Late Submission of MDS Assessment to CMS
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) assessment was electronically transmitted to the CMS system within the required 14 days after completion for one resident. Specifically, a quarterly MDS assessment for a female resident with a history of aortocoronary bypass graft, congestive heart failure, atherosclerotic coronary heart disease, and diabetes was completed and signed by the Corporate RN Assessment Coordinator, but was not submitted to CMS until nine days past the required deadline. The MDS was completed on one date, but the submission occurred after the 14-day window, as confirmed by the CMS Submission Final Validation report, which flagged the record as submitted late. Interviews with facility staff revealed that the MDS Coordinators were not responsible for submitting the assessments and were unaware of the reason for the delay. The responsibility for uploading the MDS assessments was assigned to the RN who signed the MDS as completed. The Administrator confirmed that the expectation was for MDS assessments to be completed and transmitted as scheduled, with the Corporate RN responsible for submissions. The facility referenced the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments, which requires submission within 14 days of completion.