Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14 days of completion for eight sampled residents. According to the Resident Assessment Instrument (RAI) Manual, all non-admission OBRA and PPS assessments must be completed and submitted no later than 14 days after the Assessment Reference Date (ARD). However, review of the records showed that multiple quarterly and annual MDS assessments for these residents were submitted significantly past the required timeframe, with some assessments being submitted several months after the ARD. During staff interviews, the MDS Coordinator confirmed that the identified assessments were submitted late and stated she was unaware of the delays. The deficiency was identified through staff interviews, record review, and examination of the RAI Manual, which established the timeliness criteria that were not met for the affected residents.