New nursing home survey process raises compliance standards, emphasizing documentation and resident-centered care.
Expansive changes to the nursing home survey process went into effect on April 28, 2025. These changes emphasize new priorities for surveyors during on-site inspections and those reviewing staffing and other data before physical inspection. After multiple delays, the new process also brings increased scrutiny to a range of already closely watched areas, from the management of psychotropic medications to infection control. The new survey process raises the bar on documentation and resident-centered care, potentially catching facilities relying on outdated systems or shortcuts. These recent changes present opportunities for improvement but also pose real compliance risks if providers are not prepared.
The Centers for Medicare & Medicaid Services (CMS) first issued a draft of updates in November. The guidance, including the all-important Appendix PP, has expanded to more than 900 pages and includes several new or significantly revised critical element pathways. Experts have offered reminders about potential pain points and advice on how to address them.
F641 Accuracy of Assessments
Surveyors will now be looking for patterns of inaccurate Minimum Data Set (MDS) data or inappropriate completion of the MDS for a resident’s status. MDS information impacts the facility payment rate and standing in terms of the quality monitoring process. A pattern within a nursing home of clinical documentation or MDS assessment or reporting practices that result in higher Patient Driven Payment Model scores, not triggering Care Area Assessments or unflagging Quality Measures, where the information does not accurately reflect the resident’s status, may indicate payment fraud or attempts to avoid reporting negative quality measures. While this change was spurred by CMS’ ongoing interest in the use of schizophrenia diagnoses to exclude antipsychotic prescribing from a nursing home’s quality measures, its reach will be much broader than that. It can also lead to the investigation of the employee signing off on the MDS submission and referral to the Inspector General’s office.
F841 Responsibilities of the Medical Director
Medical Director requirements play a key role in supporting standards of care specific to all aspects of resident services, especially related to diagnosing and prescribing psychotropic medications. The Medical Director is expected to review medical records to ensure professional standards are met. It is recommended that facilities implement additional audits completed by the Medical Director, including a thorough review of Quality Assurance and Performance Improvement (QAPI) topics.
F627 Inappropriate Transfer/Discharge and F628 Transfer/Discharges Process
Facilities are expected to update their admission and discharge processes to meet the stricter requirements around ensuring a discharge is safe and appropriate. Valid reasons for facilities to discharge residents are extremely limited and should include a resident endangering others, the existence of urgent financial issues after exhausting appeals, or changes in the resident’s condition that result in the facility’s inability to meet their needs. The message is clear: if you don’t have an approved reason for discharging the resident, don’t discharge without consulting leadership and legal first. Surveyors are directed to ask for detailed documentation regarding the discharge process, including the involvement of the ombudsman. Improper discharges could directly trigger an Immediate Jeopardy (IJ) citation.
Polaris Group can assist with the new survey process changes, offering education, audits, and tools. For further information, contact our team today!
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