This week on the CMSCG Blog, we’re reviewing one of the Resident Assessment regulations, F636 Comprehensive Assessments & Timing. The intent of this regulation is to ensure that comprehensive assessments of each resident are conducted at required timeframes using the Resident Assessment Instrument (RAI). The RAI includes the Minimum Data Set (MDS), the Care Areas Assessment (CAA) Process and the RAI utilization guidelines, which when combined together, help to identify important information about the resident. This includes:
- Health status
- Goals of Care
- Functional status
- Strengths
- Needs
- Preferences
In order to identify the resident’s strengths, needs, goals, preferences and life history information, the comprehensive assessment is conducted, which captures data in a standardized manner to assist with comprehensive care planning.
“Comprehensive Assessment” – For the purposes of this regulation, a comprehensive assessment includes completion of the Minimum Data Set (MDS) and the Care Area Assessment (CAA) Process which lead to developing/reviewing the comprehensive care plan. Comprehensive MDS assessments include: Admission / Annual / Significant Change in Status Assessment / Significant Correction to Prior Comprehensive Assessment.
Per the regulation at F636, the comprehensive assessment must include everything from demographic information to disease diagnosis and health conditions to discharge planning, which gives the facility a good picture of what it needs to do for the resident to meet these goals and address the resident’s preferences. This data is required to be captured through communication with the resident/ representative, licensed and non-licensed direct care staff across all shifts and the resident’s physician in addition to direct observation of the resident. While this assessment captures a thorough view of the resident, the Interpretive Guidance (IG) reminds providers that they are responsible for addressing all needs and strengths of the residents, regardless of whether they are within the scope of the RAI or not.
Time Frame Compliance
The other important part of F636 is regarding specific time frames for when comprehensive assessments must be completed. Here’s what to know:
- A comprehensive assessment must be completed no less than every 12 months/ 366 days.
- A comprehensive assessment must be completed within 14 days of admission.
The 14-day admission timeframe excludes readmissions when there has been no significant change in the resident’s condition. The IG notes that this readmission is defined as a “temporary absence for hospitalization or therapeutic leave” after which the resident returns to the facility. If a comprehensive assessment was completed prior to the resident’s hospitalization or therapeutic leave, and the resident does not qualify for a Significant Change in Status Assessment, then the facility does not need to conduct another comprehensive assessment. However, don’t forget -providers are required to complete a comprehensive assessment any time there is a significant change in the resident’s status. Don’t worry . . . there’s an Ftag for that, too!
