CMS: Alert – Abuse Guidelines Updated by CMS

Nancy Leveille in Clinical & Quality

Please review this new guidance ASAP to ensure you are in compliance by your next standard or complaint survey.

CMS is requesting policy change and updated staff education on abuse investigation and education related to social media.  See below for full information.

Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff (S&C: 16-33-NH)

On August 5, 2016, CMS issued a memorandum on the subject: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff (S&C: 16-33-NH). It specifies that included in a resident's right to be free from all types of abuse, including mental abuse, is a right to be free from abuse facilitated or caused by nursing center staff taking or using photographs or recordings in any manner that would demean or humiliate them. In addition, the memorandum discusses facility and state responsibilities related to the protection of residents.

It also specifies that 30 days after the release of the memorandum and at the time of the next standard survey (both Traditional and QIS), the survey team will request and review facility policies and procedures that prohibit staff from taking, keeping, and/or distributing photographs and recordings that demean or humiliate a resident(s). The survey team may request to see written policies that include this information.

The memorandum reiterates residents' rights to privacy and confidentiality, as well as to freedom from all forms of abuse - including mental abuse - noting that unauthorized and/or the taking or use of demeaning or humiliating photographs or recordings violate these rights. It provides examples of conduct that can cause mental abuse, including nursing home staff taking photographs or recordings of residents that are demeaning or humiliating using any type of equipment (e.g., cameras, smart phones, and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks.

The memorandum provides specific expectations related to the review and revision of nursing centers' abuse prevention policies and procedures, as well as staff training. Nursing centers must include abuse related to the taking and posting of unauthorized and/or demeaning photographs or videos in their investigative processes. Finally, it includes surveyor investigative protocol to ensure compliance with these requirements.

AHCA has developed Social Media Guidance for Nursing Care Centers and Assisted Living Communities to provide resources on how to effectively manage social media, review social media policies, conduct social media training, and investigate social media abuses. The guidance provides specific examples and suggested center responses to ensure residents' rights are protected. It is available on the AHCA/NCAL website under Legal Resources. Please note you must log in to view the document.

Please contact Sara Rudow with any questions. 

This message contains confidential information and is intended only for AHCA/NCAL membership. Dissemination, distribution or copying the contents of this email beyond this group is strictly prohibited.


Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20