Regulatory Update

Nursing Facilities Need to be Prepared for New Changes to CMS Surveyor Guidance

Polaris Group Profile
Polaris Group
July 19, 2022
March 14, 2023
Polaris Group Profile
Polaris Group
March 14, 2023

Get an overview of the upcoming items that surveyors will be focused on so you can prepare your facilities for citation-free surveys. 

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Nursing Facilities Need to be Prepared for New Changes to CMS Surveyor Guidance  

In late June, the Centers for Medicare and Medicaid Services (CMS) detailed changes to surveyor guidance for nursing homes which go into effect on October 24, 2022. As CMS has increased their attention on nursing home quality, safety, and staffing, surveyors have been directed to more closely assess these areas. In particular, these CMS changes are to provide details on how surveyors might better identify potential areas of non-compliance.  

Surveyor guidance will take effect October 24th

Significant changes that nursing home leadership need to be aware of include:  

  1. Incorporating payroll-based journal staffing to evaluate nurse staffing requirements
  1. Requirements for an on-site, part-time infection preventionist  
  1. Clarification of abuse reporting requirements, including new reporting templates for what should be reported by facilities in incidents
  1. Procedures for addressing unnecessary use of non-psychotropic drops and dose reduction strategies
  1. Outlining severity levels related to deficiencies on the psychosocial outcome severity guide  
  1. Guidance around resident rights, particularly for those with mental health and substance use disorders  
  1. Prohibition around requiring residents to sign binding arbitration agreements as a condition of admission.  

While not a requirement, with CMS’s new guidelines memo, they have also recommended facilities reduce the number of residents in each room to two residents to prevent infections and enhance resident privacy. CMS also strongly encourages facilities to explore facility-level changes which could afford single occupancy rooms for more residents.  

Training is available through both QSEP and Polaris Group Consulting

CMS will offer to provide training in the Quality, Safety, and Education Portal (QSEP). Polaris consultants are also available to answer any questions you may have, as there are 65 F tags that are impacted by these new CMS revisions and updates. Now is the time to prepare and train staff so facilities will be ready for the October implementation of these guidelines.  

To learn more about Polaris Group Consulting, please visit:

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