The Centers for Medicare & Medicaid Services (“CMS”) has given surveyors new rules and updates to allow surveyors to add extra attention and increase oversight in nursing homes regarding the role of the medical director and how mental disorders are diagnosed.
On November 18, 2024, the Quality, Safety & Oversight Group at CMS issued a memorandum entitled “REVISED: Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process.” (“New Surveyor Guidance Memo”).
F658 Practitioner Involvement in Diagnosis of Mental Disorders
F658 is based on 42 CFR §483.21(b)(3), which provides that the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality.
The New Surveyor Guidance Memo provides that mental disorders are diagnosed by a practitioner, using evidence-based criteria and professional standards, such as the current version of the Diagnostic and Statistical Manual of Mental Disorders (“DSM”), and are supported by documentation in the resident’s medical record. Also, supporting documentation should include, but is not limited to, evaluation of the resident’s physical, behavioral, mental, psychosocial status and comorbid conditions, ruling out physiological effects of a substance (e.g., medication or drugs) or other medical conditions, indications of distress, changes in functional status, resident complaints, behaviors, symptoms and/or state Preadmission Screening and Resident Review evaluation.
Insufficient documentation for a new mental health diagnosis means that the resident’s medical record does not contain the following:
- Documentation (e.g., nurses’ notes) indicating the resident has had symptoms, disturbances or behaviors consistent with those listed in the DSM criteria, and for the period of time in accordance with the DSM criteria.
- Documentation from the diagnosing practitioner indicating that the diagnosis was given based on a comprehensive assessment, such as notes from a practitioner’s visit.
- Documentation from the diagnosing practitioner indicating that the symptoms, disturbances or behaviors are not attributable to (i.e., ruled out) the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., UTI or high ammonia levels).
- Documentation regarding the effect the disturbance has on the resident’s function, such as interpersonal relationships, or self-care, in comparison to their level of function prior to the onset of disturbance.
Examples of insufficient documentation to support a mental health diagnosis would include:
- A situation where schizophrenia or another diagnosis is only mentioned as an indication in medication orders without supporting documentation.
- The addition of, or request by the facility to a practitioner for, a diagnosis of schizophrenia or another diagnosis without documentation supporting the diagnosis.
- A practitioner’s note or transfer summary from a previous provider stating “history of schizophrenia,” “schizophrenia” or another diagnosis without supporting documentation confirming the diagnosis with a previous practitioner or family, and the facility failed to provide evidence that a practitioner conducted a comprehensive evaluation after admission.
- A diagnosis list stating schizophrenia or another diagnosis without supporting documentation.
- A note of schizophrenia or another diagnosis in an electronic health record (“EHR”) without supporting documentation which populates throughout the EHR.
- A note of schizophrenia or another diagnosis in the medical record by a nurse without supporting documentation by the practitioner.
CMS is aware of situations where residents are given a diagnosis of schizophrenia without sufficient supporting documentation that meets the criteria in the current version of the DSM for diagnosing schizophrenia. For these situations, determine if non-compliance exists related to the practitioner not adhering to professional standards of practice for assessing and diagnosing a resident.
Surveyors should investigate this concern through record review and interviews with the practitioner(s), facility medical director and other appropriate nursing home staff, as well as consult with the state agency medical director as needed. Surveyors are not questioning the practitioner’s medical judgment, but rather, they are evaluating whether the medical record contains supporting documentation for the diagnosis to verify the accuracy of the resident assessment.
If the facility is unable to provide practitioner documentation that supports the new psychiatric diagnosis in question, then non-compliance exists. For example, if a new diagnosis of schizophrenia is noted in the medical record, the surveyor should verify the documentation supports the use of accepted standards of practice (e.g., current DSM criteria) for the diagnosis.
F841 – Medical Director Role
F841 is based on 42 CFR §483.70(g), which provides that the facility must designate a physician to serve as medical director. The medical director is responsible for (i) the implementation of resident care policies; and (ii) the coordination of medical care in the facility.
The New Surveyor Guidance Memo includes revisions of the medical director’s responsibilities for the nursing home.
Medical director responsibilities must include:
- Implementation of resident care policies, such as ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications and intervening with a health care practitioner regarding medical care that is inconsistent with current professional standards of care.
- Participation in the Quality Assessment and Assurance (“QAA”) committee or assign a designee to represent him/her.
- Addressing issues related to the coordination of medical care and implementation of resident care policies identified through the facility’s quality assessment and assurance committee and other activities.
- Active involvement in the process of conducting the facility assessment.
- Administrative decisions include recommending, developing and approving facility policies related to residents’ care. Resident care includes residents’ physical, mental and psychosocial well-being.
- Discussing and intervening (as appropriate) with a health care practitioner regarding medical care that is inconsistent with current standards of care, for example, physicians assigning new psychiatric diagnoses and/or prescribing psychotropic medications without following professional standards of practice.
Effective Date
The New Surveyor Guidance is effective March 24, 2025.
Practical Takeaways
- Effective March 24, 2025, surveyors will use these guidelines to survey and cite providers.
- A careful review of your mental health disorder diagnosis steps and process is needed.
- Facilities must review the role and actions of the medical director as they relate to facility assessment and QAA committees.
If you have questions or would like additional information about this topic, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
- Your primary Hall Render contact.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot give legal advice outside of an attorney-client relationship.