Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that all Minimum Data Set (MDS) assessments for residents were submitted to the State within the required 14-day period after completion. This deficiency affected all seven residents sampled, as their MDS data was either finalized but not transmitted or submitted but not reviewed and accepted within the mandated timeframe. The facility's policy requires timely and accurate completion and submission of MDS assessments in compliance with federal and state regulations, with oversight by the MDS Coordinator and the interdisciplinary team. However, due to the MDS Coordinator's frequent absences and being the sole individual responsible for MDS data, the submission process was delayed, and no other staff monitored or managed the workload in the Coordinator's absence. Record reviews confirmed that for each of the seven residents sampled, the MDS data was either finalized but not sent or was in a production batch that had not been reviewed and accepted within the required period. Interviews with the MDS Coordinator corroborated that the assessments were not submitted on time, and there was no backup process in place to ensure timely submission during the Coordinator's absence. The facility census at the time was 73 residents, and the deficiency was identified through both record review and staff interviews.