Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion for eight out of nine residents reviewed. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS assessments, including Admission, Significant Change, Quarterly, and Annual assessments, must be completed no later than 14 days after the Assessment Reference Date (ARD) and submitted to the CMS database within 14 days of completion. Review of the electronic health records (EHR) for the identified residents showed no MDS data was present for assessments with ARDs in March 2025, and there was no indication that these MDSs had been scheduled, completed, or transmitted as required. The deficiency was further substantiated by the facility's March 2025 MDS Final Validation Report (FVR) from CMS, which showed that for each of the eight residents, the most recent MDS assessments were submitted more than 14 days after their completion dates. The administrator explained that a recent change in facility ownership and EHR systems resulted in an inability to access the data for MDS assessments completed in March 2025, which contributed to the delay in submission. The lack of timely MDS transmission was identified through both record review and staff interview.