Failure to Complete Significant Change MDS After Initiation of Hospice Care
Penalty
Summary
The facility failed to complete a significant change in condition or status assessment MDS within 14 days after a resident began hospice care, resulting in an inaccurate reflection of the resident’s status. The resident was admitted with multiple diagnoses, including chronic respiratory failure with hypoxia and dementia. A physician order dated 2/19/26 documented end-of-life care with hospice services, and the resident’s care plan also documented that hospice care started on that date. Despite this documented change in condition and care approach, the facility did not complete the required significant change MDS assessment within the mandated timeframe. On 3/31/26, the MDS coordinator acknowledged that the significant change assessment had not been completed and stated it should have been. On 4/1/26, the CNO similarly stated that the significant change in condition or status assessment MDS should have been completed within 14 days of the start of hospice care and had not been. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.