05/29/2025

Survey Tip of the Week: Significant ADL Change

In the revised QSO-25-14- NH memo, CMS updated the regulatory guidance for conducting comprehensive assessments following a significant change in a resident’s condition. These changes were made to update the language to reflect the levels of assistance a resident receives for self-care and mobility activities to align with Section GG of the MDS. Under F-tag 637 §483.20(b)(2)(ii), a significant change in status assessment must be completed within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. CMS clarifies that a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status and requires interdisciplinary review or revision of the care plan, or both. The intent of the regulation is to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process.

Examples of significant ADL changes include:

• Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as partial/moderate assist, substantial/maximal assistance, dependent, resident refused, or not attempted since last assessment and does not reflect normal fluctuations in that individual’s functioning.
• Any improvement in ADL physical functioning area (at least 1) where a resident is newly coded as Independent, Setup or clean-up assistance, or Supervision or touching assistance since last assessment and does not reflect normal fluctuations in that individual’s functioning.

During the Long-Term Care Survey Process, surveyors will probe the following:

• Did the facility identify, in a timely manner, those residents who experienced a significant change in status?
• Is there documentation in the medical record when the determination was made that the resident met the criteria for a Significant Change in Status Assessment?
• Did the facility reassess residents who had a significant change in status, using the CMS-specified RAI, within 14 days after determining the change was significant?

LeadingAge Ohio encourages providers to routinely use their EMR software reports to timely identify significant ADL changes. Staying vigilant with these assessments is essential for resident-centered care and helps prevent unnecessary citations during surveys. 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.