Failure to Timely Complete MDS Assessments After Significant Change
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe following a significant change in condition for five residents who enrolled in hospice care. For each resident, the Electronic Health Record and Medicare Hospice Election forms documented the date hospice services began, but the corresponding Significant Change MDS assessments were completed and dated well beyond the 14-day requirement outlined in the 2024 Resident Assessment Instrument (RAI) Manual. The delays ranged from 18 to 25 days after hospice election, exceeding the federal guidelines for timely assessment. This deficiency was identified through clinical record review and staff interviews, which confirmed that the facility did not have a policy regarding MDS Assessments and relied solely on the RAI manual. The residents involved were all documented as having a significant change in condition due to enrollment in hospice care, which should have triggered a timely comprehensive assessment. The lack of timely MDS completion was observed for all five residents reviewed for MDS Assessments.