Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four out of six residents reviewed. Specifically, discharge MDS assessments for these residents were either completed late or not transmitted at all to CMS' Internet Quality Improvement and Evaluation System (iQIES). For example, one resident's discharge MDS was completed 35 days late and was not transmitted, while another's was completed 26 days late. In other cases, the discharge MDS was completed but not submitted to CMS as required. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the assessments were not completed or transmitted in accordance with regulatory requirements. Both staff members acknowledged that the MDS assessments should have been completed and transmitted in a timely manner after completion. The failure to transmit these assessments was identified through record reviews and staff interviews, with staff confirming the deficiencies for each affected resident.