Failure to Transmit Required Discharge MDS: The facility did not timely transmit a required Discharge MDS for a resident who was transferred to the hospital and did not return. Surveyors reviewed the resident’s record and MDS submissions and found no Discharge MDS had been sent. The MDSC confirmed the Discharge-Return Anticipated MDS was not completed or transmitted when the resident left the facility.
Failure to transmit a resident’s death MDS assessment to CMS occurred after the RN/MDS coordinator completed the assessment but did not hit the complete button. The DON and ADON stated only three staff had access to transmit MDS assessments, and they were not aware the assessment needed transmission because it was not completed in the system.
MDS assessments were not completed or transmitted timely for multiple residents, including entry tracking, quarterly, modification to quarterly, and discharge assessments. Survey review of the EHR found missing accepted transmission dates or accepted dates outside the required window, and the Regional Nurse-D confirmed the assessments were completed or transmitted incorrectly.
A required discharge MDS assessment was not completed or transmitted for a resident who was transferred to the hospital and did not return. Review of the electronic health record and staff interviews confirmed the omission, with the MDS coordinator unable to provide a reason for the oversight. Both the DON and NHA were notified of the missing assessment.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period after assessment, as evidenced by a review of assessment records and transmission logs.
The facility failed to transmit MDS assessments within the required timeframe for three residents, resulting in a deficiency. The assessments for these residents, who were either self-pay or on a Medicare Advantage Plan, were completed but not transmitted to CMS. The issue was identified through record reviews and interviews, with the facility's staff citing payor source as the reason for non-transmission.
Two residents' Quarterly MDS assessments were not transmitted to CMS within the required 7-day period after completion. The assessments, completed by an RN working remotely, were submitted late due to oversight. An LPN, new to the MDS process, confirmed the delay during a surveyor's review.
A resident's Quarterly MDS assessment was completed but not submitted to CMS within the required 14-day timeframe, resulting in a 55-day delay. The Nursing Home Administrator acknowledged the delay, citing a communication breakdown as the cause.
The facility failed to transmit MDS assessments timely for three residents, resulting in a deficiency. Completed assessments were not accepted by the iQIES system due to a coding error in the EMR system. The Director of Clinical Reimbursement confirmed the oversight, noting that the assessments were marked as completed but not transmitted. The MDS nurse was still in training, and regional staff were responsible for the transmission process.
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