Failure to Timely Complete and Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to timely complete and submit Discharge Minimum Data Set (MDS) assessments for two residents who had been discharged. Review of the clinical records for these residents showed that their Discharge MDS assessments were overdue, had not been started, and had not been submitted to the Centers for Medicare & Medicaid Services (CMS) as required. This was confirmed during an interview with the assistant director of nursing (ADON), who acknowledged that the assessments were not completed or submitted within the required timeframes. Facility policy and the CMS Resident Assessment Instrument (RAI) Manual specify that Discharge MDS assessments must be completed within 14 days of discharge and transmitted to CMS within an additional 14 days. Despite these guidelines, the responsible staff did not initiate or submit the required assessments for the two discharged residents, resulting in non-compliance with federal regulatory requirements.