Healthcare Facility Compliance 12 items
MDS / RAI Accuracy & Coding Audit (LTC)
Audit of the resident assessment instrument process in long-term care to verify MDS accuracy, timeliness, CAA linkage, and care-plan coordination.
CMS RAI Manual42 CFR 483.20MDS 3.0
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Assessment Timeliness
- Is the admission (comprehensive) MDS completed by day 14 of admission? *
- Are quarterly and annual assessments completed within the required timeframes? *
- Is a significant change in status assessment completed within 14 days of identifying the change? *
Coding Accuracy
- Do MDS item responses match supporting documentation in the medical record for the look-back period? *
- Are Section GG functional items coded using the required interdisciplinary assessment and observation? *
- Are diagnoses coded in Section I supported by physician documentation and active in the look-back? *
CAA & Care Planning
- Are triggered Care Area Assessments (CAAs) documented with decisions to proceed to care planning? *
- Is a comprehensive, person-centered care plan developed within 7 days of the comprehensive assessment? *
- Is the RAI completed by an interdisciplinary team and signed/certified as accurate? *
Transmission & Integrity
- Are MDS assessments encoded and transmitted to CMS (iQIES) within required timeframes? *
- Is there a process to correct and re-transmit MDS records identified with errors? *
- Are validation reports reviewed to confirm acceptance and identify rejected records?
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