What are the CMS Survey Updates?

The Centers for Medicare & Medicaid Services (CMS) have introduced significant revisions to Appendix PP of the State Operations Manual, with enforcement commencing on April 28, 2025. There are many areas of focus, for which specific ones require the interdisciplinary approach, including the medical director, attending physician, and both primary care/mental health advanced practice providers. These specific areas of focus include:

• Resident Rights/chemical restraints (F605)
• Transfers/Discharges (F627, F628)
• Services Provided Meet Professional Standards (F658)
• Medical Director Responsibilities (F841)
• QAPI Improvement Activities (F867)
• Pain Management (F697)

Failure to remain compliant with these changes not only leads to the facility being assessed aggressive penalties but moreover to a reduction in the quality of care rendered to the residents.  Eventus WholeHealth is proactively addressing these changes to partner with our facilities to optimize compliance and enhance the quality of care provided to our residents.

How is Eventus WholeHealth Responding to the CMS Survey Updates

In response to these regulatory enhancements, our company is undertaking strategic action with reviews of Eventus Policies and Procedures and disseminating Internal Education for all Eventus clinicians to better-align with the new CMS guidelines.  This includes the following:

• F605
  • Reinforcing our internal protocols for psychiatric psychotropic medication administration and monitoring.
  • Enhance documentation surrounding non-pharmacological interventions that have been employed by facility staff and their efficacy.  We will also continue to document suggested intervention in psychotherapy notes.
  • Enhance documentation surrounding medication justification, appropriate GDR, and timely notification to patient/decision-maker prior to starting/increasing a psychiatric psychotropic medication.
  • Review of some of the key questions that medical directors and attending physicians may be asked by surveyors in relation to this F-tag.
  • Recognizing the difference between an adverse drug reaction and effects of a medication that could be construed as a chemical restraint.
• F627 & F628
  • Reinforcing the medical director’s role in evaluating/heling to update facility policies and procedures surrounding transfers/discharges, with an emphasis on transitions of care to/from the hospital and to lower levels of care.
  • Reinforcing the medical director’s role when the facility cannot meet the needs of a resident.  We are also recommending enhanced documentation for our attending physicians and advanced practice providers in such cases.
  • The appropriate use of the Against Medical Advice (AMA) directive.
• F658
  • Reinforcing the role of the medical director on ensuring medical diagnoses are supported in the documentation, with a keen focus on the use of antipsychotics in those with schizophrenia, schizophreniform disorder, or schizoaffective disorder.
• F841
  • Encouraging the medical director to take an active role in your facility-wide assessments.
  • The role of the medical director and the facility in ensuring all mental health diagnoses are made using acceptable diagnostic criteria.
  • Medical director intervention when medical care is inconsistent with current accepted standards of care.
• F867
  • Medical director to work with the facility on ensuring health equity characteristics are accounted for when collecting/analyzing data related to adverse events/resident outcomes.
• F697
  • Reinforcing definitions of acute vs subacute vs chronic pain
  • Consideration for immediate-release opioids as opposed to extended-release ones.
  • Medical Director role in working with SDC/DON to ensure nursing staff are in-serviced on risks/benefits of such opioid therapy.

Conclusion

In conclusion, the collaborative efforts of Medical Directors, facility leadership, and nursing home owner-operators are paramount in ensuring compliance with the latest CMS Appendix PP changes. By working together, we can not only meet regulatory requirements but also significantly enhance the quality of care we provide to our patients. This unified approach fosters a culture of continuous improvement, teamwork, accountability, and excellence in patient care. Contact our team today if you have questions about how partnering with Eventus WholeHealth can benefit your facility.