05/15/2025

Survey Tip of the Week: Antipsychotic Medication Review

CMS has updated survey guidance in QSO-25-14- NH, adding specific instructions for investigating Minimum Data Set (MDS) assessment accuracy when reviewing residents receiving antipsychotic medications. This change impacts how surveyors assess compliance under F641, Accuracy of Assessments. Surveyors are now instructed to:

• Use the MDS assessment to guide their review and determine what portion of the medical record is needed to review documentation of a GDR attempt or a clinical contraindication rationale
• Review the most recent Resident Assessment Instrument or MDS Section N, item N0450 for a date that a GDR was attempted or a date that the physician determined that a GDR was contraindicated. Review the portion of the medical record that corresponds with the MDS dates to ensure the GDR was attempted or that a clinical contraindication rationale was provided.
• If there is no documented date for a GDR or a clinical contraindication on the most recent MDS assessment, review the medical record to determine if a GDR may have been attempted or a clinical contraindication rationale provided since the last MDS assessment and the time of the survey. If there is no evidence of a GDR and there is no description of the clinical contraindications, then noncompliance exists.
• Additionally, surveyors should investigate compliance with F641 if there are discrepancies in GDR documentation between the medical record and the MDS assessment(s).

CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge Ohio encourages facilities to monitor compliance using the surveyor guidance found in the State Operations Manual Appendix PP. Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.

For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the June 11 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.