CMS has been changing education related to F-Tags and SNF leaders may not have had enough exposure to the new CMS updated survey guidance and its interpretive guidelines that went into effect Nov. 26, 2014. CMS has recently published memos to its surveyors – and nursing home providers need to understand this new guidance as it affects their ratings, referrals and risk.

As started with OBRA in 1983, the regulation 483.25 states that: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.  Guidance to Surveyors: 483.25: “Use F-Tag 309 when the survey team determines there are quality of care deficiencies not covered by 483.25 (a)-(m). ‘Highest practicable’ is defined as the highest level of functioning and well-being possible, limited only by the individual’s presenting functional status and potential for improvement or reduced rate of functional decline.

The challenge here obviously lies in the objectivity of perceived well being of someone living with dementia. Increased documentation of care decisions, family involvement and resident choice is important to mitigate risk.

The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, recognized pathology and the normal aging process.

The normal aging process almost always includes cognitive loss. To decrease risk, frequent assessment and inter-team communication needs to be implemented. The yearly BIMS scores might not be sufficient to capture decline and establish corresponding care approaches.

In any instance in which there has been a lack of improvement or decline, the survey team must determine if the occurrence was unavoidable or avoidable. A determination of unavoidable decline or failure to reach highest practicable well-being may be made only if all of the following are present:

• An accurate and complete assessment

• A care plan which is implemented consistently and based on information from the assessment

• Evaluation of the results of the interventions and revising the interventions as necessary.

The survey team must determine if the facility is providing the necessary care and services based on the findings of the RAI (resident assessment instrument). If the services and care are being provided,  they need to determine if the facility is evaluating the outcome to the resident and changing the interventions as needed. Use F-Tag 309 to cite quality of care deficiencies that are not explicit in the quality of care regulations.

It is to be noted that F-Tag 309 is certainly not the only Tag that these memos target. When it comes to dementia residents and their care, F222 and F329 are obviously correlated.

This year’s project also will expand on last year’s efforts in an attempt to improve surveyor effectiveness in citing poor dementia care and the overuse of antipsychotic drugs. CMS has published Review of Care and Services for a Resident with
Dementia (for use with the Interpretive Guidance at F309). This checklist is used by surveyors in the Quality Indicator Survey process.