Mastering Compliance with F641 - Accuracy of Assessments

Understanding and actively monitoring compliance with F641 is crucial. Recent updates emphasize the need for sufficient clinical documentation to support diagnoses coded on the MDS, particularly when these diagnoses (like schizophrenia) are associated with treatments such as antipsychotic medications. Surveyors will scrutinize whether the medical record contains adequate evidence to validate MDS coding.

This post summarizes the key requirements of F641 and provides practical compliance probes to help you verify your facility's adherence.

Section 1: Key Requirements of F641 - Accuracy of Assessments

1. Overall Accuracy (§483.20(g)): The MDS assessment must accurately reflect the resident's status during the specific Observation (Look-back) Period, ending on the Assessment Reference Date (ARD). This includes medical, functional, and psychosocial problems, as well as resident strengths. If something didn't occur during the look-back period, it should not be coded.

2. Coordination (§483.20(h)): A Registered Nurse (RN) must conduct or coordinate each assessment. This involves ensuring the appropriate participation of various health professionals (physicians, therapists, social workers, dietitians, activities staff, etc.) based on the individual resident's needs.

3. Certification (§483.20(i)):

• An RN must sign and certify the completion of the assessment.

• Each individual who completes a portion of the MDS must sign and certify the accuracy of that specific portion. This signifies accountability for the information provided.

4. Documentation Supporting Diagnoses: A significant focus area is ensuring adequate clinical documentation exists in the medical record to support diagnoses coded on the MDS.

• Specific Concern: CMS highlights instances where diagnoses (e.g., schizophrenia) are coded without sufficient supporting documentation meeting established criteria (like the DSM), especially when linked to antipsychotic use.

• Required Evidence: Surveyors will look for documentation such as evaluations (physical, behavioral, mental, psychosocial), ruling out other causes (substances, medical conditions), signs of distress, functional changes, resident complaints, behaviors, symptoms, and PASARR evaluations. Lack of such documentation for a coded diagnosis constitutes noncompliance.

• Scope: While one or two instances might be cited as isolated, a pattern (three or more) of inaccurate diagnosis coding without support can lead to pattern/widespread citations and referrals to state boards or the OIG.

5. Staff Knowledge & Competency: The facility is responsible for ensuring all participants in the assessment process possess the necessary knowledge and skills to complete an accurate assessment according to RAI guidelines.

6. Signatures & Timeliness:

• Signatures (manual or electronic, where permitted by state law and facility policy) must certify accuracy.

• Policies must be in place for secure electronic signatures and access to hard copies.

• Backdating completion dates is prohibited. Recording the actual date of completion is required, even if documented after the fact.

7. Penalty for Falsification (§483.20(j)): Willfully and knowingly certifying (or causing another to certify) a material and false statement on an assessment carries significant Civil Money Penalties ($1,000 - $5,000 per assessment). Clinical disagreement alone does not constitute falsification.

8. Patterns Indicating Potential Issues: Patterns of MDS submissions or corrections that inaccurately inflate PDPM scores, avoid triggering Care Area Assessments (CAAs), or mask negative Quality Measures (QMs) may indicate noncompliance and potential fraud. This includes inaccurate coding, questionable corrections, inappropriate Significant Change assessments, or delayed/withheld submissions.

Section 2: Compliance Probes for Administrators

Use these questions to assess your facility's compliance with F641:

1. Overall Accuracy & Observation Period:

• How do we verify that MDS coding only reflects resident status and events within the specific look-back period for each item?

• What is our process for auditing completed MDS assessments against clinical documentation (progress notes, therapy notes, etc.) to ensure accuracy before submission?

2. Diagnosis Documentation:

• Crucially: When a diagnosis (especially one like schizophrenia, justifying antipsychotic use) is coded on the MDS, particularly if it's new or differs from prior records, what is our process to confirm that sufficient, objective clinical documentation (evaluations, diagnostic workups, evidence ruling out other causes) exists in the chart prior to certification?

• How do we audit records to ensure diagnoses coded on the MDS align with documented clinical evidence meeting diagnostic standards?

• Is there a clear process involving physician/practitioner confirmation and documentation before a significant diagnosis like schizophrenia is added to the MDS?

3. Coordination & Interdisciplinary Input:

• How does the RN coordinator ensure appropriate input from all relevant disciplines (therapy, social work, activities, dietary, etc.) based on resident needs?

• Are there regular IDT meetings where MDS items are discussed and validated against observations from various team members?

4. Certification & Signatures:

• Does every individual contributing to the MDS sign and date (accurately reflecting the completion date) their portion, certifying its accuracy?

• Does an RN review the complete assessment and certify its completion?

• If using electronic signatures, do we have clear, written policies addressing security, authorization, and compliance with state law? Is staff trained on these policies? Are hard copies readily accessible?

• How do we monitor to ensure completion dates are not being improperly backdated?

5. Staff Competency & Training:

• What ongoing training do MDS coordinators and contributing staff receive on RAI manual updates, coding guidelines, observation periods, and the importance of accuracy?

• How do we assess and ensure the competency of staff involved in the MDS process?

6. Auditing for Patterns & Falsification:

• Do we conduct internal audits to look for potential patterns of inaccurate coding that might affect PDPM scores or QMs?

• Is staff aware of the definition of falsification and the significant penalties associated with it?

• How are clinical disagreements handled versus instances of clear inaccuracy or lack of documentation?

Conclusion:

F641 underscores the critical importance of accurate, well-coordinated, and properly certified MDS assessments, backed by solid clinical documentation. Proactive internal auditing and robust processes, particularly around diagnosis verification, are essential not only for regulatory compliance but also for ensuring appropriate care planning and payment integrity. Regularly reviewing your processes against these key requirements and probes will help maintain compliance and support high-quality resident care.

#TheAdministratorsDilemma #LNHA #LNFA #HSE #NursingHomeAdministrator #NursingHomeAdmin #ExecutiveDirector #AIT #Leadership #LTC #SNF #SkilledNursing #NursingHome #NursingHomeLife #Healthcare #HealthcareConsulting #Regulations #MDS #PDPM #ARD #RiskManagement #Compliance #CMS #F641