Failure to Complete SCSA MDS Assessment After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment for a resident who elected to begin hospice care. According to the clinical census and health status notes, the resident's primary payer changed to hospice, and hospice services were initiated. The resident's representative signed a hospice election statement, confirming the start of hospice care. However, review of the MDS 3.0 Summary page in the electronic health record revealed that the required SCSA MDS assessment was not completed following the election of hospice services. Interviews with the MDS Coordinator and the Administrator confirmed that the facility was aware of the requirement to complete the SCSA within 14 days of the significant change, as outlined in the RAI manual. Both staff members acknowledged that the assessment was not completed for the resident after the initiation of hospice care. The RAI manual specifically requires an SCSA when a terminally ill resident enrolls in hospice while remaining in the facility, with a completion deadline of 14 days from the determination of the significant change.