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Ftag of the Week – F641 Accuracy of Assessments

This week’s “Ftag of the Week” is F641 Accuracy of Assessments, which is currently the ninth most frequently cited deficiency on standard surveys across the United States. This regulation, as its name suggests, requires that the MDS assessment accurately reflects the resident’s status at the time of assessment. The Interpretive Guidance (IG) specifically states that the assessment needs to represent an accurate picture of the resident’s status during the observation period of the MDS and only occurrences that happened during the observation period will be captured on the MDS. The regulation also emphasizes the importance of qualified staff who are knowledgeable about the resident’s needs participating in the assessment process.

Under the LTCSP, there is a Resident Assessment Critical Element Pathway which is to be used when a surveyor is not using one of the specific care area pathways or when there are concerns about MDS data completion or submission activities for that provider. However, F641 Accuracy of Assessments can be cited based on surveyors reviewing the MDS against their observations and interviews with residents/ representatives. One area where there have been a multitude of deficiencies cited this year is related to dental care. Surveyors either visually observe dental issues or residents mention them on interview, and when the MDS and CAA is reviewed, the resident’s information is often inaccurate. Two other areas to pay attention to are restraints and hospice, as both have been cited on survey numerous times this year.

There should be a mechanism in place for monitoring and validating MDS assessment coding on a routine basis. There should also be ongoing education of staff involved in the assessment process to ensure that these staff members are kept informed of all coding changes/updates related to the MDS.  Ensuring that MDSs are accurately coded is not an easy process; it takes time and effort by knowledgeable staff who are aware of the impact of inaccurate assessments on survey outcomes as well as potential reimbursement issues being identified during an external audit.

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