Failure to Timely Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) discharge assessment within the required timeframe for one resident. Clinical record review showed that the resident was admitted to the facility and later discharged to home, but the discharge MDS assessment was not completed at the time of discharge. The MDS Coordinator, who is responsible for tracking and submitting MDS assessments, missed the completion of the discharge MDS because she was on vacation and did not attend the care conference meeting where the discharge was discussed. The facility did not have an official written policy for MDS completion and submission. Documentation in the Electronic Health Record and staff interviews confirmed that the resident was discharged on a specific date, but the discharge MDS assessment was not completed and submitted until over a month later. The Resident Assessment Instrument (RAI) Manual requires that a discharge assessment be completed within 14 days of discharge and submitted to CMS within 14 days of completion, which was not met in this case.