On January 15, 2025, the Centers for Medicare and Medicaid Services (CMS) revised the November 18, 2024 Memo, QSO-25-25-07-NH, “Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process.” The revised Memo has a new reference number: QSO-25-12-NH.
The Good:
The effective date of implementation for all new guidance is now March 24, 2025. The effective date listed on the last QSO Memo was February, so it gives providers a few more weeks to get everything squared away.
The Bad:
Unfortunately, instead of there being less guidance to review, CMS has added additional areas with revised surveyor guidance and advance copies of the associated Critical Element Pathways.
What’s been added? Nursing Services and Payroll-Based Journal revisions. Regarding Nursing Services as it relates to F725 Sufficient Nursing Staff, F727 RN 8 Hrs./7 days/Wk., Full Time and F851 Payroll Based Journal, guidance for surveyors has been added to assist with using the PBJ for investigations. Additional instructions for staff interviews, observations, key elements of noncompliance and deficiency categorization have been included. Part of the guidance focuses on surveyors’ offsite prep using staffing data, so they are armed and ready when they enter a facility for survey.
Stay tuned to the CMSCG Blog for our “Ftag of the Week” series which will be covering all the updated surveyor guidance and what to expect on your next survey.
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View the January 15, 2025 QSO Memo, “REVISED: Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process” here. View this recent McKnights Long-Term Care News article, “‘Armed and ready’: Delayed guidance updates strategies for nursing home surveyors” for more information.
Preparing for survey or have a compliance concern? CMSCG’s interdisciplinary team of compliance and quality improvement consultants can help. Learn more about our nursing home consulting services, including mock surveys and other survey readiness services, and how we can work with your organization to improve its quality and outcomes. Call 631.692.4422 or email us for more information.
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