Explore Resident Assessment F-Tags, briefly covering various items to ensure compliance.
Today we explore Resident Assessment F-Tags, briefly covering various items, including Comprehensive Assessments, Readmission Considerations, Understanding Dates, RAI Process, Care Planning, Sources of Information, Timing Rules, and Assessment Probes.
F636- Comprehensive Assessments and Timing
Assessments must occur within 14 days of admission and at least once every 12 months thereafter, ensuring thorough and standardized evaluations using tools like the RAI, covering demographic details, cognitive abilities, communication skills, mood, behavior, and psychological well-being. There should also be documentation of the participation in the assessment and must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The assessments must be comprehensive, accurate, and standardized so that anyone reviewing the resident's chart knows where they can find the needed information.
F637- Comprehensive Assessment After Significant Change
In assessing residents, it's crucial to catch significant changes in their condition promptly. These assessments compare their current status to their most recent comprehensive assessments. Once a significant change is determined, the MDS process needs to be completed within 14 days. Completing assessments and care plans within these time frames is vital for effective care. Hospice enrollment or changes also require timely assessments to ensure residents receive appropriate support.
What is considered a significant change?
- Will not normally resolve itself without further intervention.
- Has an impact on one or more areas of the resident’s health.
- Requires interdisciplinary review and/or revision of the care plan.
Things to ask yourself to ensure compliance:
- Did we identify, in a timely manner, those residents who experienced a significant change in status?
- Is there documentation in the medical record when the determination was made that the resident met the criteria for a Significant Change in Status Assessment (SCSA)?
- Did the facility reassess residents who had a significant change in status, using the CMS-specified RAI, within 14 days after determining the change was significant?
F638 – Quarterly Assessment at Least Every 3 Months
The timeliness of the Q MDS is crucial in keeping your community compliant. The Q MDS must be completed within 92 days after the previous OBRA and no later than 14 days after the ARD. In cases of Significant Change in Status Assessment (SCSA), the next quarterly review is due within 3 months after the SCSA ARD. However, some states might require more frequent assessments, so it is important to be familiar with the laws specific to where you are located.
Things to ask yourself to ensure compliance:
- Does your facility assess residents, using the CMS-specified quarterly review assessment, no less than once every 3 months, between comprehensive assessments?
- Is there evidence of resident and/or resident representative participation in the assessment process? Examples include participating in the resident interviews and providing information about preferences or discharge goals.
F640 – Encoding/Transmitting Resident Assessment
Facilities must provide resident-specific information to ensure accurate payment and quality measures while monitoring residents' progress. This involves encoding and transmitting MDS data to CMS within 14 days, including required items for entry, transfer, discharge, or death. Only CMS-required MDSs should be sent, excluding assessments for private insurance or managed care companies like Humana, which may require separate MDS submissions for billing purposes.
F641 – Accuracy of Assessments
Each resident's assessment will be coordinated by and certified as completed by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify the accuracy of the portion of the assessment he or she completed. “Accuracy of Assessment” means that the appropriate, qualified health professionals correctly document the resident’s medical, functional, and psychosocial problems and identify the resident's strengths to maintain or improve the medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).
Things to ask yourself to ensure compliance:
- Based on your total review of the resident, observations, interviews and record reviews, does each portion of the MDS assessment accurately reflect the resident’s status as of the Assessment Reference Date?
- Is there evidence that the health professionals who assessed the resident had the skills and qualifications to conduct the assessment? For example, has the resident’s nutritional status been assessed by someone who is knowledgeable in nutrition and capable of correctly assessing a resident?
F642 – Coordination/Certification of Assessment.
Essentially, everyone who puts information into the MDS is responsible for signing to the accuracy of those MDS elements. Once all of the elements are addressed and signed, a registered nurse, not an LPN but an RN, is required to sign the completion of the MDS. These signatures should be dated on the day they completed their portion. Most places are gonna have this electronic signature in the charting system, and they should have a policy to ensure proper security measures are in place for protecting electronic signatures. They also need a policy to ensure surveyors and other authorized users can have access to those clinical records.
Things to ask yourself to ensure compliance:
- Are the appropriate certifications in place, including the RN Coordinator’s certification of completion of an MDS assessment or Correction Request, and the certification of individual assessors of the accuracy and completion of the portion(s) of the assessment or tracking record completed?
F646 – MD/ID Significant Change Notification
This tag is going to be referring to the PASARR Program (Pre-Admission Screening and Resident Review) and significant changes. The intent is to ensure that individuals with mental disorders or intellectual disabilities continue to receive the care and services they need in the most appropriate setting when a significant change in their status occurs. The facility is required to notify the appropriate state mental health authority or intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in their physical or mental condition. PASARR Level II is to function as an independent assessment process for this population with special needs, in parallel with the facility’s assessment process. Nursing facilities should know their State’s PASARR policy on referral to the SMH/ID authority.
Things to ask yourself to ensure compliance:
- When a significant change in status was identified in a resident with a mental disorder or intellectual disability, was the appropriate state mental health or intellectual disability authority promptly notified?
- Does the facility have a process in place to notify the appropriate state mental health or intellectual disability authority when a resident with a Level II PASARR has a significant change in his or her mental or physical status?
If you're having trouble answering the various compliance check questions, reach out to Polaris Group today and see how we can help your facility.
