Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure timely electronic submission of Minimum Data Set (MDS) assessments to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day period after completion. Specifically, for three sampled residents with significant medical conditions such as cerebral infarction, hypertension, dementia, anxiety, atrial fibrillation, chronic kidney disease, and altered mental status, the MDS assessments were completed but not transmitted to the system within the regulatory timeframe. The MDS Nurse confirmed that the assessments for these residents were completed on specific dates but were not submitted until several weeks later, exceeding the 14-day requirement. Record reviews and staff interviews revealed that the MDS assessments for these residents, who required varying levels of staff assistance with activities of daily living and were cognitively impaired, were not submitted as per CMS regulations. The DON acknowledged the requirement for timely submission and the importance of notifying CMS of any changes in resident care. The deficiency was further supported by reference to the CMS Resident Assessment Instrument (RAI) Manual, which outlines the 14-day submission requirement for MDS data.