Understanding the 14-Day Timeline for Correction
For long-term care facilities, accuracy in documentation is paramount. The Centers for Medicare & Medicaid Services (CMS) requires facilities to use the Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS), to assess and document resident health information. A critical aspect of this is the significant correction assessment, used to rectify major errors in a previously submitted comprehensive assessment. Staff have a strict timeline to address these issues promptly.
According to CMS guidelines, once facility staff identifies a significant error in a prior comprehensive assessment, they must complete the correction assessment within 14 calendar days. This 14-day period begins on the day the error is identified. This timeline ensures that a resident's overall clinical status, care plan, and payment classification are not negatively impacted by inaccurate information for an extended period.
What Constitutes a Significant Error?
A significant correction assessment is required only for 'major' errors, not minor coding mistakes. CMS defines a major error as one where the resident's overall clinical status is not accurately represented on the MDS, and the error has not been corrected by a more recent assessment. Examples of major errors might include incorrect coding that impacts a resident's quality measures, payment categories, or inaccurately reflects their clinical needs, which could affect their care plan. Minor errors, such as a simple typo that doesn't impact the resident's status, can be handled differently without requiring a full significant correction assessment.
The Difference Between a Significant Change and a Significant Correction
It is important for facility staff to distinguish between a significant correction and a significant change in status assessment. While both have a 14-day completion window, they are triggered by different events and serve different purposes.
| Aspect | Significant Correction of a Prior Comprehensive Assessment | Significant Change in Status Assessment |
|---|---|---|
| Trigger | Identification of a major error in a previous comprehensive assessment. | A major decline or improvement in the resident's clinical status. |
| Purpose | To rectify inaccurate data that does not accurately reflect the resident's condition at the time of the previous assessment. | To reassess a resident's current status and update the care plan to reflect their changing needs. |
| Resident's Condition | Based on inaccurate past data, not the resident's current clinical state. | Based on a current, observable change in the resident's condition that requires review. |
| Restarting Schedule | Resets the schedule for subsequent annual and quarterly assessments. | Resets the schedule for the next annual assessment. |
The Process for Completing a Significant Correction
To ensure compliance, facility staff must follow a precise process when a significant error is identified. Missing a deadline can result in non-compliance findings during a survey and potential penalties.
- Identify the Significant Error: The interdisciplinary team, or an MDS coordinator, identifies a major error in a previously submitted comprehensive assessment during a record review or quality assurance process.
- Document the Finding: The initial identification of the significant error must be documented in the resident's medical record, typically in the progress notes.
- Determine the Assessment Reference Date (ARD): The ARD must be set within 14 calendar days of the determination date that the significant error occurred.
- Complete the Assessment: The full comprehensive MDS assessment, including Care Area Assessments (CAAs), must be completed within 14 days of the new ARD.
- Complete the Care Plan: A new care plan reflecting the corrected information must be completed within 7 days of the RAPs completion date.
- Transmit the Data: The corrected MDS must be transmitted electronically to the federal CMS database within 14 days of the care plan completion date.
Consequences of Non-Compliance
Missing the 14-day deadline or failing to perform a significant correction can have serious consequences. CMS and state survey agencies use MDS data for quality monitoring, public reporting, and determining payment rates. If a facility fails to submit an acceptable plan of correction within the specified timeframe, it can lead to enforcement actions, including termination of the provider agreement. Accurate and timely assessments are critical to both regulatory compliance and providing high-quality, appropriate care to residents.
For further details on federal requirements for the Resident Assessment Instrument, refer to the CMS RAI Manual.
