Survey Alert! Revised LTC Surveyor Guidance: What You Need to Know
Long-term care facilities are about to undergo significant changes as CMS releases revised surveyor guidance aimed at elevating care quality and resident safety. On November 18, 2024, the Centers for Medicare & Medicaid Services (CMS) issued significant revisions to the Long-Term Care (LTC) Surveyor Guidance, emphasizing improvements to quality and compliance in nursing homes. These changes aim to enhance oversight, streamline processes, and support resident health and safety. Long-term care leaders must prepare now to meet the updated standards, as these revisions become effective on February 24, 2025.
Here’s what you need to know:
Key Areas of Revised Guidance
- Admission, Transfer, and Discharge
- Clarifications to Guidance: CMS prohibits admission agreements requiring third-party payment guarantees, providing examples of non-compliance in updated guidance
- New Tags: Consolidates and reassigns tags to clarify noncompliance and reduce the overlap of citations.
- Tags F622-F626 and F660-F661 will be deleted.
- The terms “facility-initiated” and “resident-initiated” will be removed.
- The guidance from the deleted Tags has been reorganized, with some revisions to clarify when a transfer or discharge is non-compliant.
- Inappropriate transfers and discharges are now under F627 (Inappropriate Discharges) and F628 (Transfer and Discharge Process).
- Psychotropic Medications and Chemical Restraints
- Streamlined Guidance: Regulations for unnecessary psychotropic medications (formerly F758) are merged into F605 to promote consistency and strengthen the message that facilities must prevent the unnecessary use of psychotropic medications.
- “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.
- Resident Rights: Residents must be fully informed and participate in decisions about initiating or increasing psychotropic medications, including the right to accept or decline the medication.
- F757 (Unnecessary Medications): Revised to only include guidance for non-psychotropic medications.
- Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway: Revised to include investigative elements to align with the updated guidance.
- Professional Standards and Medical Director Responsibilities
- Revised Guidance F658 (Professional Standards): Instructions for investigating concerns regarding antipsychotic medications prescribed without sufficient supporting documentation of an approved indication for use.
- Clarified Guidance for Medical Director Oversight: At F841, ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications and issues related to the coordination of medical care and implementation of resident care policies identified through the facility’s quality assessment and assurance committee and other activities were incorporated into the guidance.
- Investigations: Updated Unnecessary Medications and QAPI critical element pathways incorporate questions for interviewing the Medical Director for assessing adherence to professional standards.
- Accuracy/Coordination/Certification:
- Updated Guidance: Guidance for F641 (Accuracy of Assessments) updated to add instructions for investigating MDS accuracy when there are concerns regarding use of antipsychotic medications with insufficient documentation to support a medical condition indicated for use of the medication.
- Deleted Tag: F642 (Coordination/Certification of Assessment) has been deleted and relocated under F641 Accuracy of Assessments.
- Comprehensive Assessment after Significant Change:
- Updated Guidance: Language regarding levels of assistance for self-care and mobility updated to align with Section GG of the MDS.
- Quality Assurance and Performance Improvement (QAPI)
- Focus on Health Equity: New guidance added to incorporate health equity concerns when investigating medical errors and adverse events and establishing QAPI program priorities. Facilities must analyze health outcomes by factors like race, language, and socioeconomic status to identify disparities.
- Cardio-Pulmonary Resuscitation (CPR)
- Alignment with Standards: Updates made to CPR certification to align with current nationally accepted standards.
- Infection Prevention and Control
- Enhanced Barrier Precautions: New guidance and examples regarding Enhanced Barrier Precautions incorporated into Appendix PP to align with protocols to reduce the spread of multidrug-resistant organisms (MDROs).
- COVID-19 Immunizations
- Revised Guidance: Added guidance related to staff and resident education regarding benefits and potential side effects (see CMS Memo QSO-21-19-NH)
- Pain Management
- Updated Definitions: Incorporates CDC definitions for acute, chronic, and subacute pain.
- Individualized Plans: Guidance encourages immediate-release opioid prescriptions over extended-release options when clinically appropriate and emphasizes the need for individualized opioid treatment plans.
- Physical Environment
- Revised Guidance: Allows facilities with construction or those newly certified after 11/28/2016 with two single occupancy rooms with one bathroom to meet the bedroom/bathroom requirements without undergoing major renovations.
- Survey Software and Process Updates
- CMS will update the Long-Term Care Survey Process (LTCSP) software and related tools, including revised Critical Element Pathways and Appendix PP to incorporate in the revised guidance by 2/24/2025.
Training and Implementation Timeline
- Training Availability: CMS will soon release training for providers and surveyors on the Quality, Safety, and Education Portal (QSEP). Check for updates regularly to ensure timely completion.”
- Surveyor Use: Surveyors will adopt the new guidance beginning February 24, 2025.
What LTC Leaders Should Do Now
- Familiarize Your Team: Share the memorandum and Appendix PP updates with leadership and staff.
- Educate Your Team: Ensure key staff complete the CMS-provided training on QSEP to understand the revised expectations.
- Update Policies: Revise facility policies on admission agreements, psychotropic medication use, infection control, and pain management to align with the guidance.
- Review QAPI Plans: Incorporate health equity metrics into your QAPI processes to address disparities in care outcomes.
- Prepare for Surveys: Familiarize your team with the revised Critical Element Pathways and software updates.
Where to Access Resources
- Training: CMS Quality, Safety, and Education Portal (QSEP)
- Survey Resources: CMS will update all documents under the “Survey Resources” section on the CMS Nursing Homes website.
Effective Date
These changes go live February 24, 2025 and CMS plans to publish these updates in Appendix PP in February 2025. To stay compliant, ensure all staff are informed and prepared within the next 90 days.
These updates reflect CMS’s commitment to improving long-term care standards. By acting now, LTC leaders can ensure smooth transitions, maintain compliance, and continue delivering top-tier resident care.
