Another week, another opportunity for us to review the upcoming regulatory guidance changes in State Operations Manual Appendix PP – now coming your way on April 28, 2025. We reviewed F658 as part of our CMSCG “Ftag of the Week” blog series in June 2018, but we’re back at it to help nursing homes understand the new guidance for this tag.
The regulation states the services provided or arranged for by the facility must meet professional standards of quality. The intent of F658 has been revised, and now reads, “to assure that all services, as outlined by the comprehensive care plan, being provided meet professional standards of quality.” The Interpretive Guidance (IG) has been further revised to address concerns related to mental health diagnoses – something we pointed out in our recently revised Ftags of the Week for F641 Accuracy of Assessments and F841 Responsibilities of the Medical Director – are you seeing the pattern? It’s pretty clear that these practices may be much more common than anticipated, even if it’s not an issue in your own facility.
The IG includes the same “supporting documentation” requirements in the medical record that we listed in our Ftag of the Week for F641, so if you need a refresher, you can view that here. Where F658 really packs a punch is the long list of guidance that reflects what is insufficient documentation – and the list may include areas that you’ve been trying to get by on.
IG Examples of Insufficient Documentation for a New Mental Health Diagnosis
If the resident’s medical record does not contain documentation addressing all of the following when a new mental health diagnosis is added, you’ll likely run into trouble:
- Indication of the resident’s behaviors/ symptoms/ etc. which are consistent with those listed in the DSM criteria for that mental diagnosis and which are consistent with the time frame set out by the DSM. This could – and should, at a minimum – include Nurses’ Notes.
- The diagnosing practitioner has indicated that the diagnosis was made based on a comprehensive assessment, where the resident’s symptoms/ behaviors/ disturbances have been ruled out as not attributable to another medical condition or the effect of another medication or substance use. This could include notes from the practitioner’s visit.
- How the resident’s function is being impacted compared to his/ her prior level of function.
The IG also provides a list of what would be considered insufficient documentation to support a mental health diagnosis. Let’s review that next.
IG Examples of Insufficient Documentation to Support a Mental Health Diagnosis
Even though the revised IG refers to “mental health” diagnoses, it’s still primary focused on Schizophrenia. These examples are definitely a compilation of ways that our team at CMSCG has seen some providers try to validate a diagnosis, so pay attention to what’s going on in your own facility. A mental health diagnosis cannot be supported when:
- The diagnosis is only mentioned as an indication in medication orders without supporting documentation.
- The facility requests that a practitioner add a diagnosis without supporting documentation.
- A practitioner adds a diagnosis without supporting documentation.
- Documentation from a previous care location or provider indicates a diagnosis or “history of” a diagnosis without supporting documentation to confirm the diagnosis either by the prior practitioner or family and the facility did not ensure that a comprehensive evaluation was conducted after admission.
- The diagnosis is listed on a diagnosis list without supporting documentation.
- A note indicating a diagnosis in the EMR populates throughout the resident’s medical record but does not have sufficient supporting documentation.
- A Progress Note or other documentation by a nurse includes a medical diagnosis but there is no supporting documentation by the practitioner.
There’s even more in the revised guidance with specifics about Schizophrenia and related disorders. Check back next week for Part 2.
