Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within the required 14 days after completion. This deficiency was identified during a recertification survey, affecting 10 out of 37 sampled residents. The facility's policy on MDS assessments, reviewed in January 2025, did not specify a timeline for submission. The survey revealed that the MDS assessments for several residents were completed but not submitted within the mandated timeframe, with actual submission dates significantly delayed beyond the scheduled dates. Interviews with the MDS Coordinator and the Administrator highlighted awareness of the issue, with the Coordinator acknowledging the late submissions and the Administrator noting ongoing discussions about the problem. The facility recognized the delay in submissions during Quality Assurance meetings and was in the process of hiring new assessors to address the issue. Despite these discussions, the deficiency persisted, as evidenced by the late submission of MDS assessments for multiple residents, which was documented in the validation reports with warning messages indicating the records were submitted late.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. DON in-serviced MDS Coordinator regarding timely submission of MDS. II. Identification a. DON and MDS Coordinator reviewed all MDS submissions from start of 2025. b. The facility respectfully states that all identified issues have been corrected. III. Systemic Changes a. DON and MDS Coordinator reviewed and updated MDS Policy on 3/11/25 to indicate submission timeline for MDS submission. b. Administrator in-serviced all staff who complete portions of MDS on timely submission beginning on 3/7/25 and as new hires came on board. c. 2 per diem MDS assistants hired and given new schedules on 3/11/25. d. MDS case load divided by floor to ensure timely submission. IV. Monitoring a. DNS and MDS Coordinator developed an audit tool to ensure due MDS assessments are submitted in a timely manner. Audit tool will review all due MDS Assessments. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The MDS Coordinator will be responsible to ensure correction of this deficiency.