Providers and consultants who work closely with nursing homes on compliance issues are both bristling at extensive new regulations — especially those that dictate how they can use certain medications — and embracing the application of fewer citations in other caregiving areas.

They are reacting to news that the Centers for Medicare & Medicaid Services on Monday posted online an advanced copy of surveyor guidance that will go into effect in February 2025. The new guidance, coming in at nearly 900 pages, includes extensive changes to discharge planning, antipsychotic use, chronic pain management and other rules used to guide and assess nursing home quality.

“It is going to be imperative that facilities review these changes and come up with a solid education plan prior to February and that they take the time to review the updated critical element pathways and utilize those documents in their trainings as those are the ‘road maps’ for state surveyors,” said Sabrena McCarley, secretary of the National Association of Rehab Providers and Agencies and director of clinical reimbursement for Transitional Care Management.

While the changes touch a range of survey topics, McCarley said CMS highlighted two key themes in its update: the need for supportive documentation in the medical record and collaboration among a nursing home interdisciplinary team.

Changes regarding the use of antipsychotic medications and the medical director’s role in reviewing medical diagnosis should force skilled nursing providers to ensure their processes don’t rest in the lap of a single employee. So too should reiterated calls for individualized behavioral interventions as key non-pharmacological tools to address resident behaviors.

CMS is underscoring the need for “solid systems and documentation,” McCarley added.

Focus on antipsychotics

The most extensive changes highlighted in a QSO memo that accompanied the advanced guidance appeared to be related to the agency’s efforts to reduce the use of “chemical restraints” and unnecessary psychotropic medications.

“The intent of these requirements is to ensure residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated,” the guidance states. “Also, residents must remain on psychotropic medications only when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated.”

Amy Stewart, chief nursing officer for the American Association of Post-Acute Care Nursing, noted an addition to F605 that says residents should be free from unnecessary drugs, including those “without indications for its use.”

“Adequate indications for use refers to the identified documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated for psychotropic medications,” Stewart told McKnight’s. “Without documentation in the record explaining that the practitioner has deemed that other treatments have been deemed clinically contraindicated, the indication for use is inadequate.

“F605 also states that the medication being used must be consistent with manufacturers recommendations and or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and or journals,” she added. “This means that facilities are going to have to ensure that they have adequate documentation to support the use of psychotropic medications. This goes beyond just having a diagnosis. The record will need to have robust practitioner notes about why the medication is required and documentation of failed treatments. This may require obtaining records that extend back months to years ago.”

Also concerning, she said, was CMS language referring to providers who give antipsychotic medications for “convenience and discipline” because of their “sedating or subduing effect.”

“Facility clinicians will need to monitor residents on psychotropic medications more closely and ensure these medications do not have this effect or it could be said the medication is being used for ‘convenience,’” Stewart said. The rule also compels the medical director to be more involved in reviewing diagnoses related to use of such medications and directs surveyors to question those physicians about their oversight roles.

“The bottom line here is [the need for] vigilant documentation and monitoring of psychotropic medications, their effect, the behaviors that proceed starting a psychotropic medication or a dose change,” she added.

While providers should start reviewing the changes to F605 and adjust facility practices as needed, she also cautioned about unintended consequences:  “I hope that this updated regulatory language does not impact resident safety. Facilities might be more inclined to take residents off medications or lower the dose when a resident has been stable on the medication for years,” she said.

Something to work toward

Jodi Eyigor, director of nursing home quality and policy for LeadingAge said Tuesday that CMS officials likely have “a sense of urgency to complete their work before the new administration comes in” even though many changes had likely been in the works before the election.

“In many ways, providers, including our nonprofit and mission-driven nursing home members, have already been working on these changes,” she told McKnight’s. “For example, antipsychotic medications and minimum data set (MDS) coding have been top of mind for CMS for several years. The difference is that now, there is more concrete guidance on how to implement and survey for compliance around these issues. There will likely be increased citations as a result. However, this guidance will also help providers to better align practices with CMS’ expectations.”

The number of citations increasing 79% between 2019 and 2023, and CMS gave itself additional means of fining providers effective Oct. 1.

But even with that context, there are some potential bright spots for providers in this week’s guidance.

Amy Greer, director of quality innovations for Zimmet Healthcare Services Group, told McKnight’s Long-Term Care News she was not surprised by the scope of the changes given that CMS tends to make major updates to its survey process every two to four years.

She welcomed changes that might reduce confusion and excessive citations around resident admissions, transfers and discharges. CMS reduced from eight to two the total related tags that surveyors can use to ding providers for lapses in those areas.

Many of the current tags are “redundant in their verbiage,” creating confusion for both surveyors and SNF operators and staff, she added.

“They could have been cited on several items on survey for the same issue, thus creating higher Health Inspection scores, which would negatively impact their Five-Star rating, potentially impact their finances and their plan of correction also would have been a redundant nightmare,” she said. “This is certainly  a step in the right direction in making the survey process a bit more efficient.”

Changes to discharge guidance, including the removal of the terms “facility-initiated” and “resident-initiated” are also a net positive, Greer said.

“Presently the investigative protocol leaves it up to the surveyor to decide if a transfer was facility initiated or resident initiated,” she added. “I am glad to see those terms being eliminated; this makes it more consistent across all 50 states instead of being subject to the surveyors’ interpretation of the guidance currently provided.”

Greer said the simplification should help better protect residents being transferred or discharged, but CMS also used the updates to underscore its insistence on immediate punishment for providers who try to skirt the updated rules.

The updated text calls on surveyors citing for discharge issues “at any level of scope and severity” to take the discharged resident’s current health and safety into account when developing the facility’s plan of correction. That plan could require a facility to readmit a resident until a safe and compliant discharge can be done, or coordinate a transfer of the resident to another setting where they will be safe.

“The facility should not be determined in substantial compliance until one of these two items is complete (and all other noncompliance has been corrected),” CMS said. “Additionally, for situations in which residents’ discharge locations did not meet their health and/or safety needs, enforcement should be implemented immediately. For example, a discretionary denial of payment for new admissions should be imposed to go into effect within 2 or 15 days (as appropriate), and remain in effect until a return to substantial compliance.”

The new citations will be F627 for Inappropriate Transfers and Discharges and F628 for Transfer and Discharge Process.

Holly Harmon, senior vice presiden of quality, regulatory, and clinical services at AHCA/NCAL said the organization appreciate the updated guidance “and will continue to review the changes so we can best support our members in their efforts to further improve quality care.”

“We will continue to advocate to CMS that the survey system support quality improvement, and we look forward to a continued partnership with CMS on improving guidance so our providers can deliver the best care,” she added.