Failure to Submit Required MDS Assessments for Certified Beds
Penalty
Summary
The facility failed to submit two completed Minimum Data Set (MDS) assessments for one of five residents reviewed, despite being dually certified for all beds with CMS. Electronic health record (EHR) review showed that for one resident, the quarterly and admission MDS assessments were either marked as 'in progress' or 'completed' but not submitted to the Centers for Medicare and Medicaid Services (CMS). Documentation incorrectly indicated that the unit was neither Medicare nor Medicaid certified, and therefore MDS data submission was not required, despite the facility's actual certification status. Interviews with facility staff, including the Business Office Manager and the DON, confirmed that the facility is dually certified and follows the RAI manual for MDS completion and submission. The DON acknowledged that the required entry and admission MDS assessments had not been submitted as mandated. The facility had been using a third party for MDS completion during a vacancy in the MDS Coordinator position, which contributed to the failure to submit the required assessments.