Failure to Complete Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days after two residents were admitted to hospice services. For one male resident with diagnoses including encephalopathy and protein-calorie malnutrition, records showed he was admitted to hospice services, and his care plan was updated to reflect a terminal prognosis. However, there was no documentation of a Significant Change in Status MDS Assessment being completed following his hospice admission. The MDS Coordinator acknowledged responsibility for completing the assessment but stated she did not think it was necessary and missed completing it. Similarly, a female resident with dementia and post-traumatic stress disorder was admitted to hospice services, and her care plan was revised to reflect her terminal prognosis and hospice care. Despite this, her electronic health record did not show that a Significant Change in Status MDS Assessment was completed after her hospice admission. The MDS Coordinator stated she was unaware that admission to hospice alone required a Significant Change in Status MDS Assessment and believed two qualifying changes were necessary. She also indicated she had not received education on this requirement. Interviews with facility staff, including the Regional Reimbursement Nurse and the Administrator, confirmed that the MDS Coordinator was responsible for completing these assessments and that the assessments were not completed as required. The facility did not have a specific policy on MDS assessment completion and followed the RAI manual, which mandates an SCSA when a resident enrolls in hospice. The failure to complete these assessments was directly linked to a lack of understanding and oversight regarding regulatory requirements.