The Centers for Medicare and Medicaid Services (CMS) is set to implement a series of major revisions to its long-term care survey guidelines, effective February 2025.

The changes, which were shared in an advance copy of a 900-page document, focus on a variety of areas, ranging from admission agreements and medication management to infection control and health equity considerations. The new guidance for State Survey Agencies (SAs) aims to streamline the survey process and eliminate overlapping citations.

“Health and safety updates are regularly made to address emerging trends in deficiency citations nationwide. This ensures that our guidance remains aligned with current standards of practice and reflects the evolving needs of residents. These updates are essential to maintaining the integrity of nursing home care,” David Wright, director of quality, safety and oversight, noted in the CMS memo.

The guidance will be available to surveyors starting next year on February 24.

Alicia Cantinieri, managing director for clinical reimbursement and regulatory compliance with Zimmet, told Skilled Nursing News that CMS is pushing for a greater accuracy in the minimum data set (MDS) assessments.

To that end, the federal agency has issued a change in the guidance to surveyors regarding citations in tag F641 for accuracy of assessment, whereby they are instructed to review MDS coding accuracy, but not investigate possible falsification of the MDS. 

“Strong language is also included regarding patterns of inaccurate MDS coding on three or more residents and indications that the individual knew the coding was inaccurate,” said Cantinieri, adding, “A referral should be made to the Office of the Inspector General to investigate possible falsification, which could be a potential reimbursement issue for the Medicare or Medicaid program.”

This is a change from the previous F642 guidance, which included referral to the State Agency Regional Office and Medicaid Fraud Control Unit, she said.

Changes on admissions, transfers, and discharge processes

Among other major changes, CMS is revising guidance on the admission, transfer, and discharge processes. The handling of admission agreements is a notable change in this category, and facilities may no longer include language in their admission agreements that requests or requires a third-party guarantee of payment. This move is intended to prevent financial coercion and ensure that residents are not unduly pressured to secure payment guarantees from family members or others, the memo states.

In addition, CMS has reorganized and clarified guidance regarding the transfer and discharge process. The agency is removing several outdated tags, including F622 through F626 and F660 through F661, which previously dealt with facility-initiated and resident-initiated transfers and discharges. These tags will be replaced by two new citations, with the revisions aiming to make it easier for surveyors to identify instances of noncompliance, particularly when transfers or discharges are not conducted in accordance with residents’ rights or regulatory requirements.

“To reduce the overlap of citations, improve clarity, and make it easier for surveyors to identify noncompliance, CMS is deleting [these] Tags … removing the terms ‘facility-initiated’ and ‘resident-initiated,’” Wright stated in the memo.

Oversight on psychotropics, chemical restraints

CMS is also streamlining the guidance related to the use of psychotropic medications and chemical restraints. Previously, regulations concerning the unnecessary use of psychotropic drugs were located under tag F758, but they have now been incorporated into tag F605 to simplify the survey process and increase consistency in enforcement.

This change emphasizes the need for facilities to prevent the unnecessary use of psychotropic medications, especially when they are administered for staff convenience rather than medical necessity, the federal agency noted.

“The guidance regarding ‘convenience’ has been revised to include situations when medications are used to cause symptoms consistent with sedation and/or require less effort by facility staff to meet the resident’s needs,” Wright said.

Facilities must also ensure that residents are fully informed and able to participate in decisions about their treatment, including their right to accept or refuse psychotropic medications.

“[B]efore initiating or increasing a psychotropic medication, the resident must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication,” he said.

Additionally, tag F757 for unnecessary medications has been changed to only include guidance for non-psychotropic medications.

Infection control and COVID-19 updates

Infection prevention and control also remains a priority for CMS, with several updates in this category. The new guidance incorporates the enhanced barrier precautions for preventing the spread of multidrug-resistant organisms (MDROs). Surveyors will be trained to assess compliance with these precautions during facility inspections.

Moreover, CMS has integrated updated COVID-19 immunization guidance into the survey process. Facilities will be required to educate residents and staff about the benefits and potential side effects of the COVID-19 vaccine and offer the vaccine to residents and staff as part of ongoing infection control efforts.

Other changes

Several updates have been made to address disparities in long-term care and improve professional standards and oversight of medical care in long-term care facilities.

New instructions have been added for surveyors to assess whether antipsychotic medications are being prescribed without sufficient supporting documentation. This ensures that medications are used appropriately and in accordance with medical guidelines.

Moreover, CMS has expanded the guidance under tag F841 to clarify the responsibilities of the facility’s medical director. These responsibilities now include overseeing the implementation of resident care policies and ensuring that physicians and other practitioners follow these policies when diagnosing and prescribing medications. Surveyors will also be required to interview the medical director as part of the process for investigating unnecessary medication use and quality assurance activities.

And, in an important step toward addressing disparities in long-term care, CMS has introduced new guidance for Quality Assurance and Performance Improvement (QAPI) programs. Facilities will now be required to incorporate health equity concerns when collecting and analyzing data related to medical errors, adverse events, and resident outcomes. Specifically, surveyors will be tasked with ensuring that facilities are collecting data on factors that affect health equity, such as race, socioeconomic status, and language, and that this data is used to inform the facility’s priorities and improvement efforts.

Training and software updates

CMS is also rolling out a comprehensive training program for surveyors and long-term care providers. This training will be available through the Quality, Safety, and Education Portal (QSEP) and will provide detailed explanations of the revisions to the survey guidelines. Additionally, the revised guidelines will be incorporated into the Long-Term Care Survey Process (LTCSP) software, which surveyors will begin using on February 24, 2025.

The updates will also include new and revised Critical Element Pathways (CE Pathways), which surveyors use to investigate potential care concerns. These pathways, along with other related survey documents, will be available on CMS’s Nursing Homes website by the end of February.