Failure to Complete Significant Change MDS and CAA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment and the associated Care Area Assessment (CAA) for a resident who was admitted to hospice services. The resident, who had diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux, was admitted to hospice, but the required Significant Change MDS was not completed within the mandated timeframe. Additionally, the CAA was not completed within 14 days after the initiation of the Significant Change MDS. The resident's electronic medical record did not contain an order for hospice admission, although an order was present on the hospice provider's certification form. Interviews with facility staff revealed that the nurse responsible for completing the MDS was behind due to providing direct care to residents. Another staff member indicated that both administrative and corporate staff were responsible for ensuring timely MDS completion as required by CMS. The facility was unable to provide a policy regarding the required timing for MDS completion when requested by surveyors.