F607 requires “[t]he identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect,” including for residents with communication disorders.

Implications for Speech-Language Pathology Services

As experts in the area of communication disorders, SLPs play a critical role in ensuring patients are able to effectively communicate their needs and training staff on person-centered communication strategies to prevent conflict or neglect.

Several F-tags address the obligation of the SNF to ensure the patient can effectively participate in communication.

For example, F550 states that a patient “has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility... A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident.”

The interpretive guidance highlighted in the manual notes that the SNF must “incorporate the resident’s goals, preferences, and choices” and “honor and value their input.”

Implications for Speech-Language Pathology Services

ASHA members report that in some instances, a patient who would benefit from the use of an SGD is instead given other forms of communication tools, such as an alphabet board. Based on the standards outlined in the State Operations Manual, if a patient is an appropriate candidate for an SGD and would prefer to use that over an alphabet board, the SNF should provide the SGD. Additionally, ensuring the patient can effectively communicate requires staff members to be trained in patient-centered communication strategies for patients with communication disorders.

ASHA’s Communication Access initiative could help to address this and many other F-tags by ensuring that effective communication occurs and that services are delivered in a patient-centered manner, in line with their preferences and beliefs, to ensure the patient can return to their highest practicable level of function. Effective communication happens when everyone can clearly and accurately exchange information in the ways that work best for them. For people with communication disabilities, this may mean providing different communication aids and services as required by law and regulations.

Effective communication is a basic human right. Making it accessible is especially important for people with hearing, communication, and/or cognitive difficulties, who often face barriers to health care. Communication access means people with communication disabilities have the same opportunities to take part in and fully benefit from quality services and programs as everyone else, using necessary communication supports.

When individuals don't have the information and communication supports they need, it can lead to poorer health, more chronic conditions, avoidance or delays in seeking care, medical errors, and higher health costs.

Implications for Speech-Language Pathology Services

SLPs could play a pivotal role in training the multidisciplinary team in the six core principles of Communication Access to help lessen communication barriers. By enhancing effective communication in a facility through training, the SLP could help improve patient outcomes, reduce re-hospitalizations and medical errors, and minimize the risk of F-tags associated with ensuring effective communication and patient-centered care.

F552 states the patient has the “…right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.”

Implications for Speech-Language Pathology Services

Patients and caregivers must be informed of the types of services they will receive (e.g., speech-language pathology services) and the type of clinician that will provide them (e.g., an SLP). If a patient needs swallowing services, for example, the SNF would be required to let the patient know if an SLP or an occupational therapist would provide that service.

ASHA members contact us to understand how to manage instances when services, such as speech-language pathology, have been ordered by the physician or identified as needed by a member of the SNF multidisciplinary care team but the SNF administration has modified the orders and/or plan of care. Often the patient or caregiver is not informed of this and is concerned that services they were expecting to receive are not being provided. Notification to the patient or caregiver of the plan, including changes to the plan, and a rationale for such changes may help to address these concerns.

SLPs contacting ASHA in these instances are frustrated because their employer is not providing the care needed by and/or ordered for the patient, and patients and caregivers are not sure how to proceed. SLPs could consider if utilizing this standard in discussion with the employer would help and/or if supplying the patient and caregiver with this requirement would help them advocate for the services they need.

Standard F553 states that the patient has “[t]he right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:

1. The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
2. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
3. The right to be informed, in advance, of changes to the plan of care.
4. The right to receive the services and/or items included in the plan of care.
5. The right to see the care plan, including the right to sign after significant changes to the plan of care.”

The regulations do not require the facility to provide specific medical interventions or treatments requested by the resident, family, and/or resident representative that the resident’s physician deems inappropriate for the resident’s medical condition.

Similarly, F655 requires that the plan of care is patient-centered and that the care meets the professional standards of quality of care.

Implications for Speech-Language Pathology Services

In instances when the physician and/or multidisciplinary care team’s recommendations are ignored or modified by the SNF, the participation of the patient/caregiver in the development of the plan of care and notification requirements might help to ensure the patient is receiving the identified medically necessary care. Involving the patient/caregiver in the establishment of the plan of care (i.e. expected goals, frequency, and duration) from the beginning might help minimize administrative mandates being implemented that go against the clinician's recommended care.

Additionally, in instances where the research, evidence, data, and professional standards of care indicate that the plan of care include specific services—such as speech-language pathology services—of a particular frequency, intensity, and duration, efforts by the SNF to modify the plan of care may violate the survey and certification standards.

Patients have the right to self-administer medications under F554 if the SNF has assessed the safety and efficacy of it based on factors such as:

• The resident’s physical capacity to swallow without difficulty and to open medication bottles;
• The resident’s cognitive status, including their ability to correctly name their medications and know what conditions they are taken for;
• The resident’s capability to follow directions and tell time to know when medications need to be taken;
• The resident’s comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff;
• The resident’s ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs; and
• The resident’s ability to ensure that medication is stored safely and securely.

Implications for Speech-Language Pathology Services

SLPs can play a vital role in medication management. By providing regular screenings (a formal evaluation is not always clinically indicated) of patients, SLPs can identify if any clinical changes have occurred with swallowing, cognition, and/or comprehension, thus impacting the patient’s ability to safely self-administer medications. If a patient is identified as having difficulties, SLPs can also evaluate and treat the patient to address the underlying skills impacting medication management if that is a patient goal.

The requirements for the accuracy of the assessment(s) of the patient are outlined in F461. Specifically, the manual states that the assessment must accurately reflect the resident’s status and be performed by staff qualified to assess the medical functional and psychosocial problems and who are knowledgeable about the resident’s needs, strengths, and areas of decline using the appropriate Resident Assessment Instrument (i.e. comprehensive, quarterly, significant change in status).

F462 reinforces the importance and authority of multidisciplinary care team participation in the Minimum Data Set (MDS). While a registered nurse must sign and certify that the assessment is completed, the regulations also state that each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

Implications for Speech-Language Pathology Services

While a nurse is responsible for coordination or completion of the MDS, Medicare does not restrict the clinical specialties that can be involved. In fact, given the requirements of the State Operations Manual, as well as the design of the Patient Driven Payment Model (PDPM)—which pays for services based on patient characteristics such as diagnosis and comorbidities—engagement of the multidisciplinary care team in the assessment of the patient, completion of the MDS, and development of the plan of care ensure the SNF is complying with all regulations and receiving appropriate payment for the patients it is treating. SLPs can help with several sections of the MDS.

Tag F660 requires that the discharge planning process must include the multidisciplinary care team involved in the patient’s care as well as consider the “resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.”

Implications for Speech-Language Pathology Services

ASHA members report that in some instances, a patient is either not discharged in a timely fashion or, more often than not, is discharged before the patient has achieved the goals in the plan of care, before it is safe to be discharged, and/or in ways that leave patients susceptible to avoidable problems, such as hospital readmissions. While reasons for premature discharge vary, one possibility is a particular SNF’s desire to mitigate cost and increase payment from Medicare. But premature discharges that lead to adverse events, such as readmissions, might lead to payment penalties, which could offset or eliminate any financial gain associated with a discharge.

SNFs that effectively incorporate SLPs in the discharge planning process could avoid adverse health outcomes and more effectively comply with the survey and certification standards. Avoiding adverse health events such as readmissions also ensures the SNF is not subject to negative ratings in the Nursing Home Compare system or payment penalties for low scores under the SNF quality reporting program (QRP) and/or value-based purchasing program (VBP).

Standard F676 requires that “the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. A resident [must be] given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including but not limited to dining (eating) and communication (including speech and language).”

Implications for Speech-Language Pathology Services

One example of how a SNF may violate this standard is by placing a patient on a modified diet that is not clinically appropriate for financial gains under PDPM. Another example is not honoring a patient’s preferences and modifying the diet or utilizing tube feeding because there is a concern a swallowing disorder may create a choking hazard, aspiration pneumonia, dehydration, and/or malnutrition. Instead, directly addressing the swallowing disorder or other cause—such as poor-fitting dentures—to enable the patient to participate in eating as an activity of daily living and maintain or improve that skill would ensure the SNF is meeting its obligation to provide care based on the standards of professional practice for SLPs and in line with the patient-centered plan of care.

The quality of care a patient receives in a SNF is addressed multiple times in multiple ways through the State Operations Manual. F684 defines quality of care as a “fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices.”

Implications for Speech-Language Pathology Services

Efforts by a SNF or administrative mandates that dictate or change a plan of care developed by an SLP based on the professional standards of practice may violate the survey and certification standards.

F692 requires the SNF to address a patient’s nutrition and hydration needs, including the implementation of a therapeutic diet when it is clinically indicated. Placing a patient on dietary restrictions or altered diet consistencies, such as pureed or minced and moist textures, against the resident’s expressed preferences and that result in substantial and ongoing decline in food intake could violate F692.

Application of inappropriate dietary protocols that lead to poor health outcomes such as significant or severe unplanned weight loss with accompanying irreversible functional decline that causes the resident to be placed on hospice are considered severe violations of the survey and certification standards. Such violations are classified as instances of “Level 4 Noncompliance, Immediate Jeopardy to Resident Health or Safety,” meaning the consequences for the SNF will likely be significant. Level 3 violations would include instances such as:

• The failure to revise and/or implement the care plan addressing the resident’s impaired ability to feed him/herself resulted in significant, not severe, unplanned weight change and impaired wound healing (not attributable to an underlying medical condition);
• The failure to identify a decrease in food intake, which resulted in a significant, unintended weight loss from declining food and fluids, which resulted in the resident becoming weakened and unable to participate in activities of daily living;
• The failure to assess the relative risks and benefits of restricting or downgrading diet and food consistency or to accommodate a resident’s choice to accept the related risk resulted in declining food/fluid intake and significant weight loss; and/or
• The failure to accommodate documented resident food dislikes and preference.

Some SNF patients may be or become terminally ill. The SNF must continue to address a patient’s needs even at the end of life, including by appropriately assessing and care planning on an ongoing basis. This includes attention to nutrition and hydration needs such as, but not limited to, a decline in appetite and/or difficulty eating or swallowing.

The State Operation Manual states “Care plan interventions, regarding nutrition/hydration, must be based upon the resident’s assessment, disease processes, and resident choices/directives and include amount, type, texture and frequency for food and fluids. Dietary restrictions and/or weight measurements may be revised/discontinued based upon resident/representative and attending practitioner decisions, and must be included in the medical record. If the resident’s condition has declined to the point where he/she may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration [should be considered].”

Implications for Speech-Language Pathology Services

SLPs play a critical role in assessing swallowing function, providing interventions as needed and clinically indicated to address swallowing function, and providing information to the patient and multidisciplinary team about the impact of diet modifications. Addressing nutrition and hydration needs improves the quality of life for patients and can prevent costly, preventable adverse health outcomes such as hospital readmissions, urinary tract infections, and pressure ulcers. Ultimately, SLPs should be included in the decision-making process as part of the multidisciplinary care team for patients with swallowing-related nutrition and hydration needs whenever they arise, including at the end of life.

Tag F695 establishes a standard related to the delivery of respiratory care including, but not limited to, mechanical ventilation, tracheotomy, or tracheostomy. CMS seeks to ensure the patient is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. The State Operations Manual specifically highlights the role of SLPs as members of the multidisciplinary care teams engaged in caring for patients on mechanical ventilation:

Due to the clinically complex nature of the provision of care for a resident receiving mechanical ventilation, there must be an active, ongoing interdisciplinary approach to the resident’s care, including but not limited to participation as needed, by the physician/practitioner, pulmonologist, registered nurse, pharmacist, dietitian, speech therapist, respiratory therapist, physical and/or occupational therapist, and the resident/representative. The facility, in collaboration with the attending practitioner, must provide a comprehensive assessment of the resident’s respiratory needs. The facility must provide an assessment of resident specific communication methodologies, including assessing current visual/hearing needs, cognition, level of consciousness, and identifying potential methods for communication such as writing, communication cards/boards, and/or computer access. The results of the assessment must be used in the development and implementation of a person centered care plan.

An example of “Severity Level 3 Noncompliance, Actual Harm That Is Not Immediate Jeopardy” provided in the manual shows how failure to ensure a resident on mechanical ventilation has ways to communicate can lead to a citation:

Facility failed to consistently implement a method for communication that had been established with a resident who was unable to verbally communicate due to being on a mechanical ventilator. The resident had indicated that a clipboard be used for him to write down requests and/or concerns, but night staff cleaning the room, removed it from the resident’s bedside and placed it in an area inaccessible by the resident. This had occurred several times, according to the resident who expressed anger to the surveyor when he was interviewed and provided the clipboard. He wrote that staff told him/her to relax and calm down when he could not access the communication board. The resident wrote that he feels isolated, afraid and upset when he cannot use the preferred communication method. He indicated that he did not feel as if staff could be trusted to meet his concerns, and began to cry.

Implications for Speech-Language Pathology Services

Patients on mechanical ventilation require the support of multidisciplinary care team members, including SLPs, to minimize negative health outcomes such as structural damage, as well as interventions to address these outcomes if they occur. SLPs are trained and qualified to participate in the identification and treatment of communication (including the development of alternative methods of communication, such as communication boards), hearing, and cognitive needs.

Tag F715 allows a physician to “delegate the task of writing therapy orders, consistent with §483.65, to a qualified therapist who— (i) Is acting within the scope of practice as defined by State law; and (ii) Is under the supervision of the physician… This flexibility is beneficial to the physician and the resident, allowing the physician to determine how to best use his or her time and allowing the resident to have more frequent adjustments to nutritional needs and therapy as his or her condition or abilities change.” The guidelines make clear that a physician does not need to cosign orders unless required by state law.

Implications for Speech-Language Pathology Services

ASHA members should be aware that a physician can delegate the process of developing therapy orders to an SLP, consistent with state law, and physicians do not need to sign these orders. Confirming with the state licensing board whether an SLP can develop therapy orders independently is important in operationalizing this standard. There does need to be documentation or evidence of collaboration between the SLP and physician. But not providing speech-language pathology services simply because there is not a physician order would be inappropriate if this has been delegated in line with the policy articulated in the State Operations Manual.

The requirement that the SNF provide all necessary items and services, including diagnostic tests such as an instrumental swallow study, is highlighted in Tag F776:

The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter. (ii) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.

Implications for Speech-Language Pathology Services

Federal law requires SNFs to provide and bill for all Part A and Part B services a patient needs under a policy known as consolidated billing. The obligation to provide all needed services is also reinforced through F776. Unfortunately, ASHA members sometimes inquire as to whether a SNF must provide an instrumental swallow study if needed by the patient. These members report patients are not given these tests despite the recommendations of the SLP and/or multidisciplinary care team or are discharged for the purposes of obtaining the study (so the SNF avoids incurring the cost of the study) and subsequently readmitted. SLPs who have trouble securing swallow studies for patients could rely on the survey and certification standards to advocate on behalf of their patients.

Tag F825 outlines the SNF’s obligation to provide therapy services, including speech-language pathology services, when these services are required in the resident’s comprehensive plan of care, either through employees or by obtaining the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs.

Examples of the factors state surveyors use to assess a SNF’s compliance with these requirements include:

• How are these services maintaining, improving, or restoring auditory comprehension, such as understanding common functional words, concepts of time and place, and conversation?
• How are these services maintaining, improving, or restoring the functional abilities of individuals with moderate to severe hearing loss? For example, is the individual instructed on how to effectively and independently use environmental controls to compensate for hearing loss, such as eye contact, preferential seating, and use of the better ear or hearing aid?
• How are individuals who cannot speak or hear assessed for devices such as a communication board or an alternate means of communication?
• How are these services maintaining, improving, or restoring the functional abilities of individuals with swallowing disorders? For example, are muscle re-education, swallowing, positioning, or food consistency modification techniques being employed to restore, improve, or maintain safe swallowing function?
• How are these services maintaining, improving, or restoring the functional abilities of individuals with speech disorders? For example, are muscle re-education, positioning, breathing, or other techniques being employed to maintain, improve, or restore the individual’s ability to communicate verbally?

Implications for Speech-Language Pathology Services

ASHA members raise several questions regarding this requirement. Most commonly, members who own a private practice contact us asking how they might provide speech-language pathology services to a SNF patient who is not receiving them because the SNF has either decided not to provide the service or does not have an SLP on staff.

A SNF is not “exempt” from these requirements simply because it does not have an SLP on staff. While staffing shortages are a nationwide problem across practice settings and clinical specialties, it does not absolve SNFs of this obligation. The SNF could elect to contract with a private practice SLP to provide the services to its patients. In that scenario, the SNF would submit claims to Medicare and pay a negotiated rate to the SLP. Medicare does not dictate the terms of the negotiated rate agreed upon by the SNF and SLP.

Because therapy services—including speech-language pathology services—must be provided by the SNF when medically necessary and included in the plan of care, a private practice SLP cannot provide these services to the patient. Instead, the patient and/or caregiver must work with the SNF and physician to ensure the SNF is meeting its obligation to provide these services.