Navigating the 2025 CMS Updates: Key Changes for Long-Term Care Facilities

 This article is Part 2 in a 4-part series to explain the CMS changes for LTC facilities and actionable steps for compliance. Read Part 1 for the article overview and links to the CMS memos. This article focuses on sufficient nursing staff coverage, chemical restraints, and the minimum data set.

CMS regularly updates guidance to address emerging trends in deficiency citations across the nation, focusing on enhancing resident health, safety, and quality of care. The following information is intended to help State Survey Agencies (SAs), long-term care facilities, and the public better understand how compliance will be evaluated and provides an overview of the changes and recommendations for how to best ensure compliance.

Sufficient Nursing Staff (F-725), RN 8 Hrs./7days/Wk. (F727), Full-Time DON, (F727), and Payroll Based Journal (F851)

CMS has added guidance for investigations using the Payroll Based Journal Staffing Data Report. This report will be used as one of the sources of information indicative of potential non-compliance. Instructions specific to staff interviews, observations, key elements of noncompliance, and deficiency categorization have also been added as well as instructions to surveyors based on whether the report identified concerns.

Action Steps

1. Sufficient Nursing Staff (F-725)

• Review Staffing Levels: Ensure that nursing staff levels are adequate to meet the needs of all residents, especially those requiring high levels of care.
• Implement Contingency Plans: Create contingency plans for unexpected staffing shortages, such as cross-training staff or having an on-call team available.
• Documentation Review: Ensure that staffing schedules, timecards, and other documentation reflect accurate staffing levels in compliance with regulations.

2. RN 8 Hrs./7days/Wk. (F-727)

• Verify RN Coverage: Ensure that at least one Registered Nurse (RN) is on duty for 8 hours each day, 7 days per week.
• Cross-Check Schedules: Regularly verify that staffing schedules include the required RN coverage and that there is no lapse in RN presence.
• Audit Staffing Hours: Conduct internal audits of staffing hours to confirm that the facility is consistently in compliance.

3. Full-Time DON (F-727)

• Full-Time Director of Nursing (DON): Ensure that the (DON) is employed on a full-time basis and verify that they are actively engaged in the daily operations of the facility.
• Role Responsibilities Clarity: Clearly define and document the DON’s duties and expectations, ensuring that these align with CMS guidelines.
• Cross-Training: Ensure that senior leadership or other staff are capable of stepping in temporarily if the DON is unavailable.

 4. Payroll-Based Journal (PBJ) (F-851)

• Timely and Accurate Submission: Ensure that payroll data is submitted accurately and on time using the Payroll-Based Journal (PBJ) system.
• Review Data for Compliance: Regularly review PBJ data for discrepancies, and ensure that it reflects accurate staffing hours, job categories, and staffing patterns.
• Link PBJ Data with Staffing Plans: Ensure the PBJ data correlates with the staffing plan and aligns with other reports, such as the nurse staffing hours.

5. Prepare for Survey Inspections – Mock Survey

• Conduct mock surveys focusing on PBJ practice and policies to identify potential issues before surveys.
• Implement corrective actions and re-educate staff based on findings.

Chemical Restraints/Unnecessary Psychotropic Medications:

CMS is also streamlining the guidance related to the use of psychotropic medications and chemical restraints. Regulations concerning the unnecessary use of psychotropic drugs have been consolidated under tag F605. Facilities must ensure that residents are fully informed and have the right to accept or decline psychotropic medications. Revisions to F605 and F758 integrate stricter controls on chemical restraints and stress the need for resident participation in treatment decisions. Unnecessary Medications (F757) has been revised to only include guidance for non-psychotropic medications. This change underscores the importance of facilities taking proactive steps to prevent the inappropriate use of psychotropic medications, particularly when such medications are used for staff convenience rather than genuine medical necessity.

Action Steps

1. Policy Review & Updates

• Revise Facility Policies: Ensure policies align with the new CMS guidance under F605 and F758 regarding psychotropic medication use and chemical restraints.
• Clarify Definitions: Clearly define “chemical restraint” and ensure staff understand when psychotropic medications are appropriate.
• Update Consent Procedures: Ensure policies outline informed consent processes, emphasizing resident rights.

2. Resident Rights & Informed Consent

• Full Resident Participation: Implement protocols to ensure residents (or their legal representatives) are fully informed of the risks, benefits, and alternatives before starting psychotropic medications.
• Educate Residents and Families: Provide clear, accessible information about psychotropic medications and the facility’s approach to minimizing their use.

3. Medication Review & Reduction Efforts

• Strengthen Gradual Dose Reduction (GDR) Practices: Implement a robust process for regularly evaluating the need for continued psychotropic medication use.
• Involve Pharmacists and Consultants: Schedule routine medication reviews with pharmacists to identify unnecessary psychotropic medication use.
• Monitor Alternative Interventions: Document non-pharmacological interventions attempted before prescribing psychotropic medications.

4. Staff Training & Compliance Monitoring

• Provide Regular and Ongoing Education: Train staff on alternative behavioral interventions, informed consent, and proper documentation practices.
• Monitor for Misuse: Conduct internal audits to ensure psychotropic medications are not used for staff convenience or as a substitute for appropriate care.

5. Prepare for Survey Inspections – Mock Survey

• Conduct mock surveys focusing on psychotropic medications and chemical restraint practice and policies to identify potential issues before surveys.
• Implement corrective actions and re-educate staff based on findings.

Minimum Data Set (MDS)

CMS has emphasized improved accuracy and thorough investigation of Minimum Data Set (MDS) assessments. Surveyors are well trained to evaluate accuracy and identify noncompliance when concerns arise about insufficient documentation supporting a medical condition for residents receiving antipsychotic medications. These considerations have been integrated into the guidance under Accuracy of Assessment (F641). Additionally, regulatory references and guidance previously found under Coordination/Certification of Assessment (F642) have been consolidated into F641, resulting in the removal of tag F642.

Action Steps

1. Strengthen MDS Assessment Accuracy and Documentation

• Conduct Thorough Assessments: Ensure that all MDS assessments accurately reflect residents’ medical conditions, behaviors, and medication use.
• Verify Supporting Documentation: Cross-check MDS data with clinical records, physician notes, care plans, and medication administration records (MARs) to ensure consistency.
• Implement Pre-Submission Audits: Regularly review MDS assessments before submission to identify discrepancies or missing documentation.
• Ensure Consistency of Records: Align MDS documentation with care plans, progress notes, and physician orders to prevent inconsistencies.
• Document Medical Necessity for Antipsychotics: Clearly record clinical justifications, behavioral symptoms, and alternative interventions attempted before initiating or continuing antipsychotic medications.

2. Enhance Staff Training & Competency

• Provide Ongoing MDS Training: Ensure all MDS coordinators, nurses, and interdisciplinary team members are trained on accurate coding and documentation requirements.
• Educate on Antipsychotic Documentation: Train staff to properly document medical necessity, behaviors, and alternative interventions for residents on antipsychotic medications.

3. Strengthen Interdisciplinary Collaboration

• Physician & Nursing Communication: Foster collaboration between MDS coordinators, physicians, pharmacists, and nursing staff to ensure accurate assessment and documentation.
• Integrate Behavioral Health and Pharmacy Teams: Involve behavioral health specialists and pharmacists in reviewing residents receiving antipsychotic medications.
• Enhance Care Plan Coordination: Ensure that care plans align with MDS assessments and reflect residents’ current needs and treatment plans.

4. Prepare for Survey Inspections – Mock Survey

• Conduct mock surveys focusing on MDS accuracy.
• Implement corrective actions and re-educate staff based on findings.