On November 18, 2024, the Centers for Medicare & Medicaid Services (CMS) released revised guidance for nursing home surveyors. These updates, which will take effect on February 24, 2025, cover key areas, such as Admission, Transfer and Discharge, Chemical Restraints/Unnecessary Psychotropic Medication, Resident Assessment, Quality of Life and Quality of Care, Administration, Quality Assurance Performance Improvement (QAPI), Infection Prevention and Control, and others. Additionally, CMS made clarifications and technical corrections throughout Appendix PP.
The release includes important resources for nursing home surveyors and providers. Training on the updated guidance will be available shortly after the publication of the memorandum. An advance copy of the Critical Element Pathways and Appendix PP is attached to the memo, and survey resources will be published by February 24, 2025. These resources will be accessible to State Survey Agencies (SAs), long-term care facilities, and the public, providing a clear understanding of how compliance will be assessed. Surveyors will begin using the new guidance to evaluate compliance starting on February 24, 2025, through the Automated Survey Process Environment (ASPEN) system.
The revisions span many important areas. These include updates to the guidance on Admission, Transfer, and Discharge; Chemical Restraints and Unnecessary Psychotropic Medication; Professional Standards and Medical Director roles; Accuracy, Coordination, and Certification; Comprehensive Assessment following Significant Change; QAPI and Quality Assurance and Improvement (QAA) Activities; Cardiopulmonary Resuscitation (CPR); Pain Management; the Physical Environment; Infection Prevention and Control; and COVID-19 Immunization. CMS has also made technical corrections to various citations, removing erroneous references and fixing typographical errors.
To reflect these changes, CMS is updating the Long-Term Care Survey Process (LTCSP) software application. Surveyors will use the updated version of the software for surveys beginning on February 24, 2025. Additionally, other key survey documents, including the Critical Element (CE) Pathways, will be revised to reflect these changes. Advance copies of the affected pathways are attached to the memo, and the full set of updated survey documents will be available on the CMS Nursing Homes website in the “Survey Resources” section by February 24, 2025.
To support these updates, CMS will make guidance training available to nursing home surveyors and providers through the Quality, Safety, and Education Portal (QSEP) at https://qsep.cms.gov/welcome.aspx. This training will help users understand the revisions and their implications for nursing home surveys.
The guidance can be accessed here.
Compliance Perspective
Issue
CMS has issued revised guidance for nursing home surveyors that will take effect in 2025. These revisions span critical areas such as Admission, Transfer, and Discharge; Chemical Restraints; Resident Assessment; Infection Prevention and Control; and others. These updates aim to improve the quality of care and ensure that facilities comply with current standards, but they also present challenges for nursing homes to ensure policies, procedures, and staffing are aligned with the new regulations. Facilities will need to update their operational practices to reflect these changes, ensuring that resident care, safety, and regulatory compliance are maintained.
Discussion Points
- Review and update your policies and procedures to align with the CMS revisions that take effect in 2025. Specifically, assess how the various changes will impact daily operations and care practices. Ensure policies are in place to meet the new expectations set forth by CMS, and that they reflect the most current standards for resident care and safety.
- Ensure that staff receive training on the updated CMS guidelines, including new regulations for Admission, Discharge, Resident Assessments, and Infection Control. Document all training sessions, including the specific updates covered and any resources provided (such as the revised Critical Element Pathways).
- Audit to ensure your facility is in compliance with the new CMS guidelines once they take effect 2025. This includes auditing resident assessments, care plans, infection control practices, and the use of psychotropic medications to ensure these are aligned with CMS’s updated expectations. Audit your staff’s adherence to updated policies and procedures, especially in key areas like chemical restraint use and pain management. Review the implementation of these policies to ensure that staff are consistently following the updated protocols.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
