Late Completion of Significant Change in Status Assessment After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one resident following a significant change in condition, specifically after the resident was discharged from hospice services. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA MDS must be completed within 14 days of a resident revoking hospice benefits. In this case, the resident was discharged from hospice, but the SCSA MDS was completed 13 days late, exceeding the required timeframe. Record reviews and staff interviews confirmed that the MDS coordinator was responsible for updating the SCSA MDS after such significant changes. Both the Registered Nurse and the MDS Coordinator acknowledged that the assessment was not completed within the required period. The Director of Nursing also confirmed that the assessment was late, which did not meet the facility's expectations for timely completion of MDS assessments.