As the MDS nurse, your role is absolutely vital under the new Revised Guidance for Long-Term Care Facilities. Your dedication and expertise make a significant difference in the quality of care provided to residents. Please take a moment to review the important details outlined below and continue making a positive impact in our community.

“Center for Clinical Standards and Quality
Ref: QSO-24-13-NH
DATE: June 18, 2024
TO: State Survey Agency Directors
FROM: Directors, Quality, Safety & Oversight Group (QSOG) and Survey & Operations
Group (SOG)
SUBJECT: Revised Guidance for Long-Term Care Facility Assessment Requirements
Background:
On May 10, 2024, CMS published new regulations under §483.71, Facility Assessment,
as part of the Medicare and Medicaid Programs; Minimum Staffing Standards for Long-
Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency
Reporting final rule (89 FR 40876). These new provisions become effective 90 days
after publication and must be implemented by August 8, 2024. The new requirements
specify that the facility assessment must include an evaluation of diseases, conditions,
physical or cognitive limitations of the resident population, acuity (the level of severity
of residents’ illnesses, physical, mental, and cognitive limitations, and conditions) and
any other pertinent information about the resident population as a whole that may affect
the services the facility must provide. The assessment of the resident population should
drive staffing decisions and inform the facility about what skills and competencies staff
must possess in order to deliver the necessary care required by the residents being
served. The assessment of the resident population should also contribute to identifying
additional needs for residents, such as the physical space, equipment, assisted
technology, individual communication devices, or other material resources that are
needed to provide the required care and services to residents. In conducting the facility
assessment, the facility must ensure active involvement from key individuals, such as the facility’s leadership, and direct care staff (e.g., nurses), and also solicit input from
residents and families.
State Operations Manual (SOM), Appendix PP
Appendix PP of the SOM has been updated to include the revised regulatory requirements that
were released in the final rule, and updated guidance for F838 – Facility Assessment. This
version of Appendix PP is effective August 8, 2024.

Memorandum Summary

• Under the “Minimum Staffing Standards for Long-Term Care (LTC) Facilities and
  Medicaid Institutional Payment Transparency Reporting” final rule, the requirements for
  Facility Assessment have been revised. These revised requirements have been moved to
  42 CFR 483.71. Existing regulations at 42 CFR 483.70(f) through (q) have been
  redesignated as paragraphs (e) through (p), respectively.
• CMS is issuing revised guidance for State Survey Agencies and long-term care facilities
  (LTC) on the revised requirements.” https://www.cms.gov/files/document/qso-24-13-nh.pdf#xd_co_f=YmE0ODA1M2MtMWU2ZC00NjlkLWE0NzYtMzU2OGEzNmYxNjJk~ page 1-2 (last accessed on 8-14-24)

What does this mean for you as the MDS Nurse?

MDS nurses are at the forefront of driving accurate data used to determine who the resident population is and what their needs are. This, in turn, helps determine what staff competencies and skill sets are necessary to provide the level and types of care needed for the resident population. The MDS assessments will also help identify the physical resources needed for the residents, such as mechanical lifts, bariatric equipment, dialysis equipment, ventilators (if provided in your facility), bladder scan, dopplers, and oxygen equipment, among others.

The MDS may help facilities determine what programs need to be updated, such as:

• Substance abuse program
• Dementia care program
• Any cultural needs of residents admitted

Per memo: .

“An assessment of the resident population is the foundation of the facility assessment. Therefore,
the assessment must address the resident population including both the number of residents and
the facility’s resident capacity. In addition, it must include an evaluation of diseases, conditions,
physical and behavioral health needs, cognitive status, acuity of the resident population, and any
other pertinent information consistent with resident assessments that may affect and plan for the
services the facility must provide (e.g., MDS data). Examples of other pertinent information
about the resident population the facility serves may include race, ethnicity, disability, sexual
orientation, gender identity, socioeconomic status, preferred language, health literacy or other
factors that affect access to care and health outcomes related to health equity. The assessment
of the resident population will also contribute to identifying the physical environment, equipment
(medical and non-medical), assisted technology, individual communication devices, or other
material resources that are needed to provide the required care and services to residents.”

“Therefore, the facility assessment
must include an evaluation of the overall number of facility staff needed to ensure sufficient
number of qualified staff are available to meet each resident’s needs as identified through
resident assessments and care plans.” https://www.cms.gov/files/document/qso-24-13-nh.pdf#xd_co_f=YmE0ODA1M2MtMWU2ZC00NjlkLWE0NzYtMzU2OGEzNmYxNjJk~ page 7 (last accessed 8-14-24)

Potential facility tags:

“KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F838, the surveyor’s investigation will generally show that the
facility failed to do any one of the following:

• Annually and as necessary, conduct, document, review and update a facility-wide
  assessment; or
• Address or include in the facility assessment the minimum requirements as described in
  sections § 483.71(a), (b), and (c).
  POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION
  If the survey investigation reveals that there are not sufficient or competent staff refer to:
• F639, §483.21(b)(3), Comprehensive Person-Centered Care Planning;
• F725 or 726, §483.35(a),(c) for any nursing services not related to behavioral health care
  or dementia care;
• F741, §483.40 for any staff caring for residents with dementia or a history of trauma
  and/or post-traumatic stress disorder;
• F801, §483.60(a) for Food and Nutrition staff;
  ADVANCED COPY
  Page 11 of 11
• F826, §483.65(b), Specialized rehabilitative services;
• F839, §483.70(e), Staff qualifications;
• F837, §483.70(d), Governing Body
• F865, §483.75, QAPI/QA&A
  DEFICIENCY EXAMPLES
• One of the sampled residents had experienced a fall while staff were transferring them
  from the bed to a chair as a result of a faulty mechanical lift. The resident’s care plan
  indicates requiring a two-person assist using a mechanical lift. After the fall, the resident
  was evaluated and although he did not suffer any physical harm, upon interview he did
  express psychological harm and stated he was afraid of using these lifts and would prefer
  to remain in bed. Interviews with direct care staff indicated that many of the lifts are old,
  in frequent need of repair, and often malfunction when used. A review of the current
  Facility Assessment did not include or address equipment necessary to provide for the
  needs of residents and did not have active involvement of direct care staff in the process.
• The facility recently admitted several individuals, some that follow a vegan diet and
  others that follow the Judaism faith, both of which include dietary restrictions. These
  individuals did not previously reside in the facility and represents a substantial change in
  the resident population. The residents expressed concerns that they are not always able to
  choose foods that are consistent with their cultural beliefs. Upon review of the facility
  assessment, the facility did not review and update their assessment based on this change
  in their resident population. As a result, the facility did not adjust the menus for these
  newly admitted residents. When reviewing the Facility Assessment, the survey team
  identified that while the assessment included all the required components, it had not been
  reviewed for any potential updates in the last 15 months. Facilities are required to review
  and update the assessment as necessary and at least annually. Even though there were no
  changes to resident needs, staffing, or other resources, the facility’s failure to review the
  assessment within 12 months may result in the facility failing to identify a factor that
  would require a change to the assessment, thereby potentially placing the residents at risk
  for at least minimal harm.” https://www.cms.gov/files/document/qso-24-13-nh.pdf#xd_co_f=YmE0ODA1M2MtMWU2ZC00NjlkLWE0NzYtMzU2OGEzNmYxNjJk~ pg10-11 (last accessed 8-14-24)

In summary, as an MDS nurse, your role is more critical than ever under the Revised Guidance for Long-Term Care Facilities. Your expertise directly influences the quality of care and compliance within our facility. We count on your dedication and attention to detail to navigate these changes successfully. Thank you for your ongoing commitment and professionalism.

To access the entire Memorandum see https://www.cms.gov/files/document/qso-24-13-nh.pdf#xd_co_f=YmE0ODA1M2MtMWU2ZC00NjlkLWE0NzYtMzU2OGEzNmYxNjJk~

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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