Late Submission of MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for five sampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) within the required 14-day timeframe following the completion of the assessments or care plans. Specifically, the quarterly and annual MDS assessments for these residents were submitted between seven and fourteen days late, as evidenced by a review of the facility's transmittal records. The electronic medical record (EMR) system in use at the facility compiles a list of due dates for MDS assessments, and the policy requires submission within 14 days of completion, but this protocol was not followed for the residents in question. During an interview, the MDS Coordinator, an LPN, was unable to provide a clear explanation for the late submissions. She indicated that a third-party company assists with MDS processing and sometimes reports that assessments have been submitted when, in fact, they have not. The LPN also mentioned the possibility of a system glitch contributing to the issue. The Resident Assessment Instrument Manual was referenced, confirming the requirement for timely submission of comprehensive and other MDS assessments.