Failure to Complete Timely MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change in condition for two residents who were admitted to hospice care. For one resident, the electronic health record documented hospice enrollment, but the Significant Change MDS assessment was not completed within the required timeframe, as the assessment was finalized 20 days after hospice admission. For the second resident, there was no evidence that a Significant Change MDS assessment was completed at all following hospice enrollment, as verified by the MDS Coordinator during a review of the resident's records. According to the 2024 Resident Assessment Instrument (RAI) Manual and the facility's own policy, a comprehensive assessment is required within 14 days of a significant change in a resident's status, such as enrollment in hospice care. The failure to complete and transmit these assessments as required was identified through clinical record review, staff interview, and policy review, and involved two residents out of a census of 54.