F636 — Comprehensive Assessments and Timing
Failure to complete a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity (MDS) within 14 days of admission, no less than once every 12 months, and within 14 days after a significant change.
Reg cite · 42 CFR 483.20(b)(1)(2)
11 surveys in corpus
7 states
What surveyors look for
- Admission MDS completed within 14 days, signed by the RN coordinator
- Significant Change in Status Assessment (SCSA) within 14 days of meeting trigger criteria
- Quarterly assessments completed every 92 days, annuals every 366 days
- Care Area Assessments (CAAs) completed for every triggered area, documented in the resident chart
Common gotchas
- MDS coded for a higher acuity than documented in the chart (Section GG mismatch)
- Significant changes missed because nursing didn't trigger SCSA review
- PDPM HIPPS coding driven by upcoding rather than clinical reality
- ARD (Assessment Reference Date) windows missed by 1-2 days
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record review, facility document review and facility policy review, the facility failed
to ensure a Minimum Data Set (MDS) assessment was completed in the required timeframe of 14 days for
4 (Resident, #85, #135, #184) of 4 residents reviewed for MDS assessment and timing.
The findings in…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
b. A review of the completed MDS for Resident was electronically signed as completed by Registered
Nurse (RN) #4 on [date].
6. Review of a facility document, Notice of Admission, indicated Resident was admitted on [DATE]
with diagnoses that included respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure,
chronic obstructive pulmonary disease, chronic kidney disease and Raynaud's syndrome.
a. A record review of Resident ' s EHR on [date] at 10:12 AM, revealed no admission MDS was
c…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
The facility identified a census of 74 residents. The sample included 18 residents. Based on observation,
record review, and interviews, the facility failed to fully complete the annual comprehensive Minimum Data
Set (MDS) for Resident (R) 45 by not completing documentation analysis for triggered care areas. This
placed this resident at risk for inaccurate reflections of the resident's status a…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On [date] at 02:24 PM Administrative Nurse D stated the MDS coordinator was responsible for ensuring
that the MDS was completed including the CAA all the information was documented and the care plan was
updated.
The undated facility Resident Assessment - RAI policy documented: Documentation of the summary
information regarding the additional assessment performed on the care areas triggered by the completion
of the MDS. The assessment process would include direct observation and communication with the
resident, a…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interviews, it was determined that the facility failed to complete comprehensive
Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care
planning and maintain current and accurate assessment records. This was evident for 1 (Resident) of
6 residents…
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
Related F-tags
Just got cited at F636? Draft your POC in minutes.
Upload your 2567, choose your state, and get a CMS-compliant POC draft you can edit and submit.
Start the drafter →