CMS SOM App. PP, Tag F639

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 in the 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 in a

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.