Surveyors will be evaluating for compliance in new ways, as a result of nursing home survey changes for 2025. While significant, these changes reflect federal initiatives that associations and operators have been seeing for some time now.

Nursing home providers are parsing through recent, significant changes to the survey process and trying to grasp the implications for compliance and the potential for citations. But the future of these changes is uncertain.

The updates will likely result in more citations as surveyors become more familiar with the new processes and expectations from the Centers for Medicare & Medicaid Services (CMS)once the changes are implemented in February, associations said, but it remains to be seen how the incoming Trump administration will move forward with enforcement.

“Certainly in 2026, and beyond, I would anticipate that a lot of this will be ditched and or scaled back,” said Fred Bentley, managing director for post-acute and long-term care and senior living practice at ATI Advisory. “This is just a last gasp from the outgoing administration.”

The changes, which were shared in an advance copy of a 900-page document on Nov. 19, focus on a variety of areas, ranging from admission agreements and medication management to infection control and health equity considerations.

Randi Hansen, director of corporate compliance with Health Dimensions Group (HDG), said two key areas of survey changes to focus on first are tags related to reduction of unnecessary psychotropic medications, and updates to admission, transfer and discharge processes.

“This is a reflection of the outgoing administration’s broader policy priorities in health care,” Bentley said of the 2025 survey changes. Provisions in survey changes around the safety of Covid vaccinations and infection control, for one, will be on shaky ground, especially if Robert F. Kennedy Jr. and Dr. Mehmet Oz are confirmed to be the next Department of Health & Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) secretaries, respectively.

“We’re still in the very early stages. Trying to discern RFK Jr.’s and Dr. Oz’s priorities is tricky … they are far from traditional Republican appointees,” said Bentley.

It’s unclear to what extent the Trump administration will try to scale back or de-emphasize some of the things that are supposed to go into effect in February, or what they’re actually allowed to change once regulation is in the books.

But, it is standard fare for an outgoing administration to try to extend its influence after leaving office, Bentley said.

Amy Greer, director of quality innovations with Zimmet Healthcare Services Group, said CMS usually makes major changes to surveys every two to four years, with changes in June 2022 reflecting updates to abuse and neglect tags, infection control, mental health and substance abuse disorder and staffing.

“It’s easy to think that this was CMS putting regulations into effect prior to the new administration taking effect in 2025, but it has been very clear over the past few years that psychotropic usage and reduction, and infection control, have been priorities with CMS,” Greer told SNN.

Survey changes in line with federal initiatives

Jodi Eyigor, director of nursing home quality and policy with LeadingAge, told SNN the survey updates weren’t entirely anticipated, but associations were monitoring CMS moving in this direction. Many of the updates address issues the agency prioritized in the past, she said.

More paperwork and more enforcement doesn’t deliver quality care, Holly Harmon, senior vice president of quality, regulatory and clinical services for the American Health Care Association and National Centers for Assisted Living (AHCA/NCAL), said of the survey changes. The group will continue to advocate for a survey system that supports quality improvement, she added.

Providers can prepare for improved compliance, with protocols clearly stated and available to the public, Eyigor said. Guidance will help streamline the survey process and eliminate overlapping citations, she said, as seen in revised approaches to admission, transfer and discharge citations.

“CMS has consolidated seven F-tags into two,” Eyigor said of streamlined citations for admission, discharge and transfers. “Additionally, the guidance now eliminates the distinction between resident-initiated and facility-initiated discharges, shifting the focus to ensuring that all discharges meet the criteria of being ‘appropriate’ and compliant.”

The removal of a distinction between who initiated a discharge underscores a stronger emphasis on residents’ rights to return after hospitalization or therapeutic leave, Hansen said, another reflection of the outgoing administration’s initiatives.

There’s a focus on ensuring residents aren’t discharged or transferred to a setting that doesn’t meet their needs, Hansen added.

“Operators must assess returning residents at the time of their proposed return and there can be no determination that their needs cannot be met or that their return poses safety or health risks to others,” said Hansen. “These updates will make discharges even more complex.”

Psychotropic med redux, MDS coding take priority

Unnecessary psychotropic medications and accuracy of MDS coding should take priority for operators, Eyigor said. Operators would do well to pay close attention to how practices related to these topics will be evaluated and enforced.

Survey changes related to the MDS reflect what nonprofit organizations have been experiencing when it comes to schizophrenia audits over the past few years, only this time with greater weight to consequences for coding without sufficient documentation, Eyigor said.

Another noteworthy change – the reclassification of unnecessary psychotropic medications now cited under F605, chemical restraints, rather than F757, unnecessary drugs. Updates concerning psychotropic medications in particular will “create a reckoning” in long-term care, Eyigor said.

“LeadingAge strongly opposes the use of chemical restraints. However, it seems that this guidance could result in a reluctance to admit residents with any psychotropic medications, including antidepressants or antianxiety medications,” noted Eyigor.

Greer echoed this, adding that the F605 tag can bring “highly negative connotations” on a survey and affect a facility’s five-star rating. Greer doesn’t agree with CMS’ stance that antipsychotics should be a drug of “last resort,” and removing medication from residents to satisfy regulation may be detrimental to a resident’s overall health.

“What facilities are really going to have to focus on here is having the proper documentation that warrants the usage of the medication and show that all other interventions were done before the nurse went for that pill for the resident; education needs to start now with staff that this documentation is imperative,” said Greer

There’s a fear that a nursing home might not be able to adequately obtain necessary history to ensure sufficient documentation.

Touching on implementation of enhanced barrier precautions as part of infection control survey updates, Eyigor said it’s been difficult to find a balance between use of personal protective equipment (PPE) and preserving the dignity of residents and ensuring a homelike environment.

“While CDC is able to point to evidence that the use of Enhanced Barrier Precautions (EBP) decreases transmission of multidrug-resistant organisms (MDRO) in nursing homes, we are curious if the use of EBP makes a significant enough impact on adverse outcomes to support implementation when compared to the negative impacts on residents’ psychosocial wellbeing,” said Eyigor.