Up next on the CMSCG Blog is our Ftag of the Week for F740 Behavioral Health Services. We delayed covering this regulation since we were anticipating additional significant guidance to surveyors in the State Operations Manual Appendix PP, and the Centers for Medicare & Medicaid Services (CMS) did not disappoint with its latest revisions. Behavioral health-related requirements of participation are sprinkled throughout the draft Appendix PP released on June 29, 2022, and many providers will need to dig in over the next few months to address this area of service. Nursing home populations have changed over time, and with this updated guidance, CMS is expanding its expectations for the types of residents that will be residing in these facilities going forward – namely ones with increasingly complex behavioral health needs, including those with substance use disorders (SUDs). The Agency’s expectation that providers only admit residents that they can care for has not changed, but it is now clear that CMS expects providers to ensure staff are adequately trained to meet these unique needs.
Due to the complexity of these requirements, this will be a multi-part blog series. There are several associated Ftags that we will also review and expand upon in the next couple posts on the CMSCG Blog to help you prepare for October 24, 2022.
Overview of F740 & Behavioral Health Concerns to Be Aware of
The regulation for F740 Behavioral Health Services was not revised in the most recent version of Appendix PP, but the guidance was expanded. The regulation states that nursing homes must provide the necessary behavioral health care and services to every resident, in accordance with his/her comprehensive assessment and plan of care. Let’s review some concepts and definitions.
“Behavioral health,” per the regulation, encompasses the resident’s whole emotional and mental well-being, including, but not limited to, the prevention and treatment of mental and substance abuse disorders. The definition of the commonly used phrase, “highest practicable physical, mental and psychosocial well-being” is also included at F740. To meet this highest possible level of functioning, the expectation is that a resident’s physical, mental and/or psychosocial needs with be assessed, recognized and competently and thoroughly addressed.
“Mental disorder” – is defined as a syndrome characterized by a clinically significant disturbance in an individual’s emotional regulation, behaviors or cognition. These changes reflect a dysfunction in processes underlying mental functioning, which can be developmental, biological or psychological in nature. Newly added to Appendix PP is language which states that mental disorders are usually associated with significant distress or result in a disability in social, occupational or other key activities.
The Interpretive Guidance (IG) includes a section on conditions frequently seen in nursing homes residents which may require the facility to provide appropriate services or support to address those conditions and associated needs. These include depression, anxiety/ anxiety disorders, schizophrenia and bipolar disorder. Let’s review some of the key points from each section:
Depression (i.e. Clinical Depression or Major Depressive Disorder) is:
- A common and serious mood disorder
- Not a natural part of aging
- Older adults in a nursing home setting are more at risk to be depressed than their counterparts living in the community
- Difficult to identify in late life due to factors including cognitive impairment, complexity of multiple chronic medical conditions that may compound the problem, the loss of significant relationships and/or roles in life, and the loss of functional ability
The IG states that although depression present differently in older adults, it is still the responsibility of the facility to ensure that an accurate diagnosis is established. Common symptoms of depression can include:
- Fatigue
- Sleep disturbance
- Appetite disturbance
- Agitation
- Difficulty concentrating
- Apathy
- Withdrawal
- Expressions of guilt
- Suicidal ideation
About Anxiety and Anxiety Disorders (i.e. Generalized Anxiety Disorder, Panic Disorder, Post-Traumatic Stress Disorder)
- General anxiety and anxiety disorders can have subtle distinctions and require a qualified professional to accurately diagnose the individual.
- General anxiety involves “occasional worry” about circumstantial events and is a common reaction to stress
- Anxiety disorders could include additional symptoms such as intense anxiety or excessive fear that could become debilitating and cause significant distress to the individual experiencing them
- An additional complexity to an accurate diagnosis of anxiety is that anxiety can be a symptom of other disorders. An individual living with dementia or who has been diagnosed with depression may also exhibit anxiety.
Schizophrenia is:
- A serious mental disorder that may interfere with an individual’s ability to manage his/her emotions, think clearly, relate to others, and can impact decision-making
- Symptoms can include disorganized speech, delusions, all forms of hallucinations, diminished expression, catatonic behavior, grossly disorganized behavior and/or decreased initiative
- Generally diagnosed in individuals between the ages of 12-40. Throughout the guidance to surveyors, CMS remarks about the increase in late-life schizophrenia diagnoses in nursing home residents to justify the use of antipsychotics without triggering the associated Quality Measure. The IG states that a qualified practitioner using professional standards and evidence-based criteria must be utilized for an appropriate diagnosis to be established.
About Bipolar Disorder:
- Bipolar disorder is a mental disorder that can cause dramatic shifts in an individual’s energy level and moods (i.e. shifting between high “manic” mood and low “depressive” mood). The individual’s ability to think clearly may also be inhibited.
- The symptoms and their severity can vary by person, as well as how frequently they are experienced. There are different forms of Bipolar Disorder which are based on the frequency and extent of the individual’s cycles. The manic and depressive cycles are more significant than the general ups-and-downs other people may experience occasionally.
In addition to ensuring that nursing home residents with mental disorders are appropriately assessed, diagnosed and provided with the necessary care and services to maximize their quality of life, CMS greatly expanded its expectations for nursing homes regarding treatment of residents with substance use disorders.
“Substance use disorders” – include the recurrent use of drugs and/or alcohol that results in significant clinical and functional impairment. Issues associated with SUDs can include worsening health conditions, disability and impact the individual’s ability to address major life responsibilities such as working or participating in family/home life activities.
Many nursing homes likely did not anticipate that they would need to eventually help fill the behavioral health services gap occurring throughout the country, so a structured approach to identifying residents with these unique needs is the first step in determining, at a high level, the services that should be being provided in the facility. In our next post, we will look at resident assessments and where facilities should be looking to identify residents’ behavioral health needs.
CMS Compliance Group, Inc.
CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm with extensive experience servicing post-acute and long term care facilities and agencies. With the idea of continuous quality improvement in mind, CMS Compliance Group’s interdisciplinary team provides a unique approach to client service, ensuring that all departments can achieve and maintain compliance while improving quality of care.
Our consultants provide proactive and reactionary compliance consulting services to clients across the country and have an established reputation for rapidly addressing and successfully resolving the most serious issues that occur in nursing homes, assisted living, home health agencies and other providers.
To learn more about our nursing home consulting services, please visit our website or contact us to discuss how we can help you prepare for these upcoming regulatory changes.
