Late Submission of MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for a resident within the required 14-day period after the assessment was completed. The resident, who was admitted with diagnoses including diabetes mellitus, cerebrovascular accident, and anemia, had an MDS assessment dated 10/21/2024. This assessment indicated that the resident was independent in cognitive skills for daily decision-making but totally dependent on staff for eating, oral hygiene, and personal hygiene. However, the MDS was not submitted to the Centers for Medicare and Medicaid Services (CMS) until 11/21/2024, which was beyond the 14-day submission requirement. During an interview and record review, the Minimum Data Set Nurse (MDSN) confirmed that the MDS assessment was submitted late and acknowledged the importance of timely submission to comply with regulations. The facility's policy, dated 1/2018, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. The delay in submission resulted in incorrect data being transmitted to CMS, potentially affecting the continuity of care for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Minimum Data Set Nurse (MDSN) reviewed Resident 93's Minimum Data Set (MDS) assessment, dated 10/21/2024. MDSN noted Resident 93's MDS Assessment Reference date was 10/21/2024 and had been submitted late to the CMS on 11/21/2024. There were no negative outcomes related to this deficient practice for Resident 93, who discharged home on 11/7/24. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter's MDS submissions. There were 2 residents affected by this deficient practice. There were no negative outcomes noted for residents affected. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the facility Consultant and Administrator in-serviced the Director of Nursing, MDSN, and MDSN Assistant on the facility's policy and procedure titled, "MDS Completion and Submission Timeframes," with emphasis on the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes, including but not limited to submitting MDS assessments within 14 days after the completion to the Centers of Medicare and Medicaid Services (CMS). The Medical Records Director will conduct an audit on MDS assessments daily for five days weekly for two weeks and monthly thereafter to ensure MDS assessments were transmitted to CMS within 14 days after completion. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for submitting MDS assessments to CMS within 14 days after completion for three months or until compliance is met.