Late Transmission 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 (CMS) Data System within the required 14-day period after completion. This deficiency was identified during a Recertification Survey conducted from March 2, 2025, to March 7, 2025. The survey revealed that for five residents, the MDS assessments were completed but not transmitted within the mandated timeframe. Specifically, the assessments for these residents were completed in early February 2025 but were not transmitted until March 2, 2025, exceeding the 14-day requirement. The facility's policy, revised in May 2024, mandates that submissions should adhere to the Resident Assessment Instrument manual and federal and state guidance. Despite this, the Director of Nursing, who also serves as the MDS Coordinator, acknowledged the oversight in timely submission during an interview on March 7, 2025. The facility's validation report dated March 5, 2025, confirmed the late transmission of all five submissions, indicating a lapse in adherence to the established policy and regulatory requirements.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 F 640 Element #1: The MDS compliance consultant will educate the MDS coordinator on timely submissions. Element #2: The facility will review the last month's submissions to ensure they were submitted timely. Element #3: The policy and procedure for MDS completion will be updated to include timely submissions. The MDS consultant will in-service the MDS coordinator on the revised policy upon the completion of the update to the policy. Element #4: An audit tool will be developed by the Director of Nursing to monitor monthly for timely MDS submissions. Audits will be done for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5: Director of Nursing 5/1/25