/2025 was supposed to be submitted by 1/22/2025. The MDS director submitted this MDS on 3/6/2025, and it was accepted by the system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have MDS assessments completed have the potential to be affected by the same deficient practice. On (MONTH) 27, 2025, the MDS director generated a report of all MDS assessments that have not been submitted to ensure that there were no assessments that were late to be transmitted. There were no assessments (MDS) that were late to be transmitted. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The interdisciplinary team (IDT) reviewed the policy and procedure, on 03/24/2025, titled “MDS 3.0 Completion”. The IDT recommended adding to the responsibilities of the MDS director the following statement: Submit the MDS to both the CMS database as well as the state veterans home (SVH) databases within the timeframes established within the Resident Assessment Instrument guidelines as well the regulation under 483.20 (f)(1)-(4). In addition, the following statement was added: The MDS director, or designee will, generate the list for submission for all MDS assessments that are completed at a minimum, on a weekly basis. This list will be compared to the MDS calendar which contains all resident assessments that are scheduled, and is prepared by the MDS staff after reviewing the previously completed assessments. This will ensure that all MDS assessments which are due to be completed are submitted timely. The Facility Administrator, Director of Nursing and Medical Director reviewed the policy on 03/24/2025 and approved the addition. Beginning on 03/25/2025, the Director of Nursing (DON) re-educated all MDS staff members regarding the policy and procedure for MDS completion, including the change to the submission guidelines. This education will be completed by 03/28/2025. IV. The facility’s compliance will be monitored using the following Quality Assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that all completed MDS assessments are transmitted as per the RAI guidelines as well as the regulations under 483.20 (f) (1)-(4). Each week the MDS Director, or designee, will generate a list of all completed MDS assessments. They will compare the list of completed assessments to the MDS calendar to ensure that all scheduled assessments due for completion are completed and ready for transmission. Residents that have a completed MDS will be added to the audit tool to ensure compliance with transmittal. If MDS assessments are found to be past the required deadline for transmittal, the facility administrator, Director of Nursing, and Chief Financial Officer (CFO) will be notified immediately. Re-education will be provided to the MDS staff member, by the DON, if any MDS assessments are found to be past the required deadline for transmittal. The MDS director or designee will transmit all MDS assessments that are required to be transmitted. Following transmittal, the MDS director or designee will review the “MDS 3.0 NH Final Validation Report” to ensure that there were no assessments that contained errors or rejections. Any assessments that do contain errors or rejections will be reviewed and transmitted the same day as the original transmittal. These audits will be completed weekly for six (6) months, and then quarterly for two (2) consecutive quarters. The compliance standard will be set to 100%. At the end of the second quarterly audit, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits, and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: MDS Director