Did this resident have an admission,annual MDS done previously?
1) do a d/c ret anticipated
2) when res returns to facility do a reentry
3) schedule a sig change MDS(you have 14 days to complete),include new hospice status.
4) Now continue the regular OBRA schedule..quart,quart,quart,annual
5) either do a new care plan or update the old one to include hospice interventions,physical changes etc..
6) Make sure on Care Conference that the Hospice team is included and are a part of the care planning process.
** A decline in cond is expected on a hospice resident and would not necessarily need a new sig change assessment.
** Areas to be considered for care planning: pot for pain,skin breakdown,wt loss,mobilty loss,adl self ability loss etc..
If res never had an Mds done before( admission,annual):
1) do a d/c prior to initial( you have 14 days to do an initial admission assessment).
2) When res returns schedule an Admission assessment to include hospice status.
3) Do Care Plan
4) follow OBRA schedule quart,quart,quart,annual.
Hope this help