The Centers for Medicare & Medicaid Services (CMS) has issued a memorandum to state survey agency directors outlining the focus concerns for fiscal years (FY) 2024 and 2025, along with guidance on how CMS Location staff will conduct Federal Monitoring Surveys (FMS). The memorandum also communicates the estimated FY2024 and FY2025 statutorily required number of Long-Term Care (LTC) FMS for Health and Life Safety Code (LSC)/Emergency Preparedness.
The three required LTC Health FMS concerns are:
- Nurse Staffing
- Unnecessary Psychotropic Medication
- Facility-Initiated Discharge
During these surveys, the Federal Surveyor will independently investigate the areas of concern by following the investigative protocols in Appendix PP of the State Operations Manual (SOM) and the Critical Element Pathways for the applicable concern areas. LTC LSC FMS are comprised of four survey processes aimed at advising and evaluating State Agency (SA) surveyors.
Access the CMS guidance here.
Compliance Perspective
Issue
Facilities must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to ensure 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 required facility assessment according to F838. Each resident’s drug regimen must be free from unnecessary drugs. Each resident’s entire drug/medication regimen should be managed and monitored to promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being. Facility-initiated discharges are permitted when federal regulations are followed. The regulations for discharging residents without their consent must include one of the specific reasons for why the resident is being discharged by the facility without the resident’s consent and providing adequate notice to the resident regarding the discharge.
Discussion Points
- Review your policies and procedures for staffing, psychotropic medication use and monitoring, and facility-initiated discharges. Update as needed.
- Train nursing staff on your policies and procedures for nursing skills, and ensure that each nurse demonstrates competency in providing care. Train clinical staff on your psychotropic medication policies, including the risks and benefits of this classification of drug. Train all staff on your policies and procedures for a facility-initiated discharge. Document that the training occurred and file the signed document in each employee’s education file.
- Periodically audit to determine that new staff orientation is complete to ensure competency of the employees filling each role. Audit to ensure psychotropic medications prescribed to residents list indication for use, are the correct dosage and duration, are adequately monitored by the attending physician or other designated practitioner, and that a licensed pharmacist has provided consultation. Also audit to see if there were any adverse consequences, and if so, that the dose had been reduced or discontinued. Audit all facility-initiated discharges to ensure they meet the federal requirements by having a valid basis.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
