CMS Announces Key Revisions to Nursing Home Surveyor Guidance for 2025

The Centers for Medicare & Medicaid Services (CMS) released updated guidance for nursing home surveyors that will take effect on February 24, 2025. The updates aim to enhance the quality of care and ensure compliance with evolving standards in long-term care facilities. These revisions, which will be incorporated into Appendix PP of the State Operations Manual (SOM), reflect key changes in various areas, including the role of the medical director, admission and discharge policies, medication practices, infection control, and quality assurance.

Clarification regarding the medical director’s responsibilities related to the implementation of resident care policies was added to the guidance at F841 and now includes:

• Implementation of resident care policies such as ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications and intervening with a health-care
• Participation in the quality assessment and assurance committee (QAA) or assigning a designee to represent him/her. (refer to F868)
• Addressing issues related to the coordination of medical care and implementation of resident care policies identified through the facility’s quality assessment and assurance committee and other activities
• Active involvement in the process of conducting the facility assessment (refer to F838)

In addition, the medical director's responsibilities should include, but are not limited to:

• Administrative decisions, including recommending, developing, and approving facility policies related to residents' care. Resident care includes physical, mental, and psychosocial well-being.
• Discussing and intervening (as appropriate) with a health-care practitioner regarding medical care that is inconsistent with current standards of care, for example, physicians assigning new psychiatric diagnoses and/or prescribing psychotropic medications without following professional standards of practice.

The full FTag841 can be found on page 670 here.

The QAPI and QAA review also includes medical director questions (page 856) and new interview questions on the critical element pathway for unnecessary medications (page 872), both of which can be found here.

Other Key Updates in Nursing Home Care Guidance

Admission, Transfer, and Discharge:

• Admission Agreements: CMS now explicitly prohibits admission agreements from requiring third-party payment guarantees and has added examples of noncompliance.
• Transfer and Discharge Citations: Tags F622-F626 and F660-F661 have been deleted, and the terms “facility-initiated” and “resident-initiated” have been removed. The content has been reorganized and clarified into new citations: F627 (Inappropriate Transfers and Discharges) and F628 (Transfer and Discharge Process).

Chemical Restraints/Unnecessary Psychotropic Medication:

• The guidance for unnecessary psychotropic medication (F758) has been consolidated into F605, aiming for more streamlined enforcement.
• Revised guidelines emphasize resident participation in treatment decisions, particularly before initiating or increasing psychotropic medications.
• The "convenience" clause has been expanded to include using medications that induce sedation or are used to reduce staff effort in meeting resident needs.

Accuracy/Coordination/Certification:

• F641 now includes guidance for assessing the accuracy of MDS assessments, particularly related to antipsychotic medication prescriptions.
• The content under the now-deleted F642 regarding the coordination and certification of assessments has been integrated into F641.

Comprehensive Assessment after Significant Change:

• Language has been updated to better reflect the levels of assistance needed for self-care and mobility, aligning with the MDS Section GG.

QAPI/QAA Improvement Activities:

• New guidance incorporates health equity concerns into QAPI activities. Facilities are encouraged to consider factors like race, socioeconomic status, and language when investigating medical errors and adverse events and establishing improvement priorities.

Cardio-Pulmonary Resuscitation (CPR):

• CPR certification standards have been updated to align with current nationally accepted standards.

Pain Management:

• Revisions to guidance on pain management now align with CDC definitions and emphasize individualized opioid treatment plans. There is also a greater focus on the consideration of immediate-release opioids over extended-release options.

Physical Environment:

• Facilities that received state or local construction approval after November 28, 2016, or are newly certified may now meet bedroom and bathroom facility requirements without needing major rehabilitation, provided they have two single-occupancy rooms with one bathroom.

Infection Prevention and Control:

• New guidelines incorporating recommendations from CMS Memo QSO-24-08-NH (March 2024) on enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs) have been added to Appendix PP.

COVID-19 Immunization:

• Appendix PP includes the previous guidance (from CMS Memo QSO-21-19-NH) about COVID-19 vaccination education and offering the vaccine.

PALTmed will update its Synopsis of Federal Regulations guidance for members to reflect these changes soon.