Late Completion of SCSA MDS Following Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for one resident who began receiving hospice services. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA is required when a resident enrolls in hospice, and the assessment must be completed within 14 days of the hospice election. Documentation showed that the resident started hospice services on 03/02/2025, but the SCSA MDS was not completed until 03/26/2025, which was 10 days past the required timeframe. During interviews and record reviews, the MDS Coordinator confirmed that the assessment was completed late and acknowledged that it should have been finalized by 03/16/2025. The Director of Nursing also stated that the expectation was for MDS assessments to be completed on time and agreed that the assessment was overdue. This delay in completing the required assessment was identified during the survey and cited as a deficiency.