Significant Revisions to Enhance Quality and Oversight of the LTC Survey Process –

Summary of Revised Surveyor Guidance –

Admission, Transfer, and Discharge: 

• CMS has revised guidance on the admission, transfer, and discharge processes. Most notably, this includes new guidance on the handling of admission agreements. Facilities may no longer include language in their admission agreement that requests or requires a third-party guarantee of payment.
• Removal of F-tags F622 – F626 and F660 – F661
• New citations added: Inappropriate Transfers and Discharges (F627) and Transfer and Discharge Process (F628)

Chemical Restraints/Unnecessary Psychotropic Medication: 

• Revisions have been made to regulations and guidance for the unnecessary use of psychotropics (F758), which are now incorporated into Right to be Free from Chemical Restraints (F605).
• Per CMS, 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 guidance regarding 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.
• Before initiating or increasing a psychotropic medication, facilities must also ensure that residents are fully informed and able to participate in decisions about their treatment, including their right to accept or refuse psychotropic medications. 
• Revisions were made to Unnecessary Medications (F757), which now only includes guidance for non-psychotropic medications. 
• Revisions were made to The Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway, which includes the addition of investigative elements.

Professional Standards and Medical Director:

• Revision of surveyor instructions for Professional Standards (F658) regarding resident’s diagnosed with a condition without sufficient supporting documentation for antipsychotic medications.
• Medical Director’s responsibilities related to the implementation of resident care policies was added under Responsibilities of the Medical Director (F841). 
• Incorporated into the Unnecessary Medications and Quality Assurance & Performance Improvement (QAPI) pathways is a new component that includes interviewing the Facility Medical Director.

Accuracy/Coordination/Certification:

• Coordination/Certification of Assessment (F642) has been deleted, and all references from F642 are being relocated under Accuracy of Assessment (F641).
• Instructions for investigating Minimum Data Set (MDS) assessment accuracy as well as instructions for determination of noncompliance when a concern related to insufficient documentation to support a medical condition is identified for a resident receiving an antipsychotic medication have been added to the guidance in F641.

Other areas of change include:

• Cardio-Pulmonary Resuscitation (alignment with national standards)
• Comprehensive Assessment After a Significant Change (revised to align with Section GG levels of assistance)
• QAPI/QAA Improvement Activities (incorporates health equity concerns)
• Pain Management (revised definitions)
• Physical Environment (revised bathroom facility requirements)
• Infection Prevention and Control (now includes Enhanced Barrier guidance)
• COVID-19 Immunizations (includes guidance for vaccination education on benefits and potential side effects)

Coretactics recommends you review of the QSO memo for complete details. An Advance copy of Appendix PP and the Critical Element Pathways are attached to this memo.

Training on this guidance is now available. To register, visit https://qsep.cms.gov/.

Effective Date: Surveyors will begin using this guidance to determine compliance with requirements on surveys beginning February 24, 2025. CMS feels this provides ample time for surveyors and nursing home providers to be trained on this new information.

Coretactics is ready to prepare your SNF to meet these new survey requirements before implementation in three short months. Be it staff education, updating of policies and procedures or documentation tools, Coretactics’ experts are just a call away! 518-280-1343 or Email Us!