Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was discharged from hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA comprehensive assessment must be completed within 14 days following a significant change in a resident's status. The resident in question had diagnoses including Huntington's disease and hypertension, and was noted to have moderate cognitive impairment. The most recent MDS assessment indicated the resident was receiving hospice services, but documentation showed the resident was discharged from hospice on 4/30/25. Despite the discharge from hospice, the resident's care plan continued to reference hospice care, and nursing progress notes inaccurately documented that the resident was still receiving hospice services after the discharge. A review of the medical record confirmed that no SCSA was completed within the required timeframe. Interviews with facility staff, including the MDS Nurse and DON, confirmed awareness of the requirement and acknowledged that the assessment was not completed as mandated.