Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for five residents who were reviewed for MDS accuracy and completion. Specifically, discharge MDS assessments were not completed for these residents, as confirmed by record reviews of their electronic health records, which did not show a completed discharge MDS at least 30 days after each resident's discharge. This was identified for five out of twenty-four residents reviewed. Further review of the facility's policy and the RAI Manual confirmed that all MDS assessments, including discharge and reentry records, are required to be completed and electronically transmitted to the CMS QIES Assessment Submission and Processing (ASAP) system in accordance with OBRA regulations. The RAI Manual specifies that discharge assessments must be completed within 14 days after the discharge date. The facility did not adhere to these requirements for the identified residents, resulting in incomplete and untransmitted discharge MDS data.