07/17/2025

Survey Tip of the Week: New Record Review Item

CMS has updated the surveyor resources due to the transition of the survey and certification systems from the Automated Survey Processing Environment (ASPEN) to the web-based Internet Quality Improvement and Evaluation System (iQIES). One notable change impacts the limited record review procedure related to new diagnoses of Schizophrenia. Surveyors are now instructed to review not only residents who are prescribed antipsychotic medications with a newly documented Schizophrenia diagnosis, but also residents who have received a new Schizophrenia diagnosis regardless of whether they are taking antipsychotics. 

CMS emphasizes this change under F641 in the State Operations Manual Appendix PP, stating: CMS is aware of situations where residents are given a diagnosis of schizophrenia without sufficient supporting documentation that meets the criteria in the current version of the DSM for diagnosing schizophrenia. For these situations, determine if non-compliance exists for the facility’s completion of an accurate assessment. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing.  

Surveyors should investigate this concern through record review and interviews with staff who completed the assessment. Surveyors are not questioning the physician’s medical judgement, but rather, they are evaluating whether the medical record contains supporting documentation for the diagnosis to verify the accuracy of the resident assessment.  

If the facility is unable to provide documentation which supports the MDS coding of the new diagnosis in question, then noncompliance exists at §483.20(g) and (i)(2). Supporting documentation should include, but is not limited to, evaluation(s) of the resident’s physical, behavioral, mental, psychosocial status, and comorbid conditions, ruling out physiological effects of a substance (e.g., medication or drugs) or other medical conditions, indications of distress, changes in functional status, resident complaints, behaviors, symptoms, and/or state Preadmission Screening and Resident Review (PASARR) evaluation. 

LeadingAge Ohio encourages providers to review all residents with a Schizophrenia diagnosis, as well as admission procedures, to ensure protocols are in place for obtaining appropriate supporting documentation. Facilities should also routinely monitor compliance using the surveyor guidance outlined 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 Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo.  The previously provided survey tips can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. 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 August 13 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.