Summary
Surveyor updates coming in February, what you need to know.
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The Centers for Medicare & Medicaid Services (CMS) is enhancing the oversight and compliance programs for nursing homes to improve the quality of care. Health and safety updates are regularly made to address emerging trends in deficiency citations nationwide. The areas that have been revised and will become effective February 24, 2025 are described below.
Key Areas of Revision:
- Admission, Transfer & Discharge
- Chemical Restraints/Unnecessary Psychotropic Medication
- Resident Assessment, Quality of Life and Care
- Accuracy/Coordination/Certification
- Professional Standards/Medical Director
- Quality Assurance Performance Improvement (QAPI)
- Infection Prevention and Control.
What to Know:
- Admission, Transfer, and Discharge: Clarified guidance on admission agreements and reorganized tags for better clarity. Admission agreements cannot contain language requesting or requiring third party guarantee of payment. FTags 622-626 and F661will be deleted. New citations will fall under F627 Inappropriate Transfers and Discharges and F628 Transfer and Discharge Process.
- Chemical Restraints/Psychotropic Medication: Streamlined regulations to prevent unnecessary use of psychotropic medications. F757 has been revised to only include guidance for non-psychotropic medications. F758 will be incorporated into F605.
- Professional Standards and Medical Director: Added instructions for investigating adherence to professional standards and clarified the Medical Director’s responsibilities. Clarifies Medical Director duties outlined in F841 and adds instructions for investigating adherence to F658 Professional Standards.
- Accuracy/Coordination/Certification: F641 now includes investigating MDS accuracy for insufficient documentation to support medical condition for antipsychotics. F642 is being relocated to F641. F642 is deleted.
- Resident Assessment: There will be increased scrutiny on the accuracy of assessments on the MDS. Patterns (i.e., 3 or more residents) of inaccuracies may be forwarded for investigation of falsification. Surveyors will refer cases of suspected non-compliance to state boards of nursing and the HHS Office of the Inspector General by way of the OIG’s “Submit a Hotline Complaint” link under the agency’s fraud -reporting site.
- QAPI/QAA Improvement Activities: Incorporated health equity concerns and emphasized data collection and analysis for quality improvement.
- Infection Prevention & Control: Updated guidance on Enhanced Barrier Precautions and COVID-19 immunization requirements.
- EBP is incorporated into Appendix PP.
- Covid-19 Immunization guidance regarding resident education is incorporated into Appendix PP.
- CE Pathways and Long-Term Care Survey Process are being updated and will be referenced starting 2/24/25.
Be aware of the FTag Changes:
- New FTag 627 Inappropriate Transfer/Discharge and new FTag 628 Transfer/Discharge Process will be utilized.
- FTags 622-626 and F661 will be deleted.
- FTag 605 further clarifies elements of F758.
- F758 will be incorporated into F605
- FTag 841 clarifies expectations of Medical Directors.
- FTag 641 will have elements currently found in F642.
- F642 will be deleted.
What to Do:
- Read QSO-25-07-NH.
- Review Admission Agreements removing language requesting or requiring third-party guarantee of payment.
- Schedule education meetings with Practitioners, IDT, Leadership Team and frontline staff between now and February 1, 2025.
- Address proposed FTag revisions through discussion during upcoming QAPI meetings.
- Reach out to your Polaris Consultant for details, direction and support.
- Be on the look out for additional training resources and details of updated surveyor guidance from CMS.
- Schedule a mock survey for focused audit on current practices and transitional opportunities leading up to the February 24, 2025, deadline.
- Consider an MDS focused audit to ensure 100% accuracy of assessments.
For further information regarding our incredibly successful outsourced MDS program or other partnership options with Polaris Group, a LTC industry expert, contact us today!
