Focused Dementia Care Surveys: What You Need to Know

The Focused Dementia Care Survey pilot project has completed more than two years of pilot data collection and is ready for higher levels of implementation. The project, which places special attention on facilities that have specialty dementia units, includes new survey tools for dementia care and the use of antipsychotic medications among other things.

In its November 27, 2015, memo to state survey agency directors, S&C: 16-04-NH, CMS stated: “The Centers for Medicare & Medicaid Services (CMS) completed a pilot project in 2014 to examine the process for prescribing antipsychotic medications and assess compliance with other federal requirements related to dementia care practices in nursing homes. Additionally, it was initiated to gain new insights about surveyor knowledge and skills and ways the current survey process may be streamlined to identify and cite deficient practices more efficiently and accurately.”

In 2015, CMS expanded the project to include more intensive, targeted efforts to cite poor dementia care and the overutilization of antipsychotic medications. Upon completion of the pilot and the 2015 expansion effort and based on surveyor feedback and data analysis, CMS revised the survey materials and tools.

The project is now moving forward, making it imperative that nursing facility leaders are ready for these inspections. In response to feedback from stakeholders and partners of the National Partnership to Improve Dementia Care in Nursing Homes, CMS is sharing the revised survey materials that were used during the 2014 pilot and 2015 expansion effort. The intent is that nursing facility leaders will use these tools to assess their own practices in providing resident care.

What does the survey look like?

The purpose of the on-site Focused Dementia Care Survey is to determine compliance with the regulations at §483.25, Appendix PP F309, Care and Services for a Resident With Dementia. Compliance with F309 is assessed during the Focused Survey through surveyor observations, interviews and record reviews of a sample of residents with dementia. If, during the survey, other issues unrelated to dementia are identified at the facility, these may be investigated as a separate complaint at the discretion of the state survey agency.

The S&C memo further states: “In general, 2 surveyors will be able to complete the focused survey of 5 residents in 2–3 days for a medium sized (e.g., 120–150 bed) facility. For larger facilities (e.g., over 150 beds), or facilities with a history of deficiency citations at F309 that relate to dementia care, state agency directors or managers may elect to expand the sample up to 10 residents. In addition to staff who are on site (e.g., CNAs, nurses, activities professionals, dementia unit director), surveyors will interview physicians, nurse practitioners, physician’s assistants, pharmacists, LTC ombudsmen and family members as part of the survey.”

The surveyors will complete three worksheets. Part 1 collects information about the nursing facility’s characteristics. Part 2 takes a look at dementia care policies, leadership, training and documentation. Part 3 involves the review of a nursing facility’s quality assessment and assurance (QAA) programs.

The role of the MDS coordinator

Specific items on the MDS 3.0 will get special attention in this Focused Survey. Since the original dementia-focused initiative concentrates on antipsychotic use in nursing facilities, the accuracy in section N, Medications, is vital, especially for item N0410A, Antipsychotics. In section N, the resident is assessed as to whether an antipsychotic medication was received during the look-back period of seven days.

The surveyor will be looking for the appropriateness of the medication as it relates to the resident’s overall mental health and well-being, as well as proper dose reductions. Medication should be coded “according to the medication’s therapeutic category and/or pharmacological classification, not how it is used,” notes page N-6 of the Resident Assessment Instrument (RAI) User’s Manual. For example, the drug Haloperidol may be ordered to treat anxiety. Since this drug is classified as an antipsychotic medication, it must be coded in N0410A if it was received during the look-back period, even if it was for anxiety, and receipt of the antipsychotic may still be included in the Focused Survey if the resident’s record was reviewed.

Another section of the MDS that is used during the survey is section I, Active Diagnoses. Part 2 of the surveyors’ worksheets samples residents in a specialized care or dementia unit with a diagnosis of dementia such as Alzheimer’s (I4200); or Lewy body, vascular, or other dementia (I4800). If none of these diagnoses applies, others such as TBI (I5500) or psychiatric disorders (I5700–I6100) are considered.

Part of the survey process is to ascertain whether residents diagnosed with dementia are receiving care according to a specialized practice guideline, such as CMS’s Hand in Hand series or another nationally recognized practice guideline for dementia care that emphasizes person-centered care and the prevention of abuse. Utilizing evidence-based practice standards can allow residents with behavioral symptoms to receive personalized interventions to help decrease those behaviors, especially during an antipsychotic dose-reduction period. Once again, accuracy on the MDS is vital—in this case, with section E, Behavior. Residents having physical (E0200A), verbal (E0200B) and other (E0200C) behavioral symptoms may have unmet needs requiring careful assessment and care planning.

Additionally, residents who have hallucinations (E0100A) or delusions (E0100B) may require medications to help reduce these. However, to promote quality resident care, facility staff must still consider dose reductions in such medications as well as increased resident-specific interventions.

Lastly, residents who reject care (E0800) or wander (E0900) may have unmet needs that can be addressed with resident-specific interventions to decrease the behavior. Moreover, rejection of care can be tricky to code. Page E-14 of the RAI User’s Manual defines Rejection of Care as “behavior that interrupts or interferes with the delivery or receipt of care. Care rejection may be manifested by verbally declining or statements of refusal or through physical behaviors that convey aversion to or result in avoidance of or interfere with the receipt of care.”

Case example

A resident has a diagnosis of end-stage Alzheimer’s disease. She is ambulatory and wanders around the nursing facility all day but has lost the ability to recognize hunger. Consequently, she won’t sit down at mealtimes to eat. The nursing staff document the resident as “refusing meals” and the MDS nurse codes Rejection of Care in E0800. Are the resident’s needs being met? Was every effort made to help the resident consume food or snacks? Perhaps the nursing staff could have offered the resident half a sandwich as she wanders. It is possible she would take the sandwich and begin to eat it automatically as she continues to walk around the nursing facility. This would be considered a resident-centered intervention to be included on the care plan.

Shore up documentation

No longer is it acceptable to document using words like refused, belligerent or combative. What do those words really mean? Are they helpful when trying to determine resident-centered interventions? While these types of episodes absolutely require documentation, it needs to be clear and specific. If a resident refused medication, the documentation should reflect the circumstances. For example, “The resident pushed the nurse’s hand away when offered his 8:00 a.m. medications.” Or, “The resident slapped the nursing assistant when attempted to assist her with showering.” This kind of documentation can provide opportunities for further analysis, leading to better resident-centered care-planning interventions. Perhaps the resident slapped the nursing assistant because the water was too cold. Such analysis can forge strong assessments and high-quality care for residents.

Lisa Hohlbein, RN, RAC-MT, CDP, CADDCT is Curriculum Development Specialist for The American Association of Nurse Assessment Coordination.

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