Failure to Conduct Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to conduct a Significant Change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice services. According to the Centers for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual, a Significant Change MDS is required when a terminally ill resident enrolls in a hospice program. However, the facility conducted an Annual MDS assessment instead, with an assessment reference date of April 4, 2024, despite the resident being admitted to hospice on March 29, 2024. The resident in question had diagnoses including vascular dementia and hypertension. During a staff interview, the Nursing Home Administrator acknowledged that the facility should have conducted a Significant Change MDS due to the resident's enrollment in hospice services. This oversight was identified during a survey, and a modified MDS was later provided, indicating a change to a significant change in status assessment.
Plan Of Correction
Resident R 70's MDS has been corrected to reflect significant change. All residents receiving hospice services have had their last MDS reviewed to ensure any determination of significant change is reflected on MDS. Corrections will be made as needed. RNAC has been educated on the need for significant change MDS completion within 14 days after determination of resident significant change in status and in relation to hospice services. A QA tool has been developed to review 10% of hospice residents weekly to ensure significant change MDS completion within 14 days after determination of resident significant change in status. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.