Failure to Timely Transmit Resident MDS Assessments
Penalty
Summary
The facility failed to ensure timely transmission of the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, three residents' assessments were not submitted within the federally mandated timeframes. For one resident with schizencephaly and spastic quadriplegia, the quarterly MDS assessment completed in February was not transmitted as of May, resulting in a delay of 69 days. Another resident with hypertension, type 2 diabetes mellitus, and a history of cerebrovascular accident had a quarterly assessment transmitted 7 days late and another assessment 37 days late. A third resident, who had severe disability post anoxic encephalopathy, had a comprehensive assessment due in March that was not transmitted, resulting in an 81-day delay. Interviews with the Director of Nursing (DON) confirmed that it was her responsibility to transmit the completed MDS assessments and that the facility's policy required submission within 14 days of completion. Record reviews and interviews revealed that these policies were not followed, and the DON acknowledged the lapses. The facility's own policy, reviewed during the survey, reiterated the requirement for timely electronic transmission of completed MDS assessments to the CMS QIES-ASAP system, which was not adhered to in these cases.