As previously highlighted in the LeadingAge Ohio’s The Source, the Centers for Medicare & Medicaid Services (CMS) has updated the Long-Term Care (LTC) Surveyor Guidance to enhance the quality and oversight of the LTC survey process. Surveyors will begin using the updated guidance on surveys beginning February 24, 2025. According to the QSO-25-07- NH memo, CMS has strengthened its message that facilities must prevent the unnecessary use of psychotropic medications. Additional guidance has been added to emphasize requirements related to the right to be fully informed of and participate in or refuse treatment, noting that before initiating or increasing a psychotropic medication, the resident must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication.
CMS states, in accordance with the requirements at §483.10(c), residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. To demonstrate compliance, the resident’s medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident’s consent to psychotropic medication, but other types of documentation are also acceptable. If a psychotropic medication has been initiated or increased, and there is not documentation demonstrating compliance with the resident’s right to be informed and participate in their treatment, noncompliance with §483.10(c) exists and F552 must be cited.
LeadingAge Ohio encourages facilities to monitor compliance using the surveyor guidance found in the State Operations Manual Appendix PP. Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.
For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the January 8 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.