§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 reviews and interviews with staff, it was determined that the facility failed to ensure that MDS assessments were transmitted within required timeframes for two of 16 residents reviewed (Residents R1 and R20).
Finding include:
Review of Resident R1's Discharge MDS (Minimum Data Set, a periodic mandatory assessment), dated December 19, 2023, revealed that the resident was admitted to the facility on October 25, 2023, and was discharged to the hospital on December 19, 2023. Continued review revealed that the assessment had not been completed, signed or transmitted to CMS (Centers for Medicare and Medicaid Services) as required.
Review of Resident R20's Quarterly MDS, dated January 29, 2024, revealed that the assessment was signed as completed on March 6, 2024. Continued review revealed that the assessment had not been transmitted to CMS as required.
Interview on March 13, 2024, at 10:01 a.m. the Nursing Home Administrator confirmed that the above assessments for Residents R1 and R20 were not transmitted to CMS within the required timeframes.
28 Pa Code 201.14(a) Responsibility of licensee
| | Plan of Correction - To be completed: 04/09/2024
1. Resident R1 Discharge MDS was submitted on 3/13/24. Resident R20's Quarterly MDS was submitted on 3/13/24.
2. MDS assessments for all in-house residents audited for submission compliance Assessments data submission was completed on 3/25/24.
3. MDS coordinator was educated on the need for timely and complete submission of MDS assessments.
4. MDS coordinator and/or designee will review to ensure that MDS are completed as per the required date and ready to submit timely. MDS coordinator will audit assessments weekly for 4 weeks for completion and submission, results submitted to the QAPI committee. The QAPI committee will determine the need for further audit submissions.
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