Expansive changes to the nursing home survey process went into effect Monday, emphasizing new priorities for surveyors during on-site inspections and those reviewing staffing and other data prior to physical inspection.

After multiple delays, it also brings new scrutiny to a range of already closely watched areas, from the management of psychotropic medications to infection control.

“The new survey process raises the bar on documentation and resident-centered care in a way that will catch facilities relying on outdated systems or shortcuts,” warned Melissa Brown, chief operating officer for Gravity Healthcare Consulting in comments to McKnight’s Long-Term Care News Monday. “It’s an opportunity to improve, but it’s also a real compliance risk if providers aren’t prepared.”

The Centers for Medicare & Medicaid Services first issued a draft of updates in November.  The guidance, including the all-important Appendix PP, has ballooned to more than 900 pages and includes several new or significantly revised critical element pathways.

Here, experts offer reminders about potential pain points and advice on how to head them off.

MDS missteps

Under F-641, surveyors will now be looking for patterns of inaccurate MDS data or inappropriate completion of the MDS for a resident’s status.

“MDS information as it is reported impacts a nursing home’s payment rate and standing in terms of the quality monitoring process,” said Joel VanEaton, executive vice president of PAC Regulatory Affairs and Education for Broad River Rehab.

“A pattern within a nursing home of clinical documentation or of MDS assessment or reporting practices that result in higher Patient Driven Payment Model scores, untriggering Care Area Assessments or unflagging Quality Measures, where the information does not accurately reflect the resident’s status, may be indicative of payment fraud or attempts to avoid reporting negative quality measures.”

CMS and state surveyors will be looking for inaccurate status information; corrections submitted to iQIES that do not accurately reflect the resident’s status; submission of Significant Correction Assessments where the initial assessment does not appear to have been in error; submitting Significant Change in Status Assessments where the correct criteria do not appear to be met; and delaying or withholding MDS assessments, discharge or entry tracking information or corrections to information in iQIES.

While this change was spurred by CMS’ ongoing interest in the use of schizophrenia diagnoses to exclude antipsychotic prescribing from a nursing home’s quality measures, its reach will be much broader than that. It also can lead to investigation of the employee signing off on MDS submission and referral to the Inspector Generals office.

“It is important to remember that this dovetails with the upcoming monitoring efforts that CMS will implement relative to the SNF Quality Reporting Program and Value-Based Purchasing Quality Measures. Providers should renew a focus on MDS accuracy,” VanEaton added.

Resident discharge changes

The resident discharge critical element pathway, which surveyors use as a roadmap to determine whether a deficiency occurred, has changed significantly. Overlooking changes throughout the guidance that redirect surveyors’ attention could put skilled nursing providers at risk, said Brown.

“This is because many nursing homes lean on templated admission packets and haven’t fully updated their processes to meet the stricter requirements around documenting why a discharge happens and ensuring it’s safe and appropriate,” she said. “If a surveyor finds even one instance of an improper discharge, it could trigger serious citations, major financial penalties and even lawsuits.”

Brown reminds providers that valid reasons for facility-initiated discharges are extremely limited. They could include a resident endangering others, the existence of urgent financial issues after exhausting appeals, or changes in the patient’s conditions or the facility’s capability that make it unable to meet the patient’s needs.

But, she added, the documentation for a discharge “needs to be airtight to hold up under survey — especially an involuntary discharge — and must support the reason for transfer or discharge with clinical facts.”

“If you don’t have an approved reason for discharging the resident, don’t discharge without consulting leadership and legal first,” Brown added.

Surveyors will ask for detailed documentation including assessments, meeting notes, alternatives explored and involvement of the ombudsman. And, she said, improper facility-initiated discharges can now directly trigger an Immediate Jeopardy citation.

“This needs our full attention,” she emphasized.

Increased medical director requirements

The new guidance increases focus on physicians and non-physician providers, especially the medical director’s role in key aspects of patient care. They’re now mentioned in possible tags related to meeting professional standards, and they also are now expected to have more involvement in implementing policies and procedures related to diagnosing and prescribing psychotropic medications and overseeing the medical team.

Surveyors may now interview the medical director as directed by the Unnecessary Medications and QAPI Critical Element Pathways, especially if a facility has certain diagnoses, such as schizophrenia, without supporting documentation, or if the surveyor questions the use of antipsychotic medications.

“In short, the medical director is expected to review the medical records to ensure that professional standards are being upheld when diagnosing and prescribing psychotropic medications and be able to provide evidence of medical team oversight,” said Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance for Zimmet Healthcare Services Group.

She said facilities might need to implement additional internal audits completed by the medical director and review their QAPI topics.

“This level of accountability creates a culture of quality care,” she told McKnight’s. “It ensures residents receive appropriate treatment based on accurate diagnoses, enhancing resident safety, dignity and quality of life throughout their nursing home stay.”