Failure to Timely Transmit MDS Assessments
Penalty
Summary
Mountain Top Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding the encoding and transmission of Minimum Data Set (MDS) assessments. The facility failed to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for six residents. These residents' assessments, which included quarterly and end-of-stay evaluations, were not completed or submitted on time, as evidenced by the clinical record reviews and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the residents were not completed and submitted within the mandated period. The assessments for Residents 70, 77, 58, 100, 78, and 47 were all delayed, with some remaining incomplete and unsubmitted through the survey's conclusion. This failure to adhere to the required timelines for MDS data submission was identified during the Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on April 18, 2025.
Plan Of Correction
F0640 - Encoding /Transmitting Resident Assessment A. Corrective action taken for residents identified: Residents #70, #77, #58, #100, #78, #47 - outstanding MDS completed and submitted. B. Registered Nurse Assessment Coordinator or designee will conduct an initial audit of open MDS assessments to review for timely completion. Findings will be addressed and corrected. C. Nursing Home Administrator or designee will re-educate on the required assessment completion and transmission timeframes per CMS regulations. D. Nursing Home Administrator or designee will complete an MDS tracking form weekly x6 weeks of completed assessments, to for timeliness. Any variances of completion or submission within regulatory timeframes will be addressed, and results will be shared with QA committee for review.