Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit a completed Quarterly Minimum Data Set (MDS) assessment for one resident within the required 14-day timeframe after completion. Specifically, the assessment for a male resident with multiple complex diagnoses, including Parkinson's Disease, Alzheimer's Disease, hemiplegia, dysphagia, type 2 diabetes, and gastrostomy status, was completed and signed on 1/15/25 but was not accepted by the CMS system until 1/31/25, resulting in a 16-day delay. This was identified through record review and confirmed by interviews with facility staff, who acknowledged the late transmission and attributed it to the absence of an on-site MDS Coordinator for several months. Interviews with the Director of Reimbursement, Corporate VP of Operations, and the current MDS Coordinator confirmed that the facility relied on the RAI Manual for MDS assessment procedures and did not have a separate assessment policy. The staff acknowledged that the MDS assessment should have been transmitted within 14 days of completion, as required by the RAI Manual, and recognized that the delay constituted a failure to meet regulatory requirements for timely MDS data submission.