Failure to Timely Transmit MDS Discharge Assessments
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services within the mandated timeframe for two residents. For one resident, the discharge MDS with an Assessment Reference Date (ARD) was not submitted and accepted until more than two years after the ARD, exceeding the required 14-day submission window. The MDS nurse indicated that uncertainty among staff regarding the resident's potential return delayed the completion and submission of the MDS, despite reminders about the deadline. The Interim Director of Nursing confirmed the expectation for timely MDS completion and transmission. For another resident, the discharge MDS assessment was also submitted late, with the MDS Coordinator stating that the sections did not meet the required completion times, resulting in a delayed submission. Both cases were identified through interviews and record reviews, which confirmed that the facility did not adhere to the RAI manual's requirements for timely MDS completion and transmission. The failure to submit these assessments within the required timeframe was directly observed and acknowledged by facility staff.