The Centers for Medicare & Medicaid Services (CMS) compiled an ambitious checklist of changes for the nursing home industry as part of its 2025 mission and priorities document released this week, but a lack of details on staffing-related issues and infection protocols is raising concerns about a fair survey process.
Surveyor guidance was a major part of the mission and priorities document and originally unveiled in November. The current updates focus on the use of antipsychotics, nurse staffing, Payroll-Based Journal reporting and involuntary discharges. Priority tier schedules for surveys, revised facility assessment guidance, enhanced barrier precautions, risk-based surveys and the $75 million national staffing campaign were also outlined in the CMS document published on Tuesday.
However, the devil is in the details, and for some experts, these were missing from the latest version.
Amy Greer, an RN quality innovative consultant for Zimmet Healthcare Services Group, expects these changes to press forward with the new administration, but said it would have been important to get clarity on the staffing mandate, facility assessments and details surrounding certain infection prevention protocols.
“I think that all of these will still be priorities for CMS with the new administration, I anticipate they will stay the course here,” said Greer. “The only area that I am seeing a lot of pushback on that I believe may not come to fruition is the staffing mandate, which interestingly enough was not mentioned in this memo at all, but we will have to wait and see on that outcome.”
Ambitious survey schedules amid backlog
And while CMS clarified some lingering questions, besides the staffing mandate, the future of risk-based surveys, which are currently being tested, was also not discussed in the memo.
The document briefly mentioned the $74 million national staffing campaign for nursing homes, as well as the risk-based survey approach that allows consistently higher-quality facilities to receive a more focused survey that takes less time and resources than the traditional standard recertification survey.
CMS will present a “next phase” of this risk-based approach once testing is completed. But for now, the federal agency has steered clear of providing more information about the risk-based surveys.
“CMS has been highly secretive with this pilot program,” Greer noted. “Repeated requests for more information have gone unanswered, they wouldn’t even tell us what states RBS was being performed in or what they entail.”
On the staffing campaign, Greer said the agency’s guidance on it is a source of one of her greatest frustrations. The campaign discredits and ignores licensed practical nurses and certified nurse aides in facilities, while pushing for more registered nurses.
“And yet, they just ruled that RNs do not need to be part of a nursing home survey team…so what really is making sense here?” asked Greer.
All said, at least there is some clarity on survey schedules included in the memo, said Greer.
According to the new schedule, no more than 15.9 months should elapse between completed surveys, while the interval between consecutive standard surveys must be 12.9 months or less. All nursing homes in each state should be surveyed, on average, once per year, she said.
States must conduct at least 10% of the standard health surveys on “off hours,” and at least 50% of these surveys must be from a list of facilities provided by CMS with potential staffing issues.
Surveyor guidance, facility assessments and infection prevention
When it comes to use of antipsychotics, the agency said that the volume of residents inaccurately diagnosed with schizophrenia was a big driver of the change to reduce use. The resident assessment instrument manual language has been bolstered with additional requirements to that end.
“They are really coming down hard on inappropriate psychotropic medication usage and its potential as a chemical restraint – this is definitely not going away,” said Greer. “Adding anticonvulsants to Section N on the Minimum Data Set (MDS) was no accident. CMS will now track that as they have noticed an increase in off-label usage to avoid using psychotropic medications.”
There will be a continued focus on reduction of antipsychotics use, despite conflicting recent studies on the risks versus benefits of reducing psychotropic drugs in the LTC population, she said.
CMS provided guidance for state survey agencies and operators to align with revised requirements for facility assessments, which encourage an assessment driven by staffing decisions while also informing the facility about what skills and competencies staff must possess.
Since facility assessments were effective as of Aug. 8, 2024, Greer said facilities must now prove appropriate staff competencies and skill sets, and plans for staff recruitment and retention while also showing that residents, their families and staff were included in assessment creation.
As a result, citations related to facility assessments have gone up, Greer said.
“I have been seeing increases in citations on surveys for facilities either not having updated facility assessments or not meeting the newest requirements.” said Greer.
Other requirements of note in the 2025 mission and priorities document is one pushing nursing homes to implement enhanced barrier precautions for residents with chronic wounds, or if they have in body or “indwelling” medical devices such as urinary catheters and are involved in high-contact resident care activities at the same time, CMS said.
“Clearer guidance is needed on the definition of ‘close contact,’ namely in regards to providing physical and occupational therapy, etc.,” said Greer. “We’re still seeing extremely large variations in citations across the nation in infection control under this guidance, but this is definitely not going to go away, especially in a post-Covid world.”
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Centers for Medicare & Medicaid Services, CMS, Zimmet Healthcare Services Group