Don’t Postpone Preparing for CMS’ Revised Surveyor Guidance

Don’t Postpone Preparing for CMS’ Revised Surveyor Guidance

Take advantage of the revisions to the surveyor guidance being delayed until April 28, 2025 to hardwire preparation for the changes. Now is the opportunity to complete a thorough review of the Appendix PP and CMS Critical Element Pathway revisions with facility staff and all key personnel that will be impacted by these changes. Seize the opportunity to approach implementation in a systematic and strategic manner, to ensure that policies and procedures are reviewed/revised, necessary assessments are in place, and staff have been provided with detailed training on the upcoming changes. Let’s review the key revisions to include in your readiness plan…

Although all of the CMS Revised Surveyor Guidance is important, there are key areas that warrant focus as you implement the revisions in your facilities:

Admission, Transfer, and Discharge:

• Have you updated your policies/procedures to address:
  • The facility allows residents to return to the facility following hospitalization and therapeutic leave.
  • Removal of the terms “facility-initiated” and “resident-initiated”.
  • The Against Medical Advice (AMA) policy aligns with current guidance and facility staff are trained on what AMA means.
  • Admission Agreements do not contain language that specifically requests or requires a 3rd party to personally guarantee payment to a facility.
• Does staff education include:
  • Documentation needed to support the efforts made by the facility to meet the needs of the resident before a decision is made for transfer/discharge.
  • The need to document that facility staff has assessed the resident’s ability to care for themselves at home, and they cannot, that there is a caregiver in place that can care for them safely if they discharge.

Chemical Restraints/Unnecessary Psychotropic Medication

• Have you updated your policies and procedures and trained your staff on:
  • Mental Disorders should be diagnosed, using evidence-based criteria, such as the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and documented in the record.
  • If residents are admitted with a psychotropic medication, without a clearly documented indication, the prescribing practitioner and the IDT should determine if continuing the med is justified by conducting a comprehensive medical and psychiatric eval.
  • Before initiating or increasing a psychotropic med, the resident, family, and/or resident rep. must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for AP meds, in advance of such initiation or increase.
  • When prescribing a new psychotropic med, or increasing the dose, facility must address in the medical record the non-pharmacological approaches used before prescribing the med (unless contraindicated).

Professional Standards and the Medical Director

• Have you reviewed your contract with your Medical Director to make sure it addresses all of the areas CMS expects them to be involved with in the facility as it pertains to the implementation of resident care policies? By way of example, are you ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing meds and intervening when a practitioner is providing care that is inconsistent with current professional standards of practice?
• Have you educated your Medical Director and staff on:
  • The documentation requirements for psychotropic meds to be ordered, increased or changed.

QAPI/QAA Improvement Activities

• Have you incorporated Health Equity concerns into your QAPI program:
  • When interviewing, collecting and monitoring data?
  • When analyzing factors known to affect health equity (i.e., race, socioeconomic factors, language as it relates to Med errors, adverse events etc.)?
  • When considering QAPI priorities. Priorities?

Pain Management

• Have you completed the following:
  • Reviewed updates to the guidance with the medical director, other prescribers and consultant pharmacist.
  • Reviewed/updated policies and procedures r/t pain medication, if applicable.
  • Considered developing or implementing routine audits to determine if the facility is following their policies for pain management.

Accidents/Supervision

• If you allow smoking and the use of electronic cigarettes / vaping devices in your facility, have you updated your policies and training your staff on proper storage and charging of these devices?
  • Have you incorporated Substance Use Disorders (SUD) into your policies and procedures, and educated your staff on the need to monitor residents with this diagnosis for increased elopement risk?

Nursing Services

• Are you reviewing your PBJ reports quarterly at a minimum prior to the submission deadline to ensure accurate reporting of DON coverage, RN hours, weekend coverage and licensed nurse coverage 24 hours per day?

Next Steps:

Access critical training via Proactive’s 2-hour in-depth webinar that provides key insights into the New Surveyor Guidance. Thoroughly reviewing the CMS QSO letters and the Advance Copy of the Appendix PP and Critical Element Pathways via the links provided in the resources list below.

Resources:

QSO-25-07-NH

https://www.cms.gov/files/document/revised-long-term-care-ltc-surveyor-guidance-significant-revisions-enhance-quality-and-oversight-ltc.pdf

Dated November 18, 2024

QSO-25-12-NH

https://www.cms.gov/files/document/qso-25-12-nh.pdf

Dated January 15, 2025

QSO-25-24-NH

https://www.cms.gov/files/document/qso-25-14-nh.pdf

Dated March 10, 2025