Late Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) Discharge Assessment for a resident, identified as Resident 126, within the required timeframe. Resident 126 was admitted to the facility with diagnoses including a fracture of the neck of the left femur, gout, and alcohol abuse. The resident was discharged home with home health care services, including physical and occupational therapy, as well as a home health aide. The MDS Discharge Assessment was supposed to be transmitted by 11/20/2024, but it was not submitted until 2/25/2025, which was considered late. Interviews with the Director of Nursing and MDS Nurses revealed that the delay in transmitting the MDS Discharge Assessment could potentially affect billing, resident assessment, and the facility's quality measures. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual require that the MDS be transmitted electronically no later than 14 calendar days after the MDS completion date. The failure to transmit the assessment in a timely manner was identified during a review of the Final Validation Report, which documented the late submission of Resident 126's MDS assessment.
Plan Of Correction
Support staff on the facility policy and procedure Resident Assessment Instrument, with emphasis on timely submission and discharge assessments on 3/24/25. D. How the facility plans to monitor its performance to make sure solutions are sustained; The MDS Consultant/designee will monitor timely completion and submission of Resident discharge assessments. Concerns identified will be reported to the Director of Nursing and MDS Nurse for immediate completion of modification assessment and submission to QIES. The Director of Nursing/designee will report trends identified in the MDS Consultant audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction; and potential termination of this plan of correction when substantial compliance has been met. Substantial compliance shall be indicated at the discretion of the QAA Committee following three consecutive evaluations of MDS audit reports without findings of a variance to standard. Allegation of Compliance Date 3/25/2025. F 640 F 640 F 641 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The MDS added on 2/27/25 the diagnosis of Dementia to the list of active diagnoses. RT conducted an assessment on resident 29 for his CPAP on 2/26/2025. Resident 104's name was corrected in her MDS on 2/18/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; The Director of Nursing and Nurse Managers audited the MDS completion of Residents with diagnoses of dementia to ensure resident assessments were accurate and included a diagnosis of dementia under section I to identify other residents with diagnoses of dementia not accurately documented under section I on 3/17/2025. The DON and Nurse Managers audited a total of 30 resident MDS assessments. The MDS Nurse submitted a correction on 5 of 30 resident assessments requiring corrections to section I.