Navigating CMS Updates: Preparing Your Long-Term Care Facility for Compliance and Enhanced Care Standards

The Centers for Medicare & Medicaid Services (CMS) has announced significant updates to their Long-Term Care (LTC) surveyor guidance, as detailed in the recent QSO-25-07-NH memorandum. Effective February 24, 2025, these updates aim to elevate the quality of care, align with current medical standards, and address emerging trends in deficiency citations. For LTC facilities, this is both a challenge and an opportunity to reinforce best practices and improve resident outcomes.

In this article, we’ll break down the key changes and provide actionable insights to help you prepare for these regulatory shifts.

Key Areas of Revision in the CMS Guidance

1. Admission, Transfer, and Discharge Processes

The updates streamline and clarify policies around resident admission agreements, transfers, and discharges, emphasizing resident rights and reducing noncompliance ambiguities. Facilities must ensure agreements exclude third-party payment guarantees and review new citations (F627 and F628) for improper transfer and discharge processes.
“The updated CMS guidance eliminates gray areas around admission and discharge policies, making it easier for facilities to follow ethical and regulatory standards while ensuring the dignity and rights of residents are always prioritized,” explains Peggy Morrison, MSN, RN, Risk Management Consultant.

2. Use of Psychotropic Medications

CMS has enhanced regulations to prevent the unnecessary use of psychotropic medications, highlighting the importance of resident participation in treatment decisions. The revised guidance integrates stricter investigative protocols and reinforces the resident’s right to be informed and involved in their care plan.
“These updates underscore the importance of shared decision-making in medication management. Empowering residents to participate in their care improves compliance and fosters trust between facilities and residents,” says Lisa Barringer, RN, IP-CT, RAC-CT, Risk Management Consultant.

3. Comprehensive Assessments and Health Equity

The guidance emphasizes thorough documentation for medical conditions requiring specific treatments, such as antipsychotics. Health equity considerations are now integrated into Quality Assurance and Performance Improvement (QAPI) activities, urging facilities to analyze outcomes across diverse resident sub-populations.

 

Preparing Your Facility for Compliance

1. Educate Your Team

With CMS offering training through the Quality, Safety, and Education Portal (QSEP), now is the time to ensure all staff are well-versed in the revised guidance. Establish a training schedule to cover updates on infection control, resident rights, and care planning.

2. Review and Update Policies

Conduct a thorough review of current policies and compare them to the new requirements. Focus on areas like medication reviews, admission protocols, and resident assessments. Use the updated Appendix PP and Critical Element Pathways as references.

3. Strengthen Communication with Residents and Families

Transparency is key to maintaining trust and compliance. Inform residents and their families about the updates and involve them in care planning decisions. Tailor communication to be clear and accessible, aligning with CMS’s emphasis on person-centered care.

4. Implement Enhanced Infection Control Measures

The inclusion of enhanced barrier precautions and updated immunization guidance reflects the evolving landscape of infection prevention. Evaluate your current protocols and ensure they meet these enhanced standards.

The CMS revisions are more than just regulatory changes—they are a roadmap to improved care. By aligning with the updated standards, facilities can reduce deficiencies, enhance resident satisfaction, and foster a culture of continuous improvement.

“Compliance isn’t about meeting requirements; it’s about delivering better care. These updates provide facilities with the tools to elevate their services and build trust with their communities,” says Cathy Knopf, BSN, RN, Risk Management Consultant.

At AssuredPartners, we understand the complexities of navigating regulatory changes. Our team is here to help you assess risks, optimize policies, and provide resources tailored to your needs. Contact us to learn how we can support your compliance journey.