Staying informed about regulatory changes is crucial for compliance and high-quality care in skilled nursing facilities (SNFs) and long-term care nursing homes. On March 10, 2025, the Centers for Medicare & Medicaid Services (CMS) released the updated Long-Term Care (LTC) Surveyor Guidance, QSO-25-14-NH. This new guidance will take effect on April 28, 2025, introducing new expectations, revised F-tags, and significant changes in admissions, staffing, psychotropic medication use, and infection control. These changes may be challenging, but they also present opportunities to enhance care practices and provide better support for residents.
CMS Surveyor Guidance Key Updates
Admission, Transfer, and Discharge Changes: CMS states admission agreements should not require third-party payment guarantees. Such clauses can make potential residents worried about their finances and may prevent them from seeking admission.
- F627 addresses inappropriate transfers and discharges.
- F628 outlines proper transfer and discharge procedures.
For example, a facility that pressures family members to sign financial responsibility agreements may now receive citations under F627.
What Should the Facility do to Plan for This Change?
- Review and revise admission agreements to remove any third-party guarantee clauses.
- Train admissions staff on compliant practices to avoid unintentional violations.
Staffing and Payroll-Based Journal (PBJ) Compliance: CMS issued guidance for assessing staffing levels using Payroll-Based Journal (PBJ) Staffing Data Reports. This data will aid surveyors in determining if a facility meets:
- The requirements for adequate nursing staff.
- RN presence for at least 8 hours per day, 7 days a week.
- Compliance of the Director of Nursing (DON) with oversight expectations.
Ensure that your facility’s PBJ submissions are accurate and reflect actual staffing levels, as surveyors will rely on this data as a primary indicator of compliance.
What Should the Facility do to Plan for This Change?
- Implement thorough internal audits to verify the accuracy of PBJ data before submission.
- Ensure consistent RN coverage and sufficient nursing staff to meet care standards.
Unnecessary Psychotropic Medications: The guidelines for using psychotropic medications have been updated in F605, which combines earlier guidance from F758. The main points are:
- Do not use medication for staff convenience or to sedate residents.
- Residents have the right to be fully informed about their medications and can refuse them.
- Document clearly to justify the use of psychotropic medications based on a diagnosis
For instance, if a resident with dementia is prescribed an antipsychotic without proper documentation of prior behavioral interventions, this could lead to noncompliance under F605. Similarly, if a resident is not fully informed about their medications or is not allowed to refuse them, this could also lead to non-compliance. It’s important to ensure that these new guidelines treat all residents.
What Should the Facility do to Plan for This Change?
- Create care plans that include non-drug treatments.
- Keep detailed records that explain why psychotropic medications are used.
Accuracy in MDS Assessments: Accurate MDS assessments are crucial for effective care planning and reimbursement; discrepancies can result in compliance issues and impact resident outcomes.
- F641 now addresses the accuracy and coordination/certification of MDS assessments.
- The previous tag, F642, has been removed, with its regulatory references now incorporated under F641.
- Surveyors will examine whether adequate documentation exists to support medical conditions related to antipsychotic medication use.
Ensure your clinical team cross-references MDS documentation with physician orders and care plans to avoid discrepancies.
What Should the Facility do to Plan for This Change?
- Regular training for MDS coordinators on accurate assessment practices is conducted.
- Implement peer reviews to ensure consistency and accuracy in documentation.
Comprehensive Assessment after Significant Change: Language updates align with Section GG of the MDS, reflecting assistance levels for self-care and mobility activities.
Infection Prevention and COVID-19 Updates: Incorporating Enhanced Barrier Precautions reflects CMS’s commitment to controlling MDROs, highlighting the need for ongoing infection control vigilance.
- Enhanced Barrier Precautions for MDROs are now part of Appendix PP of the State Operations Manual—Advance copy page 6 of the QSO-25-14-NH Memo.
- Facilities must keep educating residents and staff about the benefits of COVID-19 vaccines, as stated in F887.
What Should the Facility do to Plan for This Change?
- Update infection control protocols to include Enhanced Barrier Precautions.
- Continue education on COVID-19 vaccination benefits to maintain high vaccination rates.
Professional Standards and Medical Director Responsibilities
- F658 now includes steps for checking if staff follow professional standards when residents are diagnosed with conditions and lack enough documentation for using antipsychotic medications.
- F841 explains the Medical Director’s role, ensuring physicians and practitioners follow facility policies about diagnosis, prescribing, and care coordination.
- Surveyors will now interview the Medical Director during investigations of unnecessary medications and Quality Assurance and Performance Improvement (QAPI) pathways.
What Should the Facility do to Plan for This Change?
- Review and update your facility’s medical governance policies to ensure alignment with these new expectations.
QAPI and Health Equity Integration: New guidance for QAPI includes:
- Analyzing factors affecting health equity (e.g., socioeconomic status, race, language barriers).
- Use data to find differences in resident outcomes.
- Change QAPI initiatives to address these differences.
For example, if fall rates are disproportionately higher among non-English-speaking residents, QAPI efforts should investigate language barriers in care planning.
What Should the Facility do to Plan for This Change?
- Analyze facility data to identify health disparities among residents.
- Develop targeted QAPI initiatives to address identified gaps and promote equitable care.
Cardio-Pulmonary Resuscitation (CPR) Updates: CPR certification requirements have been updated to align with nationally accepted standards. Verify that the staff have current CPR certifications to meet the latest guidelines.
Pain Management Guidelines
- Updates align guidance with CDC definitions for acute, chronic, and subacute pain.
- Clinicians are encouraged to prescribe immediate-release opioid medication instead of extended-release options when appropriate.
- CMS has expanded resource links on opioid use and individualized treatment plans.
What Should the Facility do to Plan for This Change?
- Update your pain management policies to follow these best practices.
- Train staff on the latest opioid prescribing guidelines. Emphasize safe prescribing practices and the need to assess patients’ pain management regularly.
Physical Environment Modifications: Recent changes allow facilities that receive construction approval from state or local authorities or get new certification after November 28, 2016, to meet bedroom and bathroom requirements by having two single-occupancy rooms with one shared bathroom. This change allows facilities to meet these requirements without undertaking major renovations.
What SNFs Must Do Before April 28, 2025
Assign F-Tag Leads and Create Compliance Teams
- Assign key team members to oversee specific F-tags.
- Example: The Director of Nursing should lead F605 compliance, while the infection control nurse oversees F880 (infection prevention).
- Develop a structured action plan for each F-tag update to ensure readiness by the deadline.
Train Staff on the New CMS Guidance
- Utilize the CMS Quality, Safety, and Education Portal (QSEP) for training resources.
- Focus training on high-priority areas like psychotropic medication use, staffing, and infection control.
- Conduct mandatory training sessions for all staff, with competency assessments to confirm understanding.
Conduct Internal Audits and Mock Surveys
- Review admission agreements to ensure compliance with new financial responsibility rules.
- Use updated Critical Element Pathways to identify gaps in clinical documentation.
- Audit your PBJ reports to confirm staffing meets CMS minimums.
- Perform mock surveys to anticipate potential deficiencies before the actual CMS survey.
Update Policies and Procedures
- Revise care policies related to chemical restraints, pain management, and QAPI initiatives.
- Ensure your CPR certification process aligns with updated professional standards.
- Update resident care plans to ensure compliance with new psychotropic medication regulations.
Monitor Regional Survey Trends
- Check QCOR data to identify top citations in your region.
- Connect with local facilities to understand recent survey focus areas.
- Establish a system for tracking survey deficiencies and implementing corrective actions proactively.
Strengthen Documentation and Compliance Systems
- Implement a documentation audit program to ensure all clinical records align with CMS expectations.
- Standardize progress notes, care plans, and physician orders to avoid discrepancies in MDS assessments.
- Ensure proper tracking of medication reviews and behavioral interventions before initiating psychotropic medications.
This revised CMS guidance isn’t just about compliance but about improving resident care. By acting now, your facility can avoid survey headaches and continue delivering high-quality, resident-centered care.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
