While the 900-plus pages of updates to surveyor guidelines is still daunting for the industry, operators have had a couple months of experience, making adjustments to the day-to-day while planning ahead.

An easy first step toward preparation since guidance changes has been to identify when a facility’s next survey is due, then prioritize areas of risk and uncertainty for a particular building – this could be psych diagnoses, opioid use, or health equity, according to Leigh Ann Frick, president of Care Navigation Consulting.

Using resources available through the Centers for Medicare and Medicaid Services (CMS) is another huge boon for operators, including the revised Appendix PP, critical element pathways, and an updated F-tag list, with additions in red.

Specifically, operators can use updated surveyor critical element pathways to prep for surveys. They provide insight on what surveyors observe, who they interview and what documentation is reviewed.

Operators can form a checklist from critical element pathways for compliance evaluation, Frick said.

“It’s like taking an open book test. These are an excellent way to understand and evaluate your compliance for all of these updates and anything that is part of the survey process,” said Frick. “It gives guidance as to what surveyors are going to do in preparation for their visit … this is your roadmap to whether or not you’re in compliance.”

Frick led a webinar on survey changes in July, months after implementation on April 28, starting with a breakdown of surveyor guidance around admissions, transfers and discharges.

Focus areas and ties to quality measures

If they haven’t already, operators are urged to review admission agreement language and remove third-party financial guarantees. Discharge policies need to involve the full care team and ensure safety, involve residents or resident representatives, and include evidence-based justification for discharge.

Psych diagnoses – schizophrenia in particular – should be priority given ties to the Five-Star Rating System, Frick added.

“From a schizophrenia audit perspective, that can impact your overall quality measures and long stay quality measures ratings by dropping a star for six months, it can suppress the short stay quality measures for six months and the long stay antipsychotic for 12 months,” said Frick.

When it comes to opioid use, Frick said residents need to know and understand what they’re taking, and if staff are increasing doses, residents need to agree. They may have addiction issues, or may not want to be on that type of medication.

Frick suggested operators divide and assign tasks across the interdisciplinary team (IDT) with deadlines as well, and provide incremental training to staff for better retention. Ensuring audits and monitoring are ongoing is crucial too, and not just a one-time event, she said.

“There’s no silver bullet. I wish there was, but I think the key is to understand that the expectation is on us to ensure that we turn over every rock so we can figure out what resources are going to work the best and safest,” said Frick.

Tangible takeaways

More specific takeaways after seeing survey changes play out in facilities, Frick said, involve Diagnostic and Statistical Manual of Mental Disorders (DSM)-based diagnosis and documentation, especially for patients with schizophrenia.

Historical diagnoses alone aren’t sufficient with the surveyor changes. Facilities need to confirm prior diagnoses with documentation or conduct new evaluations upon admission. And so, practitioners need to be trained and compliant with DSM criteria.

Frick confirmed the focus on medical directors too, adding that this person must actively oversee practitioner compliance now if they haven’t already. Meanwhile, health equity, accurate MDS coding and safe discharge practices are new focal points for surveyors.

“We have to divide and conquer. Assign the tasks, deadlines and accountability checkpoints. Use your village, infection control preventionists, staff development, medical records, social work, therapy, everybody within the IDT can play a role in this,” Frick said of surveyor focal points.

Accurate MDS data tied in with supporting psych diagnoses, Frick said, and can help with interdisciplinary collaboration and look-back documentation requested by surveyors.

One of the big changes to the MDS itself was Section G to GG, and that has affected surveyor guidance changes as well, Frick noted. Operators should focus on collaborative scoring to figure out a resident’s “usual performance” across IDT. Monitoring for functional improvement or declines between assessments keeps facilities compliant across changes to MDS and surveyor guidance alike, she said.

Frick brought up infection control and Covid immunizations too, mentioning that enhanced barrier precautions were required during high-contact care for residents infected with multi-drug resistant organisms (MDROs). Surveyors can issue an immediate jeopardy citation if outbreaks aren’t properly investigated or contained.

In terms of Covid vaccines, residents, staff and representatives need to be educated on the vaccines and they need to be offered “appropriately,” Frick said. Vaccination clinics can be set up based on interest, but documentation and education are key compliance areas, she said.

At any rate, it’s good for operators to stay proactive with audits, training and updating their policies, using surveyor tools to self-check, Frick said.