Late Submission of MDS Assessment Data
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid Services (CMS) for one resident. Specifically, the admission MDS for a resident with diagnoses including type 2 diabetes mellitus with foot ulcer, encephalopathy, and generalized muscle weakness was completed with an Assessment Reference Date (ARD) of 2/12/2025 but was not submitted to CMS until 2/26/2025, which was beyond the required 14-day timeframe. The Director of MDS confirmed that the assessment was submitted late and acknowledged that the MDS Scheduler is used to track due dates, and that the system 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. The facility's policy and procedures, as well as the CMS Resident Assessment Instrument Manual, require assessments to be completed and submitted within specific timeframes. The late submission of the MDS assessment was verified through review of the CMS Final Validation Reports and facility records.