CMS has put nursing homes on notice: schizophrenia diagnoses and antipsychotic prescribing are under the microscope like never before. In its latest offensive, the agency is zeroing in on documentation—and for many providers, that’s where the greatest risk lies.

Why CMS Is Focused on Schizophrenia

For years, CMS has tracked long-stay antipsychotic use as a quality measure. But there’s an important caveat: residents diagnosed with schizophrenia are excluded from the denominator. That means their use of antipsychotics doesn’t “count” against a facility’s quality score.

Unfortunately, CMS has found cases where schizophrenia diagnoses may have been misapplied—or not adequately documented—creating what the agency sees as a loophole that distorts quality reporting. Now, the agency is tightening oversight to ensure these diagnoses are accurate, clinically justified, and fully documented.

Documentation as the “Sticking Point”

Experts and auditors agree: the biggest vulnerability for providers isn’t necessarily whether a diagnosis is valid, but whether it is properly supported in the record.

In recent audits, CMS has repeatedly flagged gaps such as:

• Missing psychiatric evaluations or consults
• Lack of evidence that diagnostic criteria were met
• Incomplete behavioral histories or symptom tracking
• Weak or absent justification for antipsychotic use

Even when the diagnosis itself may be accurate, insufficient documentation leaves facilities exposed to citations, quality measure suppression, and survey deficiencies.

What CMS Expects from Providers

To meet CMS’s expectations and withstand survey scrutiny, facilities should ensure that every schizophrenia diagnosis is backed by a clear chain of evidence:

1. Psychiatric evaluation – Assessments tied to DSM criteria, supported by past records or collateral information.
2. Behavioral history – Symptom tracking over time, incorporated into care planning.
3. Medication justification – Clinical rationale for antipsychotic use, along with monitoring and documented attempts at gradual dose reduction (when safe and appropriate).
4. Interdisciplinary alignment – Consistency across MDS, PASARR, psychiatric consults, and nursing documentation.
5. Ongoing audit – Internal review of all schizophrenia-coded residents to confirm records are complete and defensible.

Risks of Falling Short

When documentation doesn’t measure up, CMS can impose serious consequences:

• Deficiencies and citations during surveys
• Quality measure suppression, impacting public reporting
• Star-rating penalties, with lowered quality scores for months

In a landscape where public ratings influence referrals, family confidence, and even payer relationships, those penalties can be far-reaching.

The Bottom Line

CMS’s offensive on schizophrenia and antipsychotic use is more than a compliance campaign—it’s a call for providers to shore up clinical and documentation practices. For nursing homes, the lesson is clear:

• A diagnosis without proper documentation may as well not exist.
• Every schizophrenia case should be able to stand up to audit scrutiny.
• Strong documentation not only protects providers from penalties but also ensures that resident care decisions are clinically sound and defensible.

In the end, documentation isn’t just paperwork. It’s the foundation of compliance, quality, and trust.