A resident’s discharge return anticipated MDS was not completed and transmitted in a timely manner after discharge. The MDS Coordinator confirmed the tracking assessment was late and did not know why, while the DON confirmed the resident appeared on the missing assessment report. The RAI Manual requires discharge MDS completion and transmission within specified timeframes.
The facility failed to timely submit discharge MDS assessments for two residents. Record review showed both discharge assessments were completed but not submitted, and the MDS Coordinator stated the CMS submission coding had not been updated. The DON stated MDS assessments were expected to be submitted timely after completion.
Failure to Transmit Completed MDS: A resident’s DRNA MDS was completed but not transmitted within the required timeframe. The RN/MDSC confirmed the MDS should have been sent and was unsure of the applicable deadline, and later stated there were no transmission reports because it had not been transmitted. The DON and LNHA were notified of the finding.
A resident was discharged from the facility, but the MDS record did not include a discharge assessment. Survey review found the last MDS on file was a quarterly assessment, and the MDS Coordinator confirmed the discharge MDS was missed. The LNHA later acknowledged that no discharge MDS had been completed for the resident at discharge.
Late Transmission of MDS Assessments: The facility failed to transmit MDS assessments within the required timeframe for two residents. An RN/MDSC stated she sometimes delayed transmission for Medicare residents, and she confirmed the two MDSs were late when the surveyor reviewed them. The facility policy addressed timely completion of assessments but did not include transmission timing.
The facility failed to transmit completed MDS assessments correctly for 17 reviewed residents. The MDSs were completed but submitted only as state-only assessments instead of being transmitted to CMS, and the DON and Administrator stated they were not aware of the error until the surveyor inquiry. As a result, the residents were not showing up for the provider.
The facility failed to complete and transmit required MDS assessments on time for two residents. An MDSC/RN and MDS Manager/RN acknowledged late submissions, and the MDS Manager/RN stated the assessments appeared submitted but not transmitted or accepted by CMS, suggesting an electronic records glitch. Surveyor review confirmed the comprehensive and discharge MDSs were transmitted only after inquiry and well beyond required RAI timelines.
Late MDS Submission: The facility failed to complete and transmit MDS assessments within the required timeframe for three residents. A Quarterly MDS for one resident, another Quarterly MDS for a second resident, and an Annual MDS for a third resident were all transmitted late, and the MDSC acknowledged awareness of late assessments. The DON stated that Admission, Quarterly, and Annual MDS should be completed within 14 days of the ARD.
A facility failed to complete and transmit an MDS assessment for a resident in accordance with CMS guidelines. The quarterly MDS was signed late and not submitted until well after completion, and the MDS RN who completed the assessment and the MDS RN responsible for submissions both confirmed the delay and the submission process issue.
Late MDS Transmissions: The facility failed to transmit multiple MDS assessments within the required timeframe for several residents. CMS validation reports showed late annual, quarterly, admission, and modification MDS submissions for five residents, and the MDSC/RN acknowledged that some assessments were late, including some from before she started. The DON stated that admission, quarterly, and annual MDS should be completed within 14 days of the ARD.
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