Changes to nursing home survey protocols — set to take effect April 28 — are putting a sharper focus on resident rights, documentation practices, and medication oversight. The revisions demand airtight documentation, particularly around discharge, behavioral health interventions and psychotropic drug use.

Of the ten area changes due to take place, providers should pay the most attention to updates tied to admission, transfer and discharge processes, as well as tags related to the reduction of unnecessary psychotropic medications and chemical restraints.

“That documentation will have to be airtight if, in fact, you will not be permitting the resident to return to the facility. It already is tightly regulated, but it’s really going to be enforced very strongly with these new tags,” said Sherry Thomas, registered nurse consultant.

Notices required prior to transfers, and discharge planning will need to be carefully worded and documented, along with bed-hold policies, where a resident’s bed is managed during a period of absence like a hospitalization or therapeutic leave. Most importantly, it will be imperative staff is very careful with discharge requirements documentation, and whether a resident is permitted to return to the facility.

The other eight areas of note include F tags added to the Payroll-Based Journal (PBJ), as well as F tags related to the following: professional standards and medical directors; accuracy, coordination and certification requirements; comprehensive assessment after significant change; quality assurance and performance improvement (QAPI); physical environment; quality of care and quality of life; infection prevention and control.

QAPI guidance specifically includes a new definition of health equity for surveyors, and requires facilities to collect and monitor data related to outcomes, Thomas said. Providers will be asked to prove how they measure outcomes, and surveyors will ask medical directors about areas of noncompliance.

“You’re obtaining feedback or you’re collecting any monitoring data … analyzing factors that are known to affect health equity, such as socioeconomic status, race and then language barriers,” said Thomas. “Now, with some of the changes in the federal government, with the confirmation of Dr. Mehmet Oz as the director of CMS, there could be some additional changes in the health equity definitions and requirements. Stay tuned for that.”

Overall, an emphasis on staff education, documentation and communication will help providers meet these new standards, Thomas said during a webinar on survey changes hosted by WellSky. WellSky is a technology company that provides software and services across the health care and social care continuum.

Admission, transfer and discharge survey changes

When it comes to admission, transfer and discharge changes, Thomas said admission policy now prohibits admission agreements from containing language or requiring a third-party guarantee of payment.

Also, any language within an admission agreement that would hold a third party accountable for paying the facility would violate this survey change, Thomas said.

“You will want to ensure that your admission nurses, any team member that’s doing admissions, is aware of these changes and that they are clear on what is required and what is not allowed in terms of the language,” said Thomas.

Following a hospitalization or therapeutic leave, staff needs to ensure the resident isn’t transferred or discharged in an unsafe manner which can be related to location, inadequate support and resources, or if the discharge isn’t meeting resident preferences, Thomas said.

Chemical restraints and psychotropic reductions

A significant change in terms of unnecessary psychotropic medications comes in the form of F tag 605, Thomas said, which falls under abuse. This tag will be cited if a survey team identifies an unnecessary medication as acting as a chemical restraint.

Providers will need to show a link between medical symptoms and the psychotropic medication being used. In other words, documentation needs to be clear in stating that the medication is not being used for convenience or purposes of discipline.

Psychotropic medications were removed from F 757, she said, which cites all other medications deemed unnecessary. If such drugs are being used in an excessive dose and that dose hasn’t changed for an excessive duration, that’s grounds for this tag, Thomas noted.

Avoiding tags related to unnecessary medications and chemical restraints could come down to bridging the gap between physician and pharmacy consultant notes when filling out paperwork for gradual dose reduction programs.

“If the physician is not in agreement with the consultant recommendation, they can’t just check the box that says ‘disagree,’ they have to write a rationale for why they are disagreeing with that recommendation,” said Thomas.

New guidance also stresses residents and their families to be informed and involved in treatment choices if antipsychotics are initiated or increased. Meaning, they can accept or decline the initiation of medication or an increase.

Residents, their families or representatives need to be informed of the benefits, risks and alternatives for the medication, including black box warnings for antipsychotic medications prior to implementation or upping dosage.

“There has been some pushback over the years when I’ve visited facilities and completed mock surveys about the requirement for having resident consent for these types of medications, and some facilities were not doing that,” said Thomas. “The language was a little bit murky [but now] it’s no longer murky. It’s very clear on what you have to do. So please look at your policies and procedures for these medications, look at your consent form and make sure that it aligns with the new guidance.”

Having documentation ready for PBJ changes

Other changes include added F tags to the Payroll-Based Journal (PBJ) related to nursing services, registered nurse coverage and mandatory submission of PBJ data, which Thomas said shouldn’t be too cumbersome for staff.

There have been definitions added for licensed nurses, charge nurses and scope of practice for certain roles, she said, when thinking about citations for 24-hour licensed nursing coverage. Other triggers for the new tags include reporting excessively low weekend staffing, one-star staffing, no RN hours reported, and failure to submit PBJ data for the quarter, Thomas said.

Having documentation at the ready in anticipation of these possible tags will help, Thomas added, since surveyors will be coming in “armed and ready.”

“The surveyors will now be doing a lot of off site preparation. They’re already doing quite a bit, but they’re going to be doing more off site preparation for your recertification survey,” said Thomas. “They’re going to be obtaining your PBJ staffing data report and evaluate it before they set foot in your facility. So they’re going to sort of be armed and ready, if you will, when they come in the door related to your PBJ.”

Quick hits of other surveyor guidance changes

Out of the remaining survey changes, meeting professional standards, medical director changes, and updates to infection control and prevention as well as QAPI are also quite significant, according to Thomas.

Providers must meet professional standards of quality as part of survey changes, meaning services provided or arranged need to meet professional standards of quality. Mental disorders need to be diagnosed by a practitioner using evidence-based criteria, supported by documentation in the resident’s medical record, Thomas said.

The medical director’s responsibilities have been updated as part of surveyor guidance as well, with a more defined list of what is expected. Better defined medical director responsibilities include implementation of resident care policies, addressing issues related to coordination of care and implementation of care policies, and active involvement in conducting facility assessments.

There are also survey updates related to the physical environment of facilities, such as those concerning the sharing of bathrooms between single-occupancy rooms.

Lastly, infection control updates include added enhanced barrier precautions and immediate jeopardy for certain Covid cases, as well as failure to initiate outbreak investigations.

Consultants see a lot of really good, tight policies and procedures around infection control and prevention, Thomas said, but the minutia of the day to day needs more attention to avoid the dreaded F 880 tag.

“It’s what happens on the unit, minute by minute, shift by shift, day by day, those breaches in infection control that are going to hurt you, so make sure that your practices and your education and competency checks are aligned with your policies and procedures,” said Thomas.