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의료기관 컴플라이언스 12개 항목

MDS / RAI Accuracy & Coding Audit (LTC)

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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?

MDS / RAI Accuracy & Coding Audit (LTC) 체크리스트 전체 다운로드

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