CMS Nursing Home Regulatory Guidance — 2013 Developments

The Centers for Medicare & Medicaid Services (CMS) periodically issues guidance on federal nursing home regulations in the form of a memorandum to state survey agency directors.  The survey and certification memos can assist nursing homes in survey preparation and other regulatory compliance efforts.  Some of the important 2013 CMS guidance is summarized below. 

Cardiopulmonary Resuscitation (CPR): Nursing homes should examine their CPR policy for compliance with recent CMS guidance.  S&C Memorandum, No. 14-01-NH.  According to CMS, nursing homes cannot implement facilitywide no-CPR policies.  Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives; who have not formulated an advance directive; who do not have a valid do not resuscitate (DNR) order; or who do not show American Heart Association (AHA) signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care.  In addition, facility policy should not limit staff to calling 911 when cardiac arrest occurs.  Before emergency medical services arrive, nursing homes must provide basic life support, including CPR, to a resident experiencing cardiac arrest in accordance with an advance directive, or if there is no advance directive or DNR order.

Although CMS acknowledges that CPR is ineffective in the elderly nursing home population, CMS notes the changing demographics in nursing homes.  In 2011, approximately one in seven nursing home residents were under age 65, many of whom were short-stay residents.  In addition, nursing home residents have become more ethnically diverse, which emphasizes the need for full implementation of advance directives and individualized care, CMS says.

The guidance states that nursing homes must ensure that CPR-certified staff is available at all times to provide CPR when needed.  However, CMS does not address which agencies can certify nursing home staff in CPR.  Because CMS refers to the AHA’s standards, it is likely that CMS would deem AHA CPR certification acceptable.

Access and Visitation Rights: CMS has issued a reminder concerning the right of nursing home residents to receive visitors.  S&C Memorandum No. 13-42-NH.  Nursing homes must provide 24-hour access to all individuals visiting with the resident’s consent.  However, certain visitors can be subject to reasonable restrictions designed to protect the security of all residents in the facility, such as denying access to individuals who engage in disruptive behavior.  Because CMS is reminding surveyors to ask during resident and family interviews if they understand that visitors are allowed 24 hours per day, nursing homes should review their visitation policies, as well as the implementation of these policies, to ensure that visits are not being limited or restricted against residents’ wishes, unless there is a reasonable restriction.

Naso-Gastric Tubes: CMS has revised surveyor guidance relating to naso-gastric tubes by expanding and clarifying the definition of naso-gastric tubes.  S&C Memorandum No. 13-17-NH.  Since CMS issued the regulation relating to naso-gastric tubes, found at 42 C.F.R. § 483.25(g), their use has become extremely rare, while the use of other types of enteral feeding tubes has become prominent.  The surveyor guidance expands the definition of naso-gastric tubes to include any feeding tube used to provide enteral nutrition to a resident by bypassing oral intake, such as a gastrostomy tube, jejunostomy tube, and a transgastric jejunal feeding tube.  Nursing homes should review their policies and procedures to ensure compliance with 42 C.F.R. § 483.25(g) for all residents who receive nutrition other than through oral intake.

Dementia Care: CMS has issued surveyor guidance relating to nursing home residents with dementia.  S&C Memorandum No. 13-35-NH.  The guidance expresses concern about the practice of using psychopharmacological medications to try to address behaviors without first determining whether there is a medical, physical, functional, psychological, emotional, psychiatric, social, or environmental cause.  CMS has created surveyor training about behavioral health and dementia care and updated the interpretative guidance in Appendix PP.  Based on the increased scrutiny of residents with dementia and the use of medications, nursing homes should review dementia care practices, including ensuring that medications, such as antipsychotics, are being used with adequate rationale.

Apparently nursing homes are doing a good job decreasing the use of antipsychotic drugs.  Several months after CMS issued its surveyor guidance on dementia care and drug use, it issued a press release stating that new data show that antipsychotic drug use is down in nursing homes nationwide.  The data show that nursing homes are using antipsychotic drugs less and pursuing more patient-centered treatment for residents with dementia and other behavioral health issues.

Image courtesy of Flickr by Sima Dimitric