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F639

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.20(d) Use

A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.

INTENT §483.20(d)

Facilities are required to maintain 15 months of assessment data in each resident’s active clinical record.

GUIDANCE §483.20(d)

The requirement to maintain 15 months of data in the resident’s active clinical record applies regardless of form of storage to all Minimum Data Set (MDS) records, including the Care Area Assessment (CAA) Summary, Quarterly Assessment records, Identification Information and Entry, Discharge and Reentry Tracking Records and MDS Correction Requests (including signed attestation). MDS assessments must be kept in the resident’s active clinical record for 15 months following the final completion date for all assessments and correction requests. Other assessment types require maintaining them inthe resident’s active clinical record for 15 months following:

  • The entry date for tracking records including re-entry; and
  • The date of discharge or death for discharge and death in facility records.

Facilities may maintain MDS data electronically regardless of whether the entire clinical record is maintained electronically and regardless of whether the facility has an electronic signature process in place. This is in accordance with state and local law, and when this is authorized by the long- term care facility’s policy.

Facilities that maintain their MDS data electronically and do not utilize an electronic signature process must ensure that hard copies of the MDS assessment signature pages are maintained for every MDS assessment conducted in the resident’s active clinical record for 15 months.(This includes enough information to identify the resident and type and date of assessment linked with the particular assessment’s signature pages),

The information, regardless of form of storage (i.e., hard copy or electronic), must be kept ina centralized location and must be readily and easily accessible. This information must be available to all professional staff members (including consultants) who need to review the information in order to provide care to the resident. (This information must also be made readily and easily accessible for review by the State Survey agency and CMS.) Resident specific information must also be available to the individual resident; if there are concerns, please refer to F573.

After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff, the State agency, or CMS. NOTE: States may have more stringent requirements for this process.

If there are concerns about how the results of the resident assessment are used to develop, review and revise the resident’s comprehensive care plan - See §483.21(b)(2)(iii), F657.

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