Significant Revision to Survey Process

• By: Maureen Carland
• On: 11/24/2024 12:32:23
• In: Quality/Regulatory

CMS has released QSO-25-07-NH  “Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process”.
Surveyors will use this guidance to determine compliance with requirements beginning February 24, 2025.
 
Key Changes Include:
Admission, Transfer, and Discharge

• Removal of F-tags F622 – F625 and F660 – F661.
• Addition of new citations: Inappropriate Transfers and Discharges (F627) and Transfer and Discharge Process (F628).

Chemical Restraints/Unnecessary Psychotropic Medications

• F758 (unnecessary psychotropic use) incorporated into F605 and revised.
• F757 now covers only non-psychotropic medication guidance.
• Updates to the Critical Element Pathway for unnecessary medications, including new investigative elements.

Professional Standards and Medical Director

• Revised guidance for F658 (Professional Standards) regarding antipsychotic medication diagnoses.
• Clarification added to F841 (Medical Director Responsibilities).
• Facility medical director interviews incorporated into pathways for Unnecessary Medications and Quality Assurance & Performance Improvement (QAPI).

Accuracy/Coordination/Certification

• F642 (Coordination/Certification of Assessment) deleted; references relocated to F641 (Accuracy of Assessment).
• New instructions for investigating MDS assessment accuracy and addressing insufficient documentation for antipsychotic medications.

Comprehensive Assessment After a Significant Change

• Updated language to align self-care and mobility activity levels with MDS Section GG.

QAPI/QAA Improvement Activities

• Added guidance addressing health equity concerns.

Cardio-Pulmonary Resuscitation (CPR)

• Updated CPR certification standards to align with current national guidelines.

Pain Management

• Revisions to guidance on acute, chronic, and subacute pain, incorporating updated CDC definitions.
• Expanded resource links on opioid use.
• Emphasis on individualized opioid treatment plans, including immediate-release options.

Physical Environment

• Facilities approved for construction or certified after November 28, 2016, may meet bedroom and bathroom requirements with two single-occupancy rooms and one shared bathroom without major renovations.

Infection Prevention and Control

• Added guidance on Enhanced Barrier Precautions (EBP) and new deficiency examples.

COVID-19 Immunizations

• Integrated education requirements for residents and staff from CMS Memo QSO-21-19-NH into Appendix PP.

 
AHCA and MHCA will continue to review the updates in detail and will provide more detailed information and education on the changes. 
 
Staff contact: mcarland@mehca.org