We’re back with our CMSCG “Ftag of the Week” blog series, and next up is F638 Quarterly Assessments. This is a short regulation, but it’s an important one. The regulation requires that facilities assess each resident no less than once every 3 months using the quarterly review instrument (MDS) which has been specified by each state and approved by the Centers for Medicare & Medicaid Services (CMS). The quarterly review is a non-comprehensive assessment that must be completed at least once every 92 days following the previous assessment (of any type). Since this is not a comprehensive assessment, not all MDS items are included in the assessment.
How – and Why – It’s Cited
F638 is primarily cited related to failures to complete quarterly MDS assessments within required timeframes. That’s to be expected since this reg is about timing and not much else. Let’s review the regulatory language which specifically addresses timeliness. A quarterly MDS will be considered timely if the following criteria are met:
- The Quarterly MDS’s Assessment Reference Date (ARD) is within 92 days after the ARD of the previous assessment of any kind. Specifically, the time frame is the ARD of the most recent assessment + 92 days = timely
- The MDS completion date in Section Z is no later than 14 calendar days after the ARD.
- For Significant Change is Status Assessments, the next quarterly review is due no later than 3 months after the Sig Change ARD.
Don’t forget this important note at F638: Even though a quarterly MDS doesn’t require completion of Care Area Assessments, the resident’s care plan must be reviewed and revised by the IDT after each required assessment.
It seems like it’d be easy to avoid an F638 citation, but what we typically see on mock surveys and talking with clients – as well as reviewing Statement of Deficiencies – is that the root cause of these citations is rarely a documentation problem. It’s usually a coverage gap: turnover in the role, a vacancy that remains open longer than anticipated, or a scheduling calendar that lives in one person’s head. It’s a good reminder that timeliness compliance is only as strong as its weakest link, and a surveyor isn’t going to consider the “why” when they see an assessment is late – only that it was. From a compliance standpoint, the calendar itself deserves as much attention as the assessment. Ensure you’ve got a good process in place that identifies who is responsible for tracking ARDs, who has visibility into what is coming due, and what happens if that person is out. There needs to be a back-up staff member who understands the system and keeps the team on target when a key position is not covered/vacant even for a short period of time. MDS staff turnover or workload/ scheduling gaps can bring unnecessary survey penalty points.
