senior_walkingSurveyors will be looking more closely at how skilled nursing facilities deal with advance directives, including how they educate, inform and assist residents in exercising their right to accept or refuse medical or surgical treatment and formulate an advance directive.

On Nov. 26, 2014, the Centers for Medicare and Medicaid released an update to the State Operations Manual including revised guidance for more than 20 F-Tags.

One of the most heavily revised sections, F-155, addresses advance directives and experimental research. This section includes updated investigative protocols, which advise surveyors to question whether a facility has established and implemented policies and procedures regarding the right to formulate advance directives, refuse medical and surgical treatment and other related interventions, and to decline to participate in experimental research.

Surveyors will also be looking at how a facility informs and educates residents about their rights, determines whether an advance directive is in place, determines and documents patients’ decision-making capacity, ensures patient choices are recognized and honored, and monitors care and services to ensure they are consistent with the patient’s documented choices and goals.

All changes are to Appendix PP of the State Operations Manual, and reflect guidance that has been issued via Survey & Certification memoranda between fiscal year 2003 and May 2014, according to the document summary. The new and revised material was effective as of Nov. 26, 2014.

Read the full 226-page update on CMS.gov as a PDF.


Kelley Queale is a program director for the Coalition for Compassionate Care of California.

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