Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The resident was originally admitted with diagnoses including urinary tract infection, generalized muscle weakness, and dysphagia, and was later readmitted. Review of the resident's records showed that the Quarterly MDS assessment had an Assessment Reference Date (ARD) of 4/24/2025 but was not submitted until 5/8/2025, which was the 93rd day, exceeding the 92-day requirement. The Director of MDS confirmed that the assessment was completed late and acknowledged the use of an MDS Scheduler to track due dates, which provides warnings for overdue assessments. Interviews with the Director of MDS and the Director of Nursing confirmed that timely completion and submission of MDS assessments are necessary for accurate quarterly reviews, care planning, and billing. Both staff members stated that late completion or submission of MDS assessments could result in delays in care, especially if there are significant changes in a resident's condition. Review of facility policy and the CMS Resident Assessment Instrument Manual confirmed the requirement for quarterly MDS assessments to be completed within 92 days of the previous assessment.