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GAO Report on Advance Directives in Healthcare Settings

The GAO issued a report on Advance Directives in April to examine how CMS oversees PSDA requirements across healthcare settings, including nursing homes, the challenges providers face, and the prevalence of Advance Directives across the different settings. The Patient Self Determination ACT (PSDA) was put into effect in 1990, which required nursing homes to maintain written policies and procedures regarding informing residents about their right to formulate an Advance Directive and to document their wishes.

For nursing homes, the report mentions two important S&C letters from CMS:

A more recent S&C letter from January 2015 which the report does not reference is a revision to the October 2013 CPR memo, which also includes the Appendix PP draft Guidance at F-155.

The report found that in 2013, approximately 2% of nursing homes that were surveyed received a deficiency related to Advance Directives. This number, thankfully, is low, but it bears keeping in mind that issues related to end-of-life wishes can often result in IJ situations if the Advance Directive is not carried out or is not in place for a resident in a critical situation. As we know, nursing homes, like other providers, usually put Advance Directives in place during admission, and the report confirms this to be a standard practice. Things to think about are ensuring that they are updated based on changes to resident preferences and that all documentation and identifiers match those current preferences. Many deficiencies that we see show staff unable to find the most current documentation other than what was put in place at admission or that residents are wearing colored bracelets that indicate one preference while the medical record provides contrasting preferences.

Overall, the report found that the prevalence of Advance Directives has been increasing in the past few years, and especially so in the older population that could require nursing home care.

Read the GAO report, “Advance Directives: Information on Federal Oversight, Provider Implementation, and Prevalence.”

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