CMS Releases Three Memoranda to State Agencies on Revisions and Guidance

The Centers for Medicare & Medicaid Services (CMS) has released three memoranda to the states, each revising previous versions for the following:

In addition to the memoranda and guidance, the revisions to Advance Directives and Naso-Gastric Tubes are reflected in revised surveyor training materials.  

F-Tag 155: Advance Directives (replaces previous version of S&C 12-47-NH dated September 27, 2012)

The revisions are highlighted in the Advance Copy of Interpretive Guidelines and include:

  • Removal of the term “right to accept” preceding language specific to medical and surgical treatment to correlate with the regulatory language at §483.10(b)(4).

  • Language specific to experimental research has been added to the Interpretive Guidance (IG) and correlates with the Power Point training materials.  A definition for investigational or experimental drugs has been added to the definitions sections of the IG.

  • Clarification to specify that §483.10(b)(8) applies only to adult residents and not all residents regardless of age, as evidenced in the regulatory language.

  • The Investigative Protocol has been updated to include guidelines specific to experimental research and record review considerations relative to a physician’s basis for conscientious objection and/or need for additional information related to a resident’s decisional capacity. 

  • The “Use” section of the Investigative Protocol has been revised secondary to burden reduction considerations.  Surveyors will no longer use the protocol for all residents in the survey sample, only residents who meet the parameters listed in this section.

  • Updated Power Point training slides to correlate with revisions made to the Surveyor Guidance at F-tag 155.  Revisions made to the training slides have a red font color.

F-Tag 322: Naso-Gastric Tubes (replaces previous version of S&C 12-46-NH, dated September 27, 2012)

Revisions to F-tag 322 are highlighted in the Advance Copy of Interpretive Guidelines and include:

  • Revision of the regulatory language to now resemble the formatting of §483.25(g) in the Code of Federal Regulations (CFR).

  • Additional clarification related to the expanded definition of “Naso-Gastric tubes.”

  • Updated Power Point Training slides to correlate with revisions made to the Surveyor Guidance at F-tag 322.  Revisions made to the training slides have a red font color.

Physician Delegation of Tasks in SNFs and NFs (replaces S&C-04-08, dated November 13, 2003)

CMS clarifies the regulatory differences concerning physician delegation of tasks in SNFs and NFs.  The distinction in policies between these two settings (SNFs and NFs) is based in statute and regulation.   Improper application of these regulations may affect a facility’s compliance and may also affect payment to providers.  The key to accurate application is to identify:

  1. in which setting, SNF or NF, the physician services are being provided;

  2. whether the task must be performed personally by the physician; and

  3. whether or not the non-physician practitioner (NPP) is employed by the facility.

The “setting” is determined by whether the visit to a patient in a certified bed is to a resident whose care is paid for by Medicare Part A in a SNF or under Medicaid in a NF.  The memorandum addresses the authority of NPPs (i.e., nurse practitioners, physician assistants, or clinical nurse specialists) to perform certain tasks, such as conducting physician visits and writing orders, and to sign certifications and re-certifications. The policy on co-signing orders in SNFs and NFs is also clarified.