Failure to Complete Significant Change MDS Assessment After Hospice Election
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition and elected to receive hospice care. The resident, admitted with diagnoses including Alzheimer's dementia and hyperlipidemia, began hospice services on July 1, 2024. Despite federal requirements mandating a significant change MDS assessment within 14 days of such an event, there was no documented evidence that this assessment was completed to reflect the initiation of hospice services. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the required comprehensive assessment had not been performed.