§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.
§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.
§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.
§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
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Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for two of two residents who had been discharged from the facility. (Residents 1, 3)
Findings include:
Clinical record review revealed that a discharge MDS assessment was completed on December 4, 2024, for Resident 1, however the record reflected that the MDS had not been exported as of January 15, 2025.
Clinical record review revealed that a discharge MDS assessment was completed on December 11, 2024, for Resident 3, however, the record reflected that the MDS had not been exported as of January 15, 2025.
In an interview on January 15, 2025, at 9:56 a.m., RN1 stated that the discharge MDS assessments had not been exported and transmitted to the CMS system in a timely manner.
| | Plan of Correction - To be completed: 02/07/2025
The assessment for the two of two residents who had been discharged from the Facility have been completed and transmitted. (Residents 1, 3)
Holy Redeemer TCU facility will assess all records in the system to assure all residents data is now completed and electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) immediately.
The facility RNAC will electronically transmit encoded Minimum Data Set
(MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after residents are discharged from the facility. The nurse manager and NHA or their designee will monitor MDS transmissions weekly to assure compliance. We complete this audit by running the MDS in progress list from PCC weekly to assure they are all up to date and submitted. We will also run all admissions and discharges list from the EHR and reconcile the two reports to assure no one is missed each week.
The RNAC and the Unit Manager have been in serviced on the requirement and how to comply.
MDS transmission compliance reports will be added to QAPI quarterly for next 6 months.
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