New survey guidance coming soon, CMS official says

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Evan Shulman
Evan Shulman

LEESBURG, Va. — Interpretive guidance for the new survey process incorporating Phase 2 regulations could be released over the next few weeks, a top government official said Thursday.

The Centers for Medicare & Medicaid Services had promised guidance in early summer, which officially began Tuesday, with surveyors likely to undergo training starting in July.

“We are planning to release it soon,” promised Evan Shulman, CMS Deputy Director in the Division of Nursing Homes, Survey and Certification Group, speaking at the AADNS show in Leesburg, VA.

Phase 2 regulations go into effect Nov. 28. At AADNS' show last year, many providers were surprised when Shulman unveiled the details of a new survey process. While he didn't unveil a similar bombshell Thursday, he did provide context and information for the clinicians.

Under the new computer-based survey process, which combines elements of the traditional survey process and Quality Indicator Surveys, all F-tags will be changed. The new F-tags will start at 540 and go up, but they should not be assumed to correspond with the old tags. There will be a cross-reference check, likely released in the fall, called a “crosswalk” for those deciphering the new tags.

“It's not a one-to-one switch,” Shulman said. The new survey process will have some collapsed tags, and other areas that are expanded.

“We took this as an opportunity to review interpretive guidelines and ask if it makes sense to have all of these issues with one tag, and does it make sense to have different tags with the same type of issue,” he said.

As CMS historically releases critical information Fridays, Shulman encouraged providers to monitor announcements. He reassured the audience that the agency wants providers to be prepared and know what to look forward to. It's reasonable for them to expect to continue to be asked for documents related to census and new admissions, and it's a “safe bet” that the QAPI plan and a facility assessment will be top-of-mind.

When it comes to infection control, including one surveyor reviewing pneumococcal and influenza vaccines and another looking at infection control and antibiotic stewardship. There will be a brief tour of the kitchen at the beginning, followed by a fuller kitchen inspection later, and surveyors will observe a full meal. The medication administration review is likely to stay unchanged, with a surveyor asking to observe half of med storage rooms and half of medication carts, and expand if needed.

One tense issue relates to staff competency and training. It's a top concern, Shulman said: "We are setting some expectations about what does competency look like. Are they able to practice in their scope of practice successfully?” He added "are they able to practice what they have been trained on such as identifying and addressing resident changes and conditions?"

What defines competence? 

Competency is “knowing, seeing, doing and applying,” advised Amy Franklin, RN, RAC-MT, DNS-CT, QCP-MT, in her presentation "Dare To Be Prepared: The DNS's Role in the New Emergency Preparedness and Facility Assessment Requirements."

She noted that understanding nurse competency does not solely focus on the degree.

“I've met some pretty intelligent nurses in my time and some highly educated people where I would rather have my cat take care of me,” she said. “Just because you have a degree doesn't mean you're competent. Competency is being able to apply your training in the situation it's designed for.”

She further clarified that education on all levels remains of critical importance. "Directors of nursing services should continue to encourage their nursing department to pursue their nursing educations at all levels," she said.

Remember, there's a difference between nurses freezing up under pressure, and not understanding what to do, Franklin advised.

“I've interviewed many nurses during crisis and they said, 'I froze, I didn't know what to do next.' You ask, ‘What would you have done if your brain didn't freeze?' Sometimes you need to know if they know.”

Franklin, who also is a McKnight's Ask the Nursing Expert columnist, advised having nursing staff take a questionnaire related to education, such as what applications, access points and specific educational services they are using.

“Do not allow YouTube to be your trainer unless you have vetted that out,” she warned.

CMS-nurse disconnects

While Shulman stressed that CMS is “not engaged in a 'gotcha' mentality,” and complimented “great work” on Payroll-Based Journal submissions, AADNS nurses challenged Shulman on the issue of rehospitalization measures during a question-and-answer session. One noted that  “not every hospitalization is avoidable.”

Shulman agreed, but he also noted how many facilities do not document end-of-life care planning or the trajectory of a disease, leading families to become misguided about what can be done for a resident.

But perhaps nothing illustrates the disconnect between the agency and some nurses than, when, earlier in the presentation, Shulman walked through a common hospitalization scenario. The facility says they were told by the doctor to send a resident to the emergency room, while the doctor said he did not receive a good assessment or have confidence in the nursing home.

“And then they both say, ‘The family said send Mom to the hospital,'” he said. “In that, who gets caught in the middle?”

The correct answer was “the resident.” But at least one nurse murmured, “us.”

To learn more, including information about the updated facility matrix, click here and then click to download “New Long-Term Care Survey Process.” A Medicare Learning Network call also is scheduled for July 25, Shulman said.

The AADNS meeting concludes Friday.