During a recent Director of Nursing (DON) networking call, participants shared practices and insights around ensuring informed consent for psychotropic medications—and whether similar processes are used for other medications. The discussion was timely with the updated CMS guidance outlined in the revised QSO-25-14-NH memo, which states:
In accordance with the requirements at §483.10(c), residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a medication. To demonstrate compliance, the resident’s medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident’s consent to medication, but other types of documentation are also acceptable. If a medication has been initiated or increased, and there is not documentation demonstrating compliance with the resident’s right to be informed and participate in their treatment, noncompliance with §483.10(c) exists and F552 must be cited.
One best practice shared during the networking call was the use of drug class–specific consent forms. These include preprinted information on benefits and side effects, along with documentation of the diagnosis, prescribed dosage, and any interventions that failed prior to medication use.
For more information on navigating the revised QSO-25-14- NH memo, view this LeadingAge Ohio article regarding the resident’s right to be informed. This survey tip, along with other survey tips, can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has also updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo.
DONs interested in joining future networking calls can email Stephanie DeWees at sdewees@leadingageohio.org.
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.