Staffing and certain compliance issues related to updated survey guidance coming in late March, particularly those that relate to patient discharges as well as use of psychotropic medications, are top of mind for nursing home clinical leaders in 2025.

Panelists at Skilled Nursing News’ annual CLINICAL conference, which took place early this week in Fort Myers, Florida, shared their concerns and workarounds for the problems they anticipate in 2025 amid ongoing regulatory changes.

Zendi Meharry, chief clinical officer at Cascadia Healthcare, said that while Cascadia has been fortunate with staffing, she is looking to have the staffing mandate be repealed in 2025. One of her concerns stems from the federal minimum staffing mandate being too narrowly conceived, as it fails to include certain essential roles needed to satisfy the requirements, such as respiratory therapists and hospitality workers. These roles are crucial for skilled nursing facilities with high-acuity needs, where residents may require more amenities.

Idaho-based Cascadia operates 58 facilities across five western states.

Moreover, in 2025, the stakes for using anti-psychotics as chemical restraints are much higher in the new survey guidance. Facilities could get cited more frequently and receive an immediate jeopardy (IJ) without proper documentation, she said.

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, the Centers for Medicare and Medicaid Services (CMS) said in announcing the changes last fall.

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.

“High on my list [of concerns] and that gives me anxiety at night is the move from a pharmacological tag for psychoactive drugs to F605, which is an abuse tag,” Meharry said.

And also new for this year is that discharge planning is even more important and requires careful consideration of resident needs at the time of admission.

In the revised long-term care survey guidelines, CMS plans to also implement changes to the handling of admission agreements, 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 agency stated earlier.

This means, “Only take the patients that you can care for … discharging is definitely in the harm or immediate jeopardy areas,” Meharry said.

For Toni Headstream, chief nursing officer at Elmbrook Management Company, the federal staffing mandate’s requirement to staff facilities with the 24/7 presence of a registered nurse (RN) remains one of the prime areas of worry in 2025 given the shortage of RNs in Elmbrook’s region of operation. And changes to the staffing mandate can’t come any faster to ease her mind.

Oklahoma-based, Elmbrook has 12 facilities, with 11 being skilled nursing facilities (SNFs) and one assisted living facility (ALF).

“We were all hoping for a change and still are, even though that hasn’t happened immediately,” she said.

DON-in-training programs

Elmbrook has proactively tried to address staffing shortages, particularly in developing clinical leadership, by partnering with local colleges to teach advanced practice registered nurses (APRNs) and bring students into their clinical environment, providing hands-on experience in Elmbrook nursing homes. This approach helps bridge the gap between academic learning and real-world nursing home practice. But regardless of the efforts, the shortage far exceeds demands for nurses, she said.

Additionally, Headstream said that with regards to the updated survey requirements, effective on March 24, the change requiring an RN to be designated as the director of nursing (DON) complicates matters, but Elmbrook is trying to work around the issue by more training.

“Now you have to have an RN identified as the DON, not just RN eight hours a day,” Headstream said of the new rule.

In addressing this problem, Headstream said, her organization has created a DON-in-training program, which is a bit more focused on younger clinical workers than the typical administrator-in-training program that many nursing homes tend to deploy.

“Somebody that maybe has been out of school for a couple of years, but would like to be a DON, we bring them in, and we have them go through a program for DON in training. And so, that is one way that we’re trying to stay ahead of [changing requirements],” said Headstream.

Person-centered care needs people

Meanwhile, Kristen Knapp, senior director of strategy and communications at the Florida Health Care Association, which represents over 86% of Florida’s more than 690 skilled nursing centers, said she is worried that the federal staffing mandate would damage a state-based system that works.

Since early 2000, Florida has had a state-level staffing mandate that alllows therapists and even some licensed practical nurses and non-clinical workers to be counted towards the staffing requirements. And more recently, the Florida legislature updated the staffing standards to meet the needs of residents, including those with higher acuity, such as those requiring respiratory care, or those with behavioral health care needs and recommended the care of mental health specialists, social services and activities.

“We’re really concerned that [the federal mandate] is going to undo what we’ve had in place for decades here,” Knapp said. “A one-size-fits-all model for 14,000 nursing centers across the country just doesn’t make any sense. So giving states that authority to be able to look at what you can do given the makeup of your residents is so critical,” said Knapp.

Workforce development programs and career ladder programs are underway in Florida and have been helping increase clinical workers in nursing homes in the state, Knapp said.

These include the qualified medication aide (QMA) and the qualified personal attendant program, which allows non-certified nursing aides to work in nursing homes for 120 days and get paid while undergoing training to earn their certified nurse aide (CNA) license. The latter program was made permanent in Florida in 2021, she said.

“At the end of the day, we all want person-centered care, but you have to have the people to be able to make that happen,” said Knapp.