Revised Long-Term Care Surveyor Guidance Effective March 24, 2025
Effective March 24, 2025, CMS will implement revised guidance to enhance care quality and ensure regulatory compliance. The changes to the Survey Process were first announced in November for February implementation, followed by a January update confirming the new effective date in late March 2025. The following areas are impacted by significant edits and revisions.
F627/F628 Admission, Transfer, and Discharge
- F622–F626 and F660–F661 is deleted.
- F627 and F628 are new.
- Removes terms ‘facility-initiated’ and ‘resident initiated.’
F605 Chemical Restraints/Unnecessary Psychotropic Medication
- F758 has been removed and F605 is its new location.
- New focus on medications used for staff convenience.
- Noncompliance expanded to F605, F641, F658.
F841 Professional Standards and Medical Director
- Medical Director contracts must reflect policy updates and their obligation to intervene if another practitioner is providing care inconsistence with standards of practice.
- Medical Director must be involved with the development of resident care policies.
- Medical Directors will be interviewed as part of the survey process.
F641 Minimum Data Set (MDS) Accuracy, Coordination, and Certification
- F642 deleted. F641 is the new location.
- Patterns of inaccurate coding could be referred to OIG for further investigation of falsification of records.
- Documentation must support the medical conditions identified, especially schizophrenia.
F637 Comprehensive Assessment After Significant Change
- Language updates to align with Sectio GG of the MDS.
- Resident assessment must reflect the resident’s current status.
F867 QAPI/QAA Improvement Activities
- Definition added for health equity.
- Policy contains health equity language. “Health equity” refers to the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.
- Surveyors are to ask Medical Directors about their awareness of non-compliant systems.
F678 Cardio-Pulmonary Resuscitation (CPR)
- Updates made to align with national CPR certification.
- Training may be held in physical or virtual instructor-led settings.
F697 Pain Management
- Definition of time-limited pain areas that include acute, chronic and subacute.
- Immediate-release opioids are acceptable if supported with clinician reasoning.
- Residents must be made aware of risks and benefits of pain treatments.
F918 Physical Environment
- Construction work approved after 11/28/16 meets requirements of one bathroom for two single-occupancy rooms without undergoing major reconstruction.
F880 Infection Prevention and Control
- EBP has been added to guidance.
F887 COVID-19 Immunization
- Deficiency category examples added to the spread of COVID-19.
- F887 (COVID-19) immunization added to Appendix PP.
- Documentation is required for offering and educating staff and residents on vaccines.
The revised guidance focuses on enhancing quality of care and regulatory compliance in long-term care facilities. It highlights the need for supporting documentation and collaboration among the IDT, with changes effective in March.
Providers should utilize training resources and consider support services such as Polaris Mock Surveys, MDS Accuracy Audits and Polaris-guided, facility-specific action plans to implement the changes effectively. For further information, please contact our team.
