Advance directives: what you need to know to be in compliance with Ftag F578

March 30, 2023
Polaris Group
March 30, 2023

Understand Ftag F578 and ensure your community is in compliance!

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What are advance directives?

Advance directives are legal documents that give instructions for medical care should a person be unable to communicate their own wishes. The two most common advance directives are a living will and durable power of attorney for health care. A living will outlines the medical treatments a person would want or not want and under what conditions each choice applies to guide medical treatment. A durable power of attorney for health care is a legal document that names your health care proxy; a person who can make health care decisions for you if you are unable to communicate these yourself.

What CMS policies apply to advance directives in long-term care?

The CMS Interpretive Guidance states that facilities are required to obtain a written record of resident advance directives upon admission and maintained in the medical record. Importantly, residents have a right to refuse to create an advance directive so the advance directive or the refusal to create an advance directive must be documented.

What should you be aware of regarding Ftag 578 citations?

The Interpretive Guidance specifically states that the advance directives must be kept in the same section of each of the resident’s medical records and must be readily visible to all facility staff. This is a frequent citation. The regulation also requires the advance directives be reviewed periodically to ensure there are no changes to the resident/representative’s preference.

What should be included in policies and procedures for advance directive documentation?

Your facility’s policies and procedures should include the following components:

  • How it is determined that an advance directive is in place, upon admission.
  • How it is determined that the resident wishes to formulate an advance directive.
  • How information about the right to formulate an advance directive is provided in a manner easily understandable.
  • How advance directive information is reviewed as part of the care planning process for updates.
  • Facility processes for addressing situations where physicians or staff do not believe they can provide care in accordance with the residents’ advance directives on the basis of conscientious objection.
  • How the facility utilizes their Ethics Committee in situations of discrepancy between advance directives and staff conscientious objections.


What are the action steps to ensure compliance with Ftag F578?
  • Ensure a current copy of advance directive is in the medical record for each resident.  If the red/green sticker system on the chart binder is used, make sure your facility has a system in place to review for accuracy.  
  • Make sure there is a system in place to ensure the stickers adhere to the medical record binding.
  • Ensure there is a current paper list of all advance directives readily available in the event the facility EMR is offline.
  • Ensure that the right advance directive is in the right medical record. Routinely audit records of those residents with same last names and/or same set of initials to ensure the right resident has the correct information in the correct chart.
  • Ensure the physician order matches the resident advance directive wishes. The optimal time to review this matching is when admission orders are reviewed at clinical stand-up meetings.
  • Define and designate personnel to be responsible for ensuring documents are filed accurately and timely.
  • Ensure all completed advance directive paperwork includes resident and representative input, signatures, and dates.
What else should my facility be aware of regarding this Ftag?

In response to the new focus on this FTag, facilities are developing committees and/or working sessions to review each medical record for accurate advance directives on a routine basis. Other facilities are implementing tickler (or reminder) systems and/or managing compliance through spreadsheets. Facility staff should meet with residents or their representatives on a quarterly basis at care conferences, at a minimum to discuss advance directives.

Nationally in 2022, F578 was most frequently cited as a “D” level deficiency based on the number of resident records identified with concerns. Further, in the first quarter of 2023, Polaris consultants are seeing state citations across the country at an IJ level.

Polaris Group consultants can help your facility ensure F578 compliance through mock surveys and other consultative services. Reach out for assistance for your facility today.

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