Failure to Complete Timely SCSA and Care Plan Meeting After Hospice Provider Change
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who changed hospice providers while remaining in the facility. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA must be completed within 14 days when a terminally ill resident changes hospice providers. The resident, admitted with diagnoses including malnutrition and chronic obstructive pulmonary disease, transferred from one hospice provider to another, but the required SCSA was not completed until 57 days after the change. This delay was due to a lack of communication between facility staff and the Regional MDS Coordinator, as staff were unaware that a change in hospice provider necessitated a SCSA and failed to notify the coordinator. Additionally, the resident was not offered or invited to a care plan meeting following the change in hospice provider, as required within seven days after the completion of an MDS assessment. Interviews revealed that neither the unit manager nor the social worker scheduled or attended a care plan meeting for the resident after the hospice provider change. The social worker was unaware of the requirement for a SCSA in this situation and acknowledged that the resident would have benefitted from a care plan meeting to review the plan of care. The deficiency was only identified at the end of June, resulting in the resident not being involved in care planning during this period.