The 2025 new year has begun with a whirlwind of changes in Long-Term Care – starting with New Surveyor Guidance. CMS released an advanced copy of these State Operations Manual Appendix PP (Guidance for Skilled Nursing Facilities) updates in a November QSO Memo (QSO-25-07-NH Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process). Surveyors will start using the updated guidance on February 24, 2025.
What Are the Areas of Focus?
- Admission, Transfer, and Discharge
- Chemical Restraints/Unnecessary Psychotropic Medication
- Resident Assessments
- Quality of Life
- Quality of Care
- Administration
- Quality Assurance Performance Improvement (QAPI)
- Infection Prevention and Control
Admission, Transfer, and Discharge
CMS is deleting tags F622 – F626 and F660 – F661, and removing the language “facility-initiated” and “resident-initiated.” The new tags are F627 for Inappropriate Transfers and Discharges and F628 for Transfer and Discharge Process. Revisions were done to provide clarity on whether a transfer or a discharge is noncompliant.
Chemical Restraints/Unnecessary Psychotropic Medication
CMS has integrated tag F758 Free from Unnecessary Psychotropic Meds into tag F605 Right to be Free from Chemical Restraints to increase efficiency of the survey and accuracy of citations, and removed F758 from the State Operations Manual (SOM) Appendix PP. The guidance for F757 Unnecessary Medication has been revised to exclude unnecessary psychotropic medications.
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- F605 guidance regarding “convenience” now reflects “unnecessary administration of a medication that causes (intentionally or unintentionally) a change in a resident’s behavior (e.g., sedation) such that the resident is subdued and/or requires less effort from staff. Therefore, if a medication causes symptoms consistent with sedation (e.g., excessive sleeping, drowsiness, withdrawal, decreased activity), it may take less effort to meet a resident’s behavioral needs, which meets the definition of convenience.”
- F605 guidance addresses an update to the resident’s right to accept or decline an initiation or an increase of psychotropic medication and the right to be informed of an initiation or an increase of psychoactive medication. This entails the risks, benefits, and alternatives for the medication(s).
Resident Assessments
F642 Coordination/Certification of Assessment has been incorporated in F641 Accuracy of Assessments and removed from the State Operations Manual Appendix PP. F641 guidance addresses accurate MDS assessment coding of a diagnosis related to sufficient supporting documentation related to Schizophrenia. Surveyors are instructed to investigate and evaluate if a facility has the supporting documentation in the resident’s medical record.
If there are concerns with inaccurate coding related to a diagnosis, surveyors are instructed to review:
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- F658: to determine if the documentation supports a diagnosis in accordance with standards of practice
- F644: to determine if the facility made a referral to the state designated authority when a newly evident or possible serious mental disorder was identified.
- F758: to evaluate psychotropic medication use based on a comprehensive assessment
- F841: to evaluate the medical director’s oversight of medical care
F637 Comprehensive Assessment After a Significant Change has revised language reflecting self-care and mobility items relating to section GG of the MDS.
Quality of Life and Quality of Care
Cardio-Pulmonary Resuscitation (CPR) tag F678 has updates to the CPR Certification in accordance with the national accepted standards. Pain Management tag F697 has updated guidance with acute, chronic, and subacute pain relating to the CDC definitions. Clinicians may consider prescribing immediate release opioids in place of extended-release or long-acting medications if treatment has been appropriately assessed and individualized for the resident.
Administration
Guidance has been updated in F841 Responsibilities of Medical Director tag in relation to the implementation of resident care policies regarding other physicians and practitioners. The other physicians/practitioners are to follow facility policies on diagnosing and prescribing medications and the Medical Director is to intervene with a physician/practitioner in a resident’s medical care if it is inconsistent with current professional standards of care.
Quality Assurance Performance Improvement (QAPI)
F867 QAPI/QAA Improvement Activities regulation has incorporated new guidance with health equity such as obtaining feedback, collecting and monitoring data related to sub-population outcomes, and analyzing factors that affect health equity. Factors that can affect health equity include race, sexual orientation, socioeconomic status, and/or preferred language.
Infection Prevention and Control
The guidance from QSO-24-08-NH on Enhanced Barrier Precautions has been included in the State Operations Manual Appendix PP in F880 Infection Prevention and Control with new deficiency examples.
F887 COVID-19 Immunization regulation includes in the guidance requirements for facilities to develop and implement policies and procedures that meet the resident’s, resident representatives’, and staff members’ information needs and provide the vaccines to all the residents/staff that elect to have them. Education must provide benefits and potential side effects of the COVID-19 vaccine.
How to Prepare
- Approach the Survey updates and changes with a team focus
- Ensure your team has the current resources
- Identify the changes/updates and develop a plan for implementation
- Make a plan to monitor updates between now and February 2025 when changes take effect
- Track compliance of the survey changes in your QAA/QAPI program
While we have highlighted the strongest gusts of change to the New Surveyor Guidance, there are still additional areas that have noted changes/updates in the SOM Appendix PP advanced copy. Make sure to review these updates along with published version due in February 2025.
More Resources
- QSO-25-07-NH Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process
- QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes
- QSO-21-19-NH Interim Final Rule – COVID-19 Vaccine Immunization Requirements for
Residents and Staff