Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required 14-day period after completion for three residents. According to facility policy and the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS assessments must be submitted electronically no later than 14 calendar days after the care plan or assessment completion date. Record review showed that for one resident, an annual MDS assessment was completed and signed by the MDS Coordinator but was not transmitted until well beyond the 14-day window. Similarly, a quarterly MDS for another resident and a discharge MDS for a third resident were both completed and signed but not transmitted within the required timeframe. Interviews with the MDS Coordinator confirmed that the assessments for all three residents were not transmitted timely, with the Coordinator expressing uncertainty about the reasons for the delays. The Administrator stated an expectation that all MDS assessments be completed and transmitted according to the RAI manual. The findings were based on review of resident records, facility policy, and validation reports, all of which documented the late submissions.