|
In November 2024, the Centers for Medicare and Medicaid Services (CMS) released Revised Long-Term Care (LTC) Surveyor Guidance. The memo included significant changes to guidance in Appendix PP. The memo was updated January 16, 2025, to include additional changes to the guidance. The changes will be effective, and surveyors will begin surveying based on the revised guidance, on March 24, 2025. Note: The effective date was delayed from the original memo.
CMS has updated the language to reflect the levels of assistance a resident receives for self-care and mobility activities to align with Section GG of the Minimum Data Set (MDS). Similar revisions to reflect the levels of assistance in Section GG were also made under F677-Activities of Daily Living.
Additional takeaways include but are not limited to the following:
These changes are not new regarding the MDS assessment – they are bringing Appendix PP in alignment with the current guidance in the RAI Manual found in Chapters 2 and 3.
- Assessment and documentation for ADLs changed to Section GG on October 1, 2023, with the elimination of Section G of the MDS.
- This resulted in a significant shift in ADL documentation and capture for residents not in a Medicare Part A stay, which largely impacted long-term care residents.
- Section GG is utilized to determine the Function Score under the Patient Driven Payment Model for Physical Therapy (PT), Occupational Therapy (OT), and Nursing components. The methodology for determining the score for the PT/OT components is different than the one used for Nursing. PDPM is the payment methodology for residents in a traditional Medicare Part A stay and some managed care stays.
- Many states have adopted a modified version of PDPM for their State case-mix methodology (i.e., Medicaid reimbursement), with most states only using the Nursing component.
MDS Section GG-this section includes items about functional abilities, also referred to as ADLs. The assessment of functional status (i.e., ADL performance) for the MDS occurs on admission, discharge, and throughout a resident’s stay (i.e., every MDS). Functional status is assessed based on the need for assistance when performing self-care and mobility activities.
The RAI Manual directs providers to assess the resident’s self-care performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the assessment period. CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the assessment period. Qualified clinicians are defined as healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local laws and regulations.
Significant Change in Status Assessment (SCSA) - The SCSA is a comprehensive assessment for a resident that must be completed when the facility’s interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission MDS assessment, and it is required to be completed (for the MDS/CAA(s)/care plan) no later than 14 days after the IDT’s determination that the resident had a significant change.
A “significant change” is a major decline or improvement in a resident’s status that:
- Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self-limiting”;
- Impacts more than one area of the resident’s health status; and
- Requires interdisciplinary review and/or revision of the care plan.
A significant change differs from a significant error because it reflects an actual significant change in the resident’s health status and NOT incorrect coding of the MDS. A significant change may require referral for a Preadmission Screening and Resident Review (PASRR) evaluation if a mental illness, intellectual disability, or related condition is or is suspected to be present.
For evaluating a resident’s ADLs and determining whether a resident’s abilities have declined, improved, or stayed the same within the last twelve months, the definitions specified in the State’s Resident Assessment Instrument (RAI) Manual are used in reference to the Assessment Reference Date.
For additional information AHCA’s Action Tool F637 Comprehensive Assessment After Significant Change & F677 Activities of Daily Living contains actions items and a check list which can assist your facilty with regulatory compliance.
AHCA has also developed an on-demand webinar that walks learners through each of the changes to guidance, the updates to the Critical Element Pathways (CEP), and some tips/action items necessary in order to be compliant ahead of the effective date. As a result of the updated CMS memo, additions and extending the effective date for the Appendix PP changes have been made to AHCA’s webinar, AHCA Education: Preparing for Upcoming CMS Guidance Changes: Key Updates and Action Items for Compliance. This webinar is on demand and available free to AHCA/NCAL members and $65 non-members. Remember if you are a member of Washington Health Care Association, you are also a member of AHCA and take advantage of this free resource. Please send questions to regulatory@ahca.org, and email educate@ahca.org if you need assistance with registering.
Thank you to AHCA for the development of the information contained within this communication and the associated tools. If you have questions, please contact Elena Madrid, Executive Vice President of Education and Regulatory Affairs.
| 
