Oversight and Compliance

Oversight is finally back for nursing home operators. CMS’s new memo directs investigators to review nurse competency, staffing, and residents’ quality of care. Investigators need to address unplanned weight loss, traumatic falls, injuries of unknown origin, abuse/neglect or pressure injuries. CMS warns that States must adhere to the new survey guidelines or risk losing 5% of CARES act bailout funds.

Critical element pathways help investigators check compliance. CMS Page on LTC Surveys:
https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes (w/ critical pathways, FAQs etc.)

Increasing Oversight in Nursing Homes:

Throughout the COVID-19 PHE, CMS and SAs have been unable to have the traditional level of visibility inside nursing homes to assess residents’ health and safety, and survey for facilities’ compliance. Due to the limitations of oversight during the PHE and changes in how some nursing homes may have operated, CMS is very concerned about how residents’ health and safety has been impacted, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues. Surveyors should be aware that these may be potential areas for further investigation during the survey, such as the following:

Surveying for Nurse Competency

CMS waived certain regulatory requirements that have allowed facilities to alter the manner in which they operate. For example, CMS waived the requirements that a facility may not employ a nurse aide for longer than four months if they did not meet certain training and certification requirements (42 C.F.R § 483.35(d)). We note that CMS did not waive § 483.35(c), which requires facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.

CMS is alerting SAs to pay additional attention to compliance with the requirements for nursing services at § 483.35, which states, “The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).

Change of Condition

Surveyors should review the guidance in Appendix PP of the SOM for tag F-726. This guides surveyors to assess compliance with the requirement for nursing staff to have the appropriate competencies.

As noted in the SOM, a key component of competency is the ability to identify and address a resident’s change in condition. This expectation applies to licensed and registered nurses as well as nurse aides.

These competencies are critical in order to identify potential issues early, so interventions can prevent a condition from worsening or becoming acute. Without these competencies, residents may experience a decline in health status, function, or need to be transferred to a hospital. Surveyors should refer to the Sufficient and Competent Staffing Critical Element Pathway for safety requirements.

Inappropriate Use of Antipsychotic Medications

Inappropriate use of antipsychotic medications continues to be an area of concern related to quality of care. Nursing homes must ensure that each resident’s drug regimen is free from unnecessary drugs (§ 483.45(d)). Investigators should focus on identifying the inappropriate use of antipsychotic medications, emphasize non-pharmacologic approaches and safe care practices.