Failure to Timely Submit MDS Assessment Data
Penalty
Summary
Facility A failed to provide a timely submission of a quarterly Minimum Data Set (MDS) assessment for one resident with a history of hemiplegia and hemiparesis following a cerebral infarction. The resident was admitted to the facility and had a quarterly MDS assessment with an Assessment Reference Date (ARD) of 02/24/25, which was completed on 02/25/25. However, the MDS 3.0 Missing OBRA Assessment Report indicated that the last accepted MDS assessment for this resident was dated 12/03/24, showing a gap in timely data submission. The MDS Coordinator reported completing and submitting the quarterly MDS assessment as required, but did not verify its acceptance by CMS through the validation report. The coordinator misunderstood the missing assessment report and did not recognize that the quarterly assessment had not been accepted, resulting in a delay in resubmission until prompted by a surveyor. The Director of Nursing stated that the expectation was for MDS assessments to be transmitted within 14 days of completion and for validation reports to be checked to ensure acceptance by CMS, as outlined in the CMS LTC RAI 3.0 User's Manual.