MDS Alert

Follow these tips for comprehensive assessment basics.

Assessments’ timelines are carefully designed for collecting important, standardized data on residents; to see change over time; and to help establish a consistent narrative of care.

Comprehensive assessments include completing the MDS and the care area assessment (CAA) process, the combination of which provides the groundwork for the comprehensive care plan (CCP). They are necessary upon admission, at least once annually, when a resident has experienced a significant change in status, or when a prior assessment requires a significant correction.

Remember These Numbers

The most important numbers you need to remember for the comprehensive assessment timing are 12 and 14. Comprehensive assessments should be completed no fewer than once every 12 months, and comprehensive assessments should be conducted within 14 days of admission.

“Remember, that sentence has nothing to do with timing of completion,” says Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA, MDS consultant, in Columbus, Ohio. You can find a work study about MDS section completion time through the American Association of Post-Acute Care Nursing, if you want to see how your team compares.

Important: The 14-day timeframe for admissions excludes readmissions for residents who don’t have a significant change of condition.

The comprehensive assessments require a lot of data collection, and nurse assessment coordinators (NACs) shouldn’t feel like they are solely responsible, even if they’re responsible for submitting the MDS. The assessment should be compiled with information from the resident and/or their representative, both licensed and trained care staff across all shifts, the resident’s physician, and direct observation of the resident.

The assessment reference date (ARD) is the benchmark for dating all future assessments.

ARD defined: “The specific end-point for the look-back periods in the MDS assessment process. Almost all MDS items refer to the resident’s status over a designated time period referring back in time from the Assessment Reference Date (ARD). Most frequently, this look-back period, also called the observation or assessment period, is a 7-day period ending on the ARD. Look-back periods may cover the 7 days ending on this date, 14 days ending on this date, etc.,” the RAI Manual says on page A-34.

Comprehensive Assessments Not Needed in These Situations

There are some situations where you may have started a comprehensive assessment but don’t need to finish or submit it. However, the MDS is considered part of the resident’s medical record, and any portion that is started must be saved, the RAI Manual says.

“If a resident is discharged prior to the completion deadline for the assessment, completion of the assessment is not required. Whatever portions of the RAI that have been completed must be maintained in the resident’s medical record. In closing the record, the nursing home should note why the RAI was not completed,” the RAI Manual says. The same applies in situations where a resident dies before the completion deadline.

If you’re completing an annual comprehensive assessment — not during admission or in the midst of a significant change of status assessment (SCSA) — but find that the resident is experiencing a significant change of status, you should code and complete the assessment as a significant change of status instead, the RAI Manual says.

While completing the assessment, you may encounter information that suggests the presence of a significant error in a previous assessment that was submitted and accepted into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. If you’re not already completing a significant correction of prior full assessment (SPCA) at the time, code and complete an SPCA instead of the regular comprehensive assessment instead — and also fill out and complete a correction request.

If the error you encounter is minor, the RAI Manual instructs you to continue completing the comprehensive assessment but to complete and submit a correction request.

Beware of Compliance Regulations