Nursing home surveyors should question staff members to ensure that residents’ care is aligned with their advance directives, according to a manual update recently released by the Centers for Medicare & Medicaid Services. The document released Wednesday includes revised guidance for more than 20 F-Tags, including those related to dementia care, restraints and nasogastric tubes.

The section on F-155, related to advance directives and experimental research, is one of the most heavily revised. It includes updated investigative protocols, which advise surveyors to question how a facility determines whether a resident has an advance directive, how it follows these directives and whether it periodically reassesses them.

Another revised portion of the manual addresses quality of care for residents with dementia, including potentially warranted use of antipsychotic medications. For example, a resident with a “persistent, frightening delusion” that his or her children are in danger, and who is almost constantly “inconsolable” despite caregiver and family interventions, might be a candidate for a “trial of a low dose antipsychotic medication.”

Other changes include a note that falls “do not constitute self-injurious behavior or a medical symptom” calling for the use of a physical restraint. Surveyors should attempt to ensure that staff are trying to minimize negative psychosocial impacts of feeding tubes, such as diminished social interactions at mealtimes, according to another updated section.

All the changes are to Appendix PP of the State Operations Manual, and reflect guidance that has been issued via Survey & Certification memoranda between fiscal year 2003 and May 2014, according to the document summary. The new and revised material was effective as of Nov. 26.

Click here to access the complete 226-page document.