Failure to Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the mandated 14-day timeframe for four residents. Specifically, annual MDS assessments for three residents and a discharge MDS assessment for one resident were either marked as finalized or in production batch status, indicating that they were completed but not transmitted or not sent at all. These findings were based on record review and staff interviews, which confirmed that the assessments were not submitted as required. During an interview, the Director of Nursing (DON) explained that she was new to her position and that all MDS nurses were also new and still undergoing training. The DON acknowledged responsibility for managing and coordinating the assessments and stated that the delays in transmission were due to recent personnel changes in the MDS department. The DON clarified the status terms used in the system and confirmed that the assessments had not been transmitted within the regulatory timeframe.