Failure to Timely Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit the initial Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with diagnoses including venous thromboembolism, anemia, and insomnia. The resident's initial comprehensive MDS assessment was completed on 3/28/2025, but the submission to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system did not occur until 5/9/2025, which was more than 14 days after the assessment completion date. Interviews with the MDS coordinator and the Director of Nursing confirmed that the MDS entry was submitted late and acknowledged the importance of timely submission to ensure proper communication with CMS regarding the care provided. Review of the MDS RAI Version 3.0 Manual confirmed that MDS assessments must be submitted within 14 days of completion, a requirement that was not met in this instance.