The Centers for Medicare & Medicaid Services has pushed back implementation of new surveyor guidance until March, giving regulators more time to fine-tune how they determine compliance with staffing, antipsychotic medication use, discharge planning and other rules.

The guidance had been scheduled to go into effect in February, but a reissue and renumbering of the related Quality, Safety and Oversight memo last week pushed the start date to March 24.

“My assumption about the delay is that they don’t have the surveyors fully trained and ready to go yet,” Brandie N. Elizaitis, director of operations and consultant for the CMS Compliance Group, told McKnight’s Long-Term Care News. “Releasing additional guidance in mid-January to be effective at the end of February may have been too optimistic of a timeline for this many changes and the associated training needed.”

To be sure, the changes are extensive, as outlined in the initial November announcement. The initial revisions dictated how surveyors will assess nursing homes compliance with regulations governing admission, transfer and discharge, unnecessary psychotropic medication, resident assessment, infection prevention and control, and more.

The Jan. 15 update also revises when and where surveyors should cite providers for lapses in nursing services, as well as providing more details on how to assess staffing before an on-site inspection.

“Guidance for surveyors has been added to assist with using the PBJ for investigations,” Elizaitis noted. “Additional instructions for staff interviews, observations, key elements of noncompliance and deficiency categorization have been included. Part of the guidance focuses on surveyors’ offsite prep using staffing data, so they are armed and ready when they enter a facility for survey.”

Clarifications and technical corrections were also made throughout an advanced copy of Appendix PP, a final version of which will posted in March.

Significant changes to psychotropic guidance

The final version of the appendix, the State Operations Manual’s guidebook for nursing homes, will include some significant updates to the section governing use of chemical restraints or unnecessary psychotropic medication. Language has already been added or moved to paint a better picture of how the agency is advancing its continued efforts to strictly limit the use of antipsychotics and schizophrenia diagnoses that have blurred quality measures.

Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance for Zimmet Health Care Services Group, called attention to new language that CMS said had been revised to include situations “when medications are used to cause symptoms consistent with sedation and/or require less effort by facility staff to meet the resident’s needs.”

“Documentation in the record will need to show the indications and clinical rationale for the use of the medication for the individual resident based on an assessment of that resident, including the reason why other medications/treatments are clinically contraindicated,”  Cantinieri told McKnight’s Monday.

“Also, the guidance includes the resident’s (or family, significant other, legal guardian’s) right to be fully informed of and participate in or refuse treatment, initiating or increasing a psychotropic medication,” she added. “The resident must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication. Written consent or other documentation of that consent must be present in the medical record.”

New examples also aim to help surveyors properly categorize the scope of deficiencies related to chemical restraint. The examples starting on page 144 of Appendix PP, for instance, illustrate what CMS officials expect surveyors to cite as Level 3 actual harm violations. They include:

• Failure to evaluate and monitor the resident and discontinue a psychotropic medication originally prescribed to treat a resident’s delirium. Delirium symptoms subsided but the resident remained drowsy from continued administration of the medication. While the resident remains independent with ADLs, the resident has missed some group activities due to the drowsiness.

• A resident has an order for a PRN psychotropic medication that the resident can take for anxiety. However, staff regularly administer the PRN psychotropic medication to the resident with no documented indication but during an interview, staff explained the medication helps the resident sleep, so they’ve been giving it nightly even though the resident did not request it.

That was one of many updates pointed out during a webinar hosted by The National Consumer Voice for Quality Long-Term Care Wednesday.

“They really tried hard to clarify situations in which it was appropriate to use psychotropic medications as well as situations where it was not,” said Lori Walsh, policy and program specialist for Consumer Voice. “There is definitely a theme throughout the guidance that I read regarding psychotropic medications, and that is that psychotropic medication should be the last resort.”

Walsh also referenced new language in the guidance that requires surveyors to refer concerns about patterns of record falsification to state boards of nursing. McKnight’sreported on that new provision when the changes were first unveiled in November.

More time welcomed

Elizaitis, who recently blogged about the changes, said the “obvious upside” with the latest update is that it gives providers more time to ensure they can comply.

They could potentially have even more time.

Jodi Eyigor, senior director of nursing home quality and health regulation for LeadingAge, told McKnight’s Wednesday that a regulatory freeze and review initiated by the Trump administration could apply to the guidance. An executive order issued Monday applies to “regulatory action” and any related “guidance document,” giving Trump appointees 60 days or more to review items not yet in force.