CMS Updates LTC Surveyor Guidance – LeadingAge NY Analysis: Segment 4: QAPI, Medical Director Responsibilities, and Accuracy of Assessments

(Jan. 7, 2025) As we start this new year, LeadingAge NY continues to analyze the Centers for Medicare and Medicaid Services' (CMS) updates to the guidelines for surveyors described in memorandum QSO-25-07-NH. Feb. 24, 2025, the official date of implementation, is quickly approaching, making the importance of understanding the implications for nursing home providers paramount. This article will review the modifications and major updates on Quality Assurance Performance Improvement (QAPI), Medical Director responsibilities, and accuracy of assessments.

QAPI Updates

There were several additions to the QAPI guidance sections referencing health equity. Providers should consider feedback mechanisms related to concerns about health equity and collect and monitor data related to outcomes of sub-populations to address health equity issues. Health equity should also be considered when establishing priorities for performance improvement activities. Providers may find it easiest to start with health equity issues identified through the Health Equity Confidential Feedback Reports that CMS began providing for post-acute providers in fall 2023.

This requirement is regulated under F867-§483.75(c) Program feedback, data systems, and monitoring regulation, where CMS states that a facility must establish and implement written policies and procedures for feedback.

CMS goes on to describe health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.”

CMS has also added the following interpretive guidelines for surveyors: “Facilities should consider feedback related to concerns about health equity. For example, does the facility address the needs of individuals with disabilities, limited English proficiency, with different cultural or ethnic preferences, or other health equity concerns?”

Medical Director Responsibilities and Accuracy of Assessment

CMS continues to express concerns about misdiagnosis of schizophrenia in the updated guidance. They are holding accountable not only the practitioner making the diagnosis, but also the individual assessors documenting the diagnosis on the Minimum Data Set (MDS) assessment, the individual certifying accuracy of the assessment, and the Medical Director who is responsible for oversight of medical care. The new guidance explicitly states that the Medical Director is responsible for ensuring that practitioners adhere to facility policies for diagnosing and prescribing medications and must intervene with a health care practitioner regarding medical care that is inconsistent with current professional standards of care. This would include the inaccurate assessment and/or diagnosis of schizophrenia and initiation or continuation of psychotropic medications that do not meet professional standards. More information on the requirements of documentation with psychotropic medications can be found here.

All mental health diagnoses, including schizophrenia, must be supported with documentation in the medical record, including diagnoses made by an outside practitioner prior to the resident’s admission. The nursing home must be sure that they validate the diagnosis according to professional standards of practice and supporting documentation in the medical record, which should also include the Preadmission Screening and Resident Review (PASARR) evaluation and determination report. Other types of verifying records include behavioral documentation, as well as attempts to obtain documentation regarding diagnoses from previous practitioner(s), and rationale for how the validating practitioner arrived at the assigned diagnosis.

Resident assessment regulations can be found under §483.20 at F636, F637, and F641. Providers should be aware that guidance previously under F642 has been moved to F641 Accuracy of Assessments with its new revisions. The State Operations Manual (SOM) has been updated to include the following when documenting the diagnosis of schizophrenia:

“Surveyors are not questioning the practitioner’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 practitioner documentation which supports the new psychiatric diagnosis in question, then non-compliance exists. For example, if a new diagnosis of schizophrenia is noted in the medical record, the surveyor should verify the documentation supports the use of accepted standards of practice (e.g. current DSM criteria) for the diagnosis.”

“Below are excerpts from the DSM (current as of the date of this publication)10F 1 which describe diagnostic criteria for schizophrenia, schizophreniform disorder, and schizoaffective disorder. This list is not all-inclusive and should not be used as a checklist but rather as a guide when reviewing supporting documentation.”

SCHIZOPHRENIA Diagnostic Criteria

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Continuous signs of disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less successfully treated).

SCHIZOPHRENIFORM disorder is characterized by a symptomatic presentation equivalent to Diagnostic Criteria that of schizophrenia except for its duration (less than 6 months) and the absence of a requirement for a decline in functioning.

Diagnostic Criteria

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.”

C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

SCHIZOAFFECTIVE DISORDER

A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

When residents are admitted to the facility with a mental health diagnosis, supporting documentation should include, but is not limited to:

• The PASARR evaluation and determination report from the State Mental Health Authority;

• Facility attempts to obtain documentation regarding the mental health diagnosis from the previous provider(s);

• Validation of the resident’s mental health diagnosis by the practitioner in accordance with professional standards of practice, such as reviewing information available in the medical record, including information from the previous provider(s), discussions about the diagnosis and history with the resident or resident representative, conducting a comprehensive evaluation, the need for a psychiatric or other consultations if necessary, and their determination of the resident’s diagnosis.

Use of the critical element pathways for QAPI and Resident Assessment is helpful in preparation and implementation of these updates. More information on CMS's updated surveyor guidelines can be found here.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147