Updated Surveyor Guidance: Dementia Care in Nursing Homes (May 24, 2013)

As part of its continuing initiative to reduce the use of antipsychotic medications in nursing home residents, the Centers for Medicare & Medicaid (CMS) has issued new surveyor guidance and a new training video. Specifically, Appendix P and Appendix PP of the State Operations Manual (SOM) have been updated to provide additional survey guidance.

The letter, dated May 24, 2013, “Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 – Quality of Care and F329 – Unnecessary Drugs” (Ref: S&C: 13-25-NH) outlines the seven dementia care principles that should be emphasized in nursing homes’ compliance efforts. They include:

  1. Person-Centered Care (read our related March post on resident-centered care here)
  2. Quality and Quantity of Staff
  3. Thorough Evaluation of New or Worsening Behaviors
  4. Individualized Approaches to Care
  5. Critical Thinking Related to Antipsychotic Drug Use
  6. Interviews with Prescribers
  7. Engagement of Resident and/or Representative in Decision-Making

Appendix P Update

The update to Appendix P outlines changes to the resident sampling process in traditional surveys to ensure surveyors include a sufficient number of residents with dementia who are on antipsychotics. This sample will include residents who are currently receiving or had been receiving antipsychotic medications for more than 30 days, and a comprehensive record review will be completed. For the QIS, the surveyor software will automatically provide the appropriate sample for this updated sample requirement.

Appendix PP Update

The update to Appendix PP provides interim guidance for surveyors to assess a nursing home’s compliance with F-329 – Drug Regimen Free from Unnecessary Drugs and F-309 Provide Care/Services for Highest Well Being. Specific changes at F329 include the inclusion of information on severity levels with corresponding examples as well as an updated antipsychotic medication section. F-309 has a new section regarding the review of care and services being provided for residents with dementia, and much of the guidance reflects the 7 Dementia Care Principles. ADVANCE for Long Term Care Management published an article in May on revisions to F-309 that CMS Compliance Group President Linda Elizaitis wrote, which can be viewed here.

While there is no investigative protocol available for residents with dementia for a traditional survey, CMS has recommended that surveyors use a checklist provided after the updated guidance in the letter, “Review of Care and Services for a Resident with Dementia” for further guidance. This checklist can also be used for the Quality Indicator Survey along with the appropriate Critical Element Pathway.

Surveyor Training Video

The third surveyor training video for the Improving Dementia Care and Reducing Unnecessary Antipsychotic Medicines in Nursing Homes initiative will be available after May 31st, 2013 on the CMS Surveyor Training website. This video will discuss how to cite scope and severity in the areas where the manual has been updated that were mentioned previously. Surveyors must view this video by August 31st, 2013.


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