On November 18, 2024, as part of its efforts to strengthen the quality of care provided by nursing homes through oversight and compliance programs, Centers for Medicare & Medicaid Services (CMS) issued Revised Long-Term Care (LTC) Surveyor Guidance, announcing changes designed to enhance the quality and oversight of the survey process. LTC surveyors will begin using this revised guidance on February 24, 2025. The guidance memo includes advance copies of revisions to be published in Appendix PP of the State Operations Manual (SOM) for state survey agencies, LTC facilities, and the public and revisions to the corresponding Critical Element Pathways. LTC facilities should take note of significant revisions in the following areas:
Admission, Transfer, and Discharge
- Admission agreements cannot require third-party guarantee of payment.
- New citation for inappropriate transfers and discharges (F627).
- New citation for transfer and discharge process (F628).
- Deletes F622-F626 and F660-F661.
Quality of Life and Quality of Care
Quality Assurance Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Improvement Activities
- New guidance for investigating health equity concerns based on factors such as race, socioeconomic status, and language when investigating medical errors and adverse events.
- Facilities should prioritize health equity through QAPI program.
- Surveyor can interview medical director.
Chemical Restraints/Unnecessary Psychotropic Medication
- Facilities must prevent unnecessary use of psychotropic medications.
- Redefines "convenience" to include use to reduce staff effort or as sedative.
- Resident must be fully informed of and participate in or refuse treatment.
- Moves regs and guidance for unnecessary use of psychotropics to F605.
- Citation for unnecessary medications includes only psychotropics (F757).
- Surveyor can interview medical director.
- Relevant pathway revised to provide aligned investigative elements.
Resident Assessment
Professional Standards & Medical Director
- New instructions for investigating adherence to professional standards of practice when diagnosis lacks sufficient documentation for approved indication of antipsychotic medications (F658).
- Clarifies medical director's responsibilities to implement resident care policies by ensuring physicians/practitioners adhere to policies for diagnosing and prescribing medications and other identified issues (F841).
Accuracy/Coordination/Certification
- New instructions for investigating accuracy of minimum data set (MDS) assessment (F641).
- New instructions for determining if documentation is sufficient to support medical condition of patient receiving antipsychotic medication (F641).
- Moves coordination/certification of assessment to F641 and deletes F642.
Comprehensive Assessment after Significant Change
- Updates language about level of assistance resident receives for self-care and mobility to align with Section GG of the MDS.
Cardio-Pulmonary Resuscitation (CPR)
- Aligns with current national standards.
Pain Management
- Revises acute, chronic, and subacute pain definitions to align with CDC.
- Clinicians may consider prescribing immediate-release opioids.
- Facilities need individualized opioid treatment plans.
- Provides more links and resources regarding opioid use.
Infection Prevention and Control
- Adds March 2024 guidance for enhanced barrier precautions in nursing homes to prevent spread of multi-drug resistant organisms.
- Adds May 2021 guidance for educating residents, resident representatives, and staff about COVID-19 vaccine and for administering vaccine.
Physical Environment
- Facilities with two single-occupancy bedrooms and one bathroom that get state or local construction approval or are certified after November 28, 2016 will meet bedroom and bathroom requirements without major rehabilitation.
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