Don't have a TCI SuperCoder account yet? Become a Member >>

Long-Term Care Survey Alert

Survey Strategies:

Tap This Insider Tool to Improve Dementia Care -- or Invite Survey Citations

CMS worksheet reveals clues to compliance in 2016.

What began as a five-state dementia care pilot in 2014 is now officially the concern of all long-term care providers nationwide. Late in November 2015, the Centers for Medicare and Medicaid Services (CMS) released a memo describing its Focused Dementia Care Survey Pilot — and you could be held accountable if you’re not using the tool recommended in it.

Background: CMS piloted its Focused Dementia Care Survey in 2014, expanding the effort later to six states (California, Illinois, Mississippi, Missouri, Nebraska, and Texas). The feds’ target: poor practices relating to dementia care and the (related) overuse of antipsychotic medications. The program was limited last year, but with the November 27, 2015, memo (S&C: 16:04-NH), the feds are now calling on all providers to heed the lessons learned from the pilot program.

“They do not indicate, at this time, how they will change the current survey process [based on the memo’s release],” says Nancy Leveille, RN, MS, senior director with the New York State Health Facilities Association in Albany, NY. But the feds — and provider groups — are urging providers to review the materials closely in the interest of self-help and self-assessment, and, potentially, in the interest of readying for changes to current survey guidance.

“The intent is that facilities would use these tools to assess their own practices in providing resident care,” CMS states in the memo.

To get the most out of the newly released tool, keep the following themes in mind:

Start Off Strong

Failing to take the right approach upon admission immediately opens you up to citations for a number of F tags, the worksheet warns — including strikes at these F tags: F309 (Quality of Care), F272 (Comprehensive Assessments), and F281 (Services Provided Meet Professional Standards).

First, be sure your pre-admission and admission screening processes specifically address the care needs of a resident with dementia. Involve family members fully in the admission process, asking about “previous life patterns, choices, cultural patterns, [and] preferences” with respect to everything from general likes and dislikes, daily routine, favorite foods, hobbies, and time outdoors. Ideally, CMS instructs, you should use a recognized tool to get to know residents, such as the Preferences for Everyday Living Inventory (PELI) (available from the Polisher Research Institute at!assessment-instruments/c16rg).

Base Your Dementia Care on A Program

If you are not basing dementia care on nationally recognized guidelines, know that you are seriously weakening your survey defenses. CMS recognizes nine programs by name in its survey tool. Surveyors are also prompted to recognize other relevant guidelines, but providers should make sure that their guidance is nationally recognized.

Resource: To compare programs that might boost your efforts — and compliance, see the Nursing Home Quality Campaign’s crosswalk document available at:  In addition, see the related Toolkit on page 11.

Crystal ball: Surveyors are also prompted to ask if the facility has designated a “licensed professional” to coordinate dementia care. The worksheet notes that this is “not currently a requirement,” but providers should recognize that the agency may soon make it a condition of participation.

Take Training to a New Level

More in-service training anyone? Surveyors in the focused surveys were trained to ask about frontline caregivers’ access to specialized dementia care training — specifically training prior to day one of employment followed by “periodic refresher training thereafter.” Strike out on this requirement and you are likely to be at risk for citations for a number of F-tags — including F 498 (Proficiency of Nurse Aids), F490 (Facility Administration), and F520 (Quality Assessment and Assurance).

The need for detailed and ongoing training is evident in the survey worksheet. Significantly, direct caregivers are expected to have a solid understanding of the facility’s approach to dementia care. For example, under Individualized Approaches to Treatment: Care Plan Implementation and Staffing, surveyors are directed to flag a facility for possible noncompliance if a nursing assistant is unable to “describe care approaches, such as task segmentation (e.g., breaking up tasks into each step) and others that are used, as a part of a comprehensive dementia care program.”

Double jeopardy: Furthermore, surveyors are likely to cite these shortcomings in training if your facility does not show evidence of employing accepted dementia care guidelines, the worksheet suggests.

Stay On Top of Care Trends

Another message that comes through strong and clear in the surveyor guidance is the importance of staying current on the latest medical literature and thinking about dementia care.

Case in point: In the worksheet, surveyors are instructed to query providers on their “overall philosophy of care”

--specifically, if that philosophy acknowledges that the behavior of residents with dementia is to be understood as a mode of communication.

Be sure that your staff “walk the talk” and, importantly, “talk the talk.” That is, using the wrong phrasing can lead you straight to survey woes. If a surveyor hears a manager or even a frontline caregiver go old school with talk about “problem behaviors,” rest assured, you are heading for trouble.

Take a Team Approach to Care

With the release of the new worksheet, CMS is cementing its commitment to the idea that dementia-specific training is mandatory for anyone who has contact with residents with dementia.

For example, don’t neglect your food service approach and food service staff. If food service still employs crescent “feeding” tables, you will definitely raise surveyors’ suspicions that residents’ needs are not paramount. Bibs are also on the “no” list. The worksheet even instructs surveyors to take note of “culturally appropriate meals.”

Most importantly, nursing home staff must recognize that residents are to be seen as individuals who benefit from social engagement.

Red flag: Staff who fail to interact and converse with a resident during a direct care encounter are inviting surveyor scrutiny.

The feds are definitely clear about setting high expectations for dementia care, says Linda M. Elizaitis, RN, RAC-CT, BS, president, CMS Compliance Group Inc. in Melville, NY. Caregivers are to balance competing needs and abilities with finesse, “providing stimulation (to avoid boredom)” while “appropriately limiting choices to avoid frustration/confusion,” for example. Similarly, caregivers must be sure pain is addressed, paying “particular attention to those with difficulty communicating about pain.”

Reduce The Use of Antipsychotics

Long-term care managers and clinicians must take this message to heart, says Julie Kueker, MT (ASCP), MBA, a quality improvement specialist with Quality Insights. Where should you begin — or how can you pick up the pace of progress you have already made? Remember that leadership is essential.

“Set a facility antipsychotic quality goal,” coaches Kueker. Then, focus on outcomes, making sure that all supervisors, physicians, and staff are knowledgeable about the goals, and that all employees are aware of performance expectations.

Ongoing training — and recognition for achievements made — are also essential.

Reality check: CMS aims to reduce the use of antipsychotics in nursing homes by 30 percent by the end of 2016. Ideally, your goals should be the same.

Resources: For assistance, access the AHCA/NCAL Quality Initiative — Antipsychotic Management Tool at To access S&C: 16:04-NH, go to