Enhancing Quality and Oversight in Nursing Homes: CMS’s Latest Revisions (QSO-25-14-NH)

April 25, 2025

The Centers for Medicare & Medicaid Services (CMS) has recently rolled out significant updates to the Long-Term Care (LTC) surveyor guidance, aiming to elevate the quality and oversight of nursing home care. These changes, detailed in the memorandum QSO-25-14-NH, are set to take effect on April 28, 2025, and promise to bring a host of improvements to various aspects of nursing home operations.

Updates to long-term care surveyor guidance, released by the Centers for Medicare & Medicaid Services (CMS) on November 18, address several topics and impact multiple F-tags, including removal of F-tags as guidance is relocated into other F-tags. Included in the corresponding QSO’s are updated Critical Element Pathways corresponding to the revisions.

It is important to note that the revised guidance does not change requirements. Regulations remain as they were, however interpretive guidance has changed for the specific areas outlined in the QSO.  The guidance does, however, provide more detail on how existing requirements will be surveyed and it is likely that citations will increase as surveyors become more familiar with CMS expectations for compliance with these requirements. Leaders and there team should review these changes ASAP and determine a plan to update policies and procedures, train applicable staff and audit outcomes for compliance. 

The revisions cover a wide range of areas:

  • Accuracy/Coordination/Certification: Added instructions for investigating MDS assessment accuracy and relocated regulatory references.
  • Admission, Transfer, and Discharge: Clarified guidance prohibiting admission agreements from requiring third-party payment guarantees and deleted overlapping citation tags.
  • Cardio-Pulmonary Resuscitation (CPR): Updated CPR certification standards.
  • Chemical Restraints/Unnecessary Psychotropic Medication: Incorporated regulations and guidance for unnecessary use of psychotropics into F605 and revised guidance on “convenience.”
  • Comprehensive Assessment after Significant Change: Updated language to reflect levels of assistance for self-care and mobility activities.
  • COVID-19 Immunization: Incorporated guidance on educating residents and staff about COVID-19 vaccine benefits and side effects.
  • Implementation and Training: Revised guidance will be incorporated into the LTC Survey Process software application, and training resources are available in the Quality, Safety, and Education Portal (QSEP).
  • Infection Prevention & Control: Incorporated Enhanced Barrier Precautions guidance from CMS Memo QSO-24-08-NH.
  • Pain Management: Revised guidance to align with CDC definitions and emphasized individualized opioid treatment plans.
  • Physical Environment: Revised bedroom and bathroom facility requirements for newly certified facilities.
  • Professional Standards and Medical Director: Added instructions for investigating adherence to professional standards and Medical Director responsibilities.
  • QAPI/QAA Improvement Activities: Incorporated health equity concerns into QAPI program priorities.
  • Sufficient Nursing Staff, RN 8 Hrs./7days/Wk., Full Time DON, & Payroll Based Journal: Added guidance for investigations using Payroll Based Journal Staffing Data Report.
  • Technical Corrections: Made technical corrections to many citations to remove erroneous references and correct typographical errors.

Pathway Health is featuring a Leadership Mini Series focused on the latest Appendix PP revisions. This series highlights key leadership strategies for effective implementation and organizational readiness. In addition, we’ve developed specialized training, consulting services, and updated tools to support leaders, including Appendix PP preparation consulting, revised audit processes, and practical resources to guide compliance and performance improvement.

Pathway Health offers several services and products to help facilities navigate these rule changes:

Stay tuned for more in-depth insights and discussions on how these changes will impact nursing home care and operations.

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