F641 — Accuracy of Assessments
Failure to ensure each MDS assessment accurately reflects the resident's status. Common when documentation in the medical record contradicts coded MDS items — frequently audited by CMS for fraud and Medicare Advantage downcoding.
Reg cite · 42 CFR 483.20(g)
99 surveys in corpus
26 states
What surveyors look for
- MDS coding traceable to source documentation (nurses' notes, therapy notes, MAR, TAR)
- Section GG mobility/self-care scores match physical/occupational therapy evaluation
- Section K nutrition data matches dietary intake records
- Section O therapy minutes match the actual therapy logs minute-for-minute
Common gotchas
- ADL scoring inflated to drive higher RUG/PDPM payment
- Therapy minutes coded without therapist signature on individual session logs
- Active diagnoses listed without physician confirmation in past 7 days
- Bowel/bladder incontinence under-coded to avoid Triple-Check audit
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 - Few
Ensure each resident receives an accurate assessment.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set
- a federally required assessment for long term care residents) accurately represented two residents (#37
and #97) out of 22 sampled residents. This failed practice placed the residents at risk for inadequate care
planning and services to achieve their highest practicable and funct…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
request form is required to sign the assessment certifying the accuracy of that portion of the assessment
.The information captured on the assessment reflects the status of the resident during the observation
[look-back] period for that assessment.
.
40
8
025025
[date]
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NU…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives an accurate assessment.
Based on observation, interviews, record review, and facility document review, it was determined that the
facility failed to ensure a comprehensive assessment accurately reflected a resident ' s status and needs for
1 (Resident) of 1 sample mix residents reviewed for comprehensive care plan development.
The findings are:
During an observation on [date] at 11:56 AM, this surveyor observed Resident with an oxygen
concentrator in the room running at five (5) lit…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident was inaccurate as it did not document the resident had a bi-pap.
During an interview with the MDS Coordinator on [date], she confirmed the Medicare 5-day MDS did
not note the resident had a bi-pap.
15
2
045138
[date]
Department of Health & Human Services
Centers for Medicare & Medicaid Services
Printed:
Form Approved OMB
No. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
(X3) DATE S…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives an accurate assessment.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum
Data Set (MDS) assessment was accurately completed for 2 (Residents #25, #184) of 3 residents reviewed
for MDS accuracy. Specifically, the facility failed to identify and ensure information regarding bedrails was
accurately assessed and completed on the MDS for Resident; …
Accepted POC examples
Multiple Construction:
Name of Facility Surveyed:
Facility Address (Street, City, State. Zip Code)
Name of Accrediting Organization Performing Survey (if applicable):
ID Prefix
Tag
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency should be preceded by full
regulatory or LSC identifying information)
ID Prefix
Tag
12 12VAC5-371-140(E) (3) (B). Criminal
Record Checks: Sworn Disclosure and
Reference Checks. Please cross reference
to F607.
12 VAC 5-371-250 (A) & (D) & (E)
Accuracy of Records Please cross
reference to F641
[phone]-08-11
HARBOR'S EDGE
VA
F
001
F
Multiple Construction: …
Related F-tags
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