Transitions in nursing home care will be heavily impacted by upcoming surveyor guidance, but operators can prepare by being realistic about admissions, while also cleaning up any gaps in the discharge process. At the same time, robust documentation around psychotropic medications will be a boon for operators facing updated guidance.

Much of the surveyor guidance – due to go into effect on March 24 – ties into transitions in care, affecting admissions and discharges. Given this, it’s more important than ever to ensure that the residents admitted are able to be taken care of, since it’s getting harder to transfer them out of the care setting, said Michelle Stuercke, chief clinical officer for Transitional Care Management.

New surveyor guidance starts before the surveyors even step foot into the nursing home. In assessing whether or not to admit a certain resident, a facility must make sure that it has enough clinical staff qualified to address their needs ahead of time because this can earn a citation now. That’s because the requirement for the presence of sufficient nursing staff has to be met by PBJ data as part of an annual survey, she said.

“If your PBJ is showing that you had days without registered nurse (RN) coverage, they’re going to start with a tag. They’re going to write up that F-tag before they even walk in the building,” said Stuercke. “If you’re taking residents who need IVs, but you know you have a challenge with RN coverage … you want to really step back and say, ‘Is this really an addition I should be taking?”

Stuercke spoke at Skilled Nursing News’ Clinical event this month, along with Lisa Chubb, chief clinical officer at Indiana-based Brickyard Healthcare.

Gaps leading to unsafe discharges

Also now, discharges could be flagged for something as simple as not acknowledging when there’s a language barrier and deemed unsafe, Stuercke noted. The Centers for Medicare & Medicaid (CMS) began adding health literacy requirements and social determinants of health that affect the discharge process with the Minimum Data Set (MDS) a couple years ago, she said, and asking residents about their primary language, if they could read their medication instructions,and if they have problems getting to appointments. 

“Make sure that everything we give to individuals is in a language they understand, or that their caregivers understand,” said Stuercke. “Many, many patients that age are rule followers. If the doctors tell them to do it, they’re going to do exactly what [the doctors] say.”

If safe discharge instructions were not given in a language that they understand, and that leads to a fall at home, that could come back as a pretty high scope and severity tag, said Stuercke.

Surveyor guidance stresses the importance of making sure staff provides information to the residents upon discharge in a way that they understand. In one example, Stuercke said if the nurse speaks English, other staff speaks Spanish and the packet of discharge paperwork is in English, that’s considered an unsafe discharge.

Really looking at every part of the process and tightening up any inconsistencies will help operators meet the new surveyor guidance related to discharges and admissions.

And simply having a process for communicating is not enough, according to Chubb.

“Make sure that you’ve got those processes in place and you’re documenting what you’re doing. You’re setting that goal upon admission and you’re working toward that goal,” said Chubb. “It’s something you can’t lose sight of … are we following what we said we’re going to follow to make sure there’s not a disconnect with the clinical team?”

In her experience, Chubb has found that the MDS coordinator might often not be communicating as effectively as they could with the clinical team — another opportunity to bridge gaps which lead to safer discharges.

Other changes to the survey guidance include some F-tags related to unsafe discharges being removed, and replaced with others, she added.

“They’ve taken some of the verbiage around residents and facility-initiated discharges and deleted some of those terms,” said Chubb.

Moreover, CMS has added strong language around residents appealing a discharge, noted Stuercke. Civil monetary penalties can be charged if an operator discharges them anyway despite resident appeals. If the appeals process plays out and it’s determined that the operator needs to take the resident back, and the operator refuses, that’s grounds for a CMP, Stuercke said.

“If that patient is someplace and they’re very despondent, maybe they say they miss their friends, [CMS is] really incorporating that psychosocial harm,” Stuercke said. “It really adds another layer to that discharge. You don’t want to [refuse] taking these residents back and then end up in some scary financial trouble on top of it.”

Behavioral health and transitions in care

In terms of survey changes tied to psychotropic medications, Stuercke said operators must have really good documentation proving why a resident is on such medication. And if the resident has a diagnosis, be sure to have on the ready evidence of symptoms aligned with the medical record of Diagnostic and Statistical Manual of Mental Disorders (DSM) that to the diagnosis.

This could be where artificial intelligence comes into play, she said, pulling together documentation and piecing together data to support a diagnosis.

Transitions in care for patients requiring psychotropic medication are going to be “especially important,” Stuercke added.

Operators that were part of probe audits a couple years ago ended up helping to prepare for the surveyor guidance going into effect in March, Chubb said.

Exit interviews conducted as part of that probe have served as a way to work out the kinks, especially with patients being sent to the hospital for a reason unrelated to behavioral health, and getting sent back with advanced antipsychotics and no reason or diagnosis for the prescription.

“It really starts with us educating [acute care partners] with what we’re held to, our regulatory requirements, and ensuring those providers know they have a part in that,” said Chubb.