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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.
In the changes to the requirements, CMS has relocated regulatory references and guidance previously found under F642 (Coordination/Certification of Assessment) to F641 Accuracy of Assessments. In addition, instructions to surveyors for investigating Minimum Data Set (MDS) assessment accuracy and determining whether noncompliance exists when a concern related to insufficient documentation to support a medical condition is identified for a resident receiving an antipsychotic medication were added to the guidance under F641.
Additional takeaways include but are not limited to the following:
In the guidance, accuracy of the MDS assessment means the appropriate, health professionals correctly document the resident’s medical, functional, and psychosocial problems. The MDS assessment must also identify resident strengths to maintain or improve the medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI).
Facilities are responsible for ensuring that all participants in the assessment process have the knowledge to complete an accurate assessment. CMS goes on to state that a facility/individual that willfully and knowingly provides false assessment data may be indicative of payment fraud or attempts to avoid reporting negative quality measures.
Surveyors are expected to focus on MDS coding accuracy but are not expected to investigate possible falsification of the MDS. If the surveyor identifies a pattern (i.e., three or more residents) of inaccurate MDS coding by staff who completed, signed, and certified to the accuracy of the portion of the assessment they completed, and there are indications or concerns that the individual who completed the section(s) in question knew the coding was inaccurate, a referral should be made to the Office of Inspector General for investigation of falsification.
Similar to changes in other F-tags in the advanced copy of Appendix PP, CMS expanded the guidance surrounding the diagnosis of schizophrenia and when it is appropriate to capture on the MDS. In relation to inaccurate MDS diagnosis coding (section I), CMS states that they are aware of situations where residents are given a diagnosis of schizophrenia without sufficient supporting documentation that meets the criteria in the current version of the Diagnostic & Statistical Manual (DSM) for diagnosing schizophrenia.
For these situations, guidance directs surveyors to determine if non-compliance exists for the facility’s completion of an accurate assessment. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing. Surveyors will conduct a thorough review of the medical record and interview staff who completed the MDS assessment. CMS states that surveyors are not questioning the physician’s medical judgement, but rather, they are “evaluating whether the medical record contains supporting documentation for the diagnosis to verify the accuracy” of MDS assessment.
The resident’s medical record should at least include documentation of the following:
✓ Evaluation(s) of the resident’s physical, behavioral, mental, psychosocial status, and comorbid conditions, ruling out physiological effects of a substance (e.g., medication or drugs) or other medical conditions, indications of distress, changes in functional status, resident complaints, behaviors, symptoms, and/or state Preadmission Screening and Resident Review (PASARR) evaluation.
✓ Querying a medical provider to obtain a diagnosis of schizophrenia alone for capture on the MDS is not sufficient.
✓ All diagnoses (with exception of UTI) captured under Active Diagnoses (I0100 – I8000) in Section I must also meet the following criteria outlined in the RAI Manual:
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The disease conditions in I0100 through I8000 require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days (i.e., 60-day look-back from the MDS Assessment Reference Date).
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Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
For additional information AHCA’s F-Tag Action Tool-F641 Accuracy of Assessments contains action items and a check list which can assist your facility 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.
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