When surveyors look at MDS accuracy, they’re not just checking boxes – they’re looking at whether the assessment truly reflects the resident. F641 holds the interdisciplinary team and nursing leadership accountable for how the assessment is completed, coordinated, and certified. The State Operations Manual outlines exactly what surveyors expect to see when they evaluate accuracy in practice.
The State Operations Manual (SOM) Appendix PP – Guidance to Surveyors for Long Term Care Facilities describes the federal requirements for F641 Accuracy of Assessment in §483.20 Resident Assessment, with interpretive guidance to ensure that for each resident in a long-term care (LTC) or skilled nursing facility (SNF):
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- the Minimum Data Set (MDS) accurately reflects the resident’s status during the observation period of the MDS and as of the Assessment Reference Date (ARD);
- a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals based on the physical, mental, and psychosocial needs of each resident;
- a registered nurse signs and certifies that the assessment is completed;
- each individual who completes a portion of the assessment signs and certifies the accuracy of that portion of the assessment; and
- under Medicare and Medicaid, an individual who willfully and knowingly certifies material and false statements in an MDS or causes another individual to do the same is subject to civil monetary penalties (CMPs).
CMS notes that “a pattern within a nursing home of clinical documentation or of MDS assessment or reporting practices that result in higher Patient Driven Payment Model (PDPM) scores, untriggering Care Area Assessments (CAAs) or unflagging Quality Measures (QMs), where the information does not accurately reflect the resident’s status, may be indicative of payment fraud or attempts to avoid reporting negative quality measures.” (RAI, October 2025, p. 247)
Importance of Knowledgeable Staff
The Long-Term Care Facility Resident Assessment 3.0 User’s Manual (RAI manual) does not dictate which members of the interdisciplinary team (IDT) are responsible for interviews related to the MDS. The RAI manual does indicate that the staff who are responsible for data collection and interviews should be trained to do this correctly, and the RAI manual states that “nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.” (RAI, October 2025, p. 2-5)
IDT members who are responsible for conducting resident interviews must have a good understanding of the RAI requirements for timelines and accuracy, as well as how to code the MDS when variables such as when the resident is unable or unwilling to participate in interviews, and unplanned or unexpected discharge arise. When the IDT misunderstands the requirements for timing, interviewing, and coding the interviews on the MDS, the facility risks incorrect PDPM and Case Mix Index (CMI) calculations, incorrect reimbursement, and survey tags.
Accuracy’s Impact
Members of the IDT may not realize that the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview (PHQ-2 to 9©) can impact PDPM and CMI calculations. Another common misconception related to resident interviews is thinking there aren’t coding instructions. In reality, the RAI Manual has specific instructions for coding interviews – including:
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- when the resident should have been interviewed during the lookback period of the ARD but was not interviewed
- if the resident provided nonsensical answers
- when the resident was not able to be interviewed
- if the resident refused to be interviewed
Incorrect interview information captured on the MDS in each of these situations, or coding interview (or staff assessment) data on the MDS that was not collected during the lookback period, can have far-reaching implications. These situations can result in:
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- ineffective care plans that can potentially impact resident safety – with survey implications
- inaccurate quality measure calculations and quality measure reporting both in Care Compare and the Quality Reporting Program (QRP)
- survey deficiencies and possible CMPs related to patterns of inaccurate assessments
- inaccurate reimbursement under PDPM and case-mix calculations
- federal and state audit complications such as reimbursement “claw backs” and additional audits
Protecting CMI
The result of each resident interview can impact care planning, quality measures, staffing measures, and reimbursement. Based on F641, CMS utilizes various MDS audit processes that can result in financial penalties and possible “claw backs” of payments when incorrect coding of MDS items has resulted in over-payment. This “claw back” application can affect Medicare PPS reimbursement and Medicaid reimbursement based on CMI calculations. “A willfully and knowingly-provided false assessment may be indicative of payment fraud or attempts to avoid reporting negative quality measures.” (SOM, 2025, p. 247) When CMS has sufficient concerns about improper MDS coding, facilities can face additional layers of government oversight and possible financial penalties to encourage correction of insufficient and/or improper practice, and compliance with federal regulations. To reduce the risk for any of these problems and optimize CMI, facilities should:
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- train staff to complete interviews based on the RAI manual instructions
- cross train alternate staff so interviews are not missed when regular staff are off
- ensure clear communication with the IDT when ARDs are set and when/if they change
- audit interview timing to verify this information is collected during the lookback period
- track audit findings for Quality Assurance and Process Improvement (QAPI) planning and potential Compliance and Ethics committee evaluation
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