Failure to Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14 days after completion. Review of the electronic medical record showed that the annual MDS assessment for a resident was completed and marked as 'Production Batch' on 8/3/2025, indicating it was ready for submission. However, the assessment was not transmitted to CMS by the required deadline of 8/17/2025. Interviews with facility staff revealed that the process involved sending the completed MDS assessment to the corporate office for review before submission to CMS. The Care Plan Coordinator and the MDS Coordinator both confirmed that the assessment was not forwarded to the corporate office for initial review when completed, resulting in no validation report being received and the assessment not being transmitted on time. The delay in forwarding the assessment to the corporate office directly led to the failure to meet the CMS transmittal requirement.