Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days after determining a resident had a major decline in condition and required hospice services. The resident was admitted on 11/07/25 and subsequently had a physician order on 01/16/26 for a hospice referral, followed by an order on 01/22/26 to admit the resident to hospice. A hospice admission agreement was signed by the resident’s family member on 01/17/26, and a hospice nurse documented a start-of-care visit on the same date. Despite these documented indicators that the resident’s condition had declined and hospice services had begun, record review showed no significant change MDS assessment was completed within the required 14-day timeframe. During interview, the MDS Coordinator and Regional MDS Coordinator confirmed the resident was placed on hospice services on 01/17/26, that no change in condition MDS assessment was completed, and that staff were expected to complete such an assessment within 14 days after identifying a change in condition.
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