Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days after a resident was discharged from hospice services. According to the medical record, the resident was admitted to hospice and an SCSA was completed following this admission. However, after the resident discontinued hospice services, no subsequent SCSA was completed within the required timeframe. This omission was confirmed through review of the resident's medical record and interviews with the MDS Coordinator and the Regional Resident Assessment Coordinator, both of whom verified that the required assessment was not performed after hospice discharge. The deficiency was identified during a recertification and complaint survey, where it was found that the facility did not adhere to federal requirements for timely completion of the MDS assessment following a significant change in the resident's status. The failure to complete the SCSA as mandated was specific to one resident among those reviewed, and the absence of the assessment was corroborated by both documentation and staff interviews.