MDS Alert

New guidance targets unnecessary meds, but also goes far beyond F-329.

Surveyors will soon be looking to identify psychosocial harm related to the use of unnecessary medications and much more — get ready for heavy scrutiny.

Although there are no changes to the regulatory language, the Centers for Medicare & Medicaid Services (CMS) has updated its guidance to surveyors for F-329 Drug Regimen is Free from Unnecessary Drugs in a recent Survey & Certification (S&C) memo to State Survey Agency Directors (S&C: 16-15-NH). In the memo CMS revised:

• Guidance to surveyors in Appendix PP of the State Operations Manual (SOM) under F-329 to include language regarding how unnecessary medication use may cause psychosocial harm and to make this part of the SOM easier to use for surveyors;
• Language in the Psychosocial Outcome Severity Guide in Appendix P of the SOM; and
• Selected F-tags to emphasize the risk of psychosocial harm associated with noncompliance with specific regulations.

Pay attention: CMS updated medication tables and resources for surveyors on medication uses, side effects, adverse effects, interactions, and drug classifications. The guidance aims to help surveyors identify a variety of medications that are potentially unnecessary, including medication classifications like antianxiety and hypnotic meds that CMS is capturing in the new quality measure.

Look for Added Language in 14 Other F-Tags

Background: Back in 2006, CMS issued the Psychosocial Outcome Severity Guide as part of Appendix PP of the SOM to help surveyors identify noncompliance levels regarding negative psychosocial outcomes, explains Linda Elizaitis, RN, RAC-CT, BS, President of CMS Compliance Group Inc. in Melville, N.Y.

The latest revision to the SOM Appendix PP at F-329 “is a step beyond just using the 2006 Guide for identified deficient practices — this guidance helps the surveyors to identify the issues themselves,” Elizaitis notes. “This means that surveyors will have a better understanding of the link between unnecessary medication use and negative outcomes and how to identify these issues when they go into a facility to do a survey.”

Also, CMS added language to assist surveyors with determining if there are negative psychosocial outcomes under the following F-tags:

• F-221 Right to be Free from Physical Restraints;
• F-222 Right to be Free from Chemical Restraints;
• F-223 Free from Abuse/Involuntary Seclusion;
• F-224 Prohibit Mistreatment/Neglect/Misappropriation;
• F-225 Investigate/Report Allegations/Individuals;
• F-226 Develop/Implement Abuse/Neglect, etc. Policies;
• F-241 Dignity and Respect of Individuality;
• F-242 Self Determination – Right to Make Choices;
• F-246 Reasonable Accommodation of Needs/Preferences;
• F-248 Activities Meet Interests/Needs of Each Resident;
• F-250 Provision of Medically Related Social Service;
• F-310 ADLs Do Not Decline Unless Unavoidable;
• F-320 No Behavior Difficulties Unless Unavoidable; and
• F-353 Sufficient 24 Hour Nursing Staff Per Care Plans.

Watch for Obvious (And Not So Obvious) Areas

The added language aims to help surveyors identify negative psychosocial outcomes related to an expanded list of F-tags, including some “obvious” areas such as F-221 and F-222, which are related to freedom from physical/chemical restraints, and F-223 through F226, which relate to abuse, Elizaitis notes. “Providers can certainly understand how deficient practices in these areas could also have a negative psychosocial impact on a resident.”

Likewise, adding language regarding psychosocial harm makes sense for F-tags related to a resident’s freedom to make choices and be treated in a dignified manner.

CMS also added language to F-310, which deals with declining Activities of Daily Living (ADLs). Here, you should be aware that as a resident loses his ability to be independent in completing ADLs, there may be a negative impact to his well-being at more than just the physical level, Elizaitis warns.

Your interdisciplinary team should take a careful look when you identify any decline in ADL function and consider what interventions they can put into place to address this change, Elizaitis stresses. “A facility staff needs to take this look before a survey team, especially a team that has been made aware that they are ‘to be mindful of the elevated risk of psychosocial harm’ associated with compliance with this regulation, conducts a survey.”

Extra Scrutiny on Behavior Problems

As for F-320 (behavior difficulties), “providers should be fully expecting surveyors to come through the door looking to see how behaviors are being managed,” Elizaitis warns. “The Focused Dementia Care Survey, the work of the National Partnership to reduce the use of antipsychotics in nursing homes, and the publicly available Quality Measure related to antipsychotic use rates have led to a decline in unnecessary medications.”

This means there’s a strong focus on using non-pharmacological interventions to prevent behavior difficulties. You need to consider what evidence is in a resident’s record to show that you’ve attempted these interventions and developed a person-centered behavior management plan.

Takeaway: “Providers need to think about their exposure points in this area as behavior management is a challenge to many nursing homes,” notes Elizaitis.

Staffing Plays a Part, Too

Finally, F-353 is more important than ever before, with the new mandatory submission of electronic staffing data via the Payroll Based Journal (PBJ) system. Studies have demonstrated a link between staffing levels and the quality of care provided.

“Residents have an increased likelihood to have negative outcomes under any of the F-tags cited in this memo if staffing in a facility is not sufficient,” Elizaitis cautions. “When staffing is suboptimal on any given day or shift, your team may cut corners when providing care for residents, causing psychosocial harm and/or physical negative outcomes.”

Example: Elizaitis points to the potential for psychosocial harm of an incontinence incident because staff failed to follow a toileting plan.

Watch Out for Deficient Practice Areas

Bottom line: Because the S&C memo includes information to help surveyors understand medication uses, side effects, potential adverse events, and other information that they may not have readily understood, “this means that surveyors may be better able to identify an increasing number of meds that could be deemed ‘unnecessary’ in a provider’s facility,” Elizaitis says.

The memo also contains some excellent examples of what surveyors could consider psychosocial harm, Elizaitis notes. “All providers should review this information, because it may help them to recognize the potential negative outcomes of deficient practices in areas that they may not have anticipated.”

Resource: To read the S&C memo, go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-15.pdf.