Failure to Complete and Submit Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment was updated and submitted to CMS at least once every three months as required. Specifically, a resident who had been readmitted with diagnoses including anxiety and hypothyroidism did not have their quarterly Minimum Data Set (MDS) assessment completed and transmitted within the mandated timeframe. The MDS coordinator confirmed that the quarterly MDS was due but was not completed and transmitted until nearly two months after the target date. The delay was identified during a review of the resident's electronic health records and confirmed by the facility's CMS submission report. The resident in question had a history and physical indicating a lack of capacity to make decisions. Despite this, the required quarterly MDS assessment was not completed and submitted on time, as confirmed by both the MDS coordinator and the DON. The facility's own policy requires comprehensive assessments at intervals designated by OBRA and PPS requirements, but this was not followed in this instance, resulting in a failure to provide CMS with timely and accurate resident information for quality care measure and tracking purposes.