Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments within the required timeframes for six sampled residents. These residents had various diagnoses, including schizophrenia, hypokalemia, tachycardia, dementia, generalized anxiety disorder, encephalopathy, Parkinson's disease, schizoaffective disorder, major depressive disorder, migraine, and generalized muscle weakness. Record reviews showed that both admission and quarterly MDS assessments were not completed or submitted on time for each of these residents, with some assessments being completed or transmitted several days or even months after the required deadlines. Interviews with the MDS Coordinator (MDSC) confirmed that the MDS assessments for the identified residents were not exported or submitted in a timely manner. The MDSC acknowledged that assessments were completed late and, in some cases, not uploaded to the third-party system used for submission. The MDSC also explained the importance of timely MDS completion and transmission, noting that delays could result in inaccurate resident assessments and care planning. The Director of Nursing (DON) also confirmed that the facility did not adhere to Medicare guidelines for MDS assessment completion and transmission. The DON stated that the MDSC is responsible for ensuring timely completion and submission of MDS assessments and emphasized the importance of following federal regulations to ensure accurate care planning and reporting. Review of the facility's policy and the CMS Resident Assessment Instrument Manual confirmed the required timeframes for MDS completion and transmission, which were not met in these cases.