Navigating CMS Survey Changes in 2025

With over 30 years dedicated to the long-term and post-acute care industry, currently serving as Director of Regulatory Affairs at PointClickCare, I’d like to share how the recent and significant updates made by Centers for Medicare & Medicaid Services (CMS) to their long-term care (LTC) surveyor guidance will reshape compliance in our industry.

Adapting to a New Compliance Landscape

Navigating change can be challenging – especially when it comes with the potential for increased penalties – and while the regulatory framework remains unchanged, CMS’s updated surveyor guidance refines how compliance is measured. The stakes are higher now, with penalties tied not only to per-day but also per-instance. Although the initial enforcement date of February 24, 2025, has been extended one month to March 24, 2025, this change is quickly approaching.

By understanding the revised guidance now, facilities can avoid costly surprises and focus on delivering quality care.

Critical Challenges in the New Survey Process

There are three areas that stand out as critical challenges in the new survey:

• Chemical Restraints and Psychotropic Medications: CMS has intensified its scrutiny of schizophrenia diagnoses after audits revealed significant documentation gaps. Facilities must now provide more detailed evidence of the diagnosis and obtain resident consent for every psychotropic medication/dose change. This raises the bar for compliance, making it essential to tighten processes around psychotropic medication management.
  The added emphasis on transparency means that facilities can no longer rely on past practices. Clear documentation and ongoing resident engagement are essential to meet these new expectations.
• Accuracy of Assessments: Errors in Minimum Data Set (MDS) assessments can trigger severe consequences, including state board reporting and Office of Inspector General (OIG) referrals. Accurate, timely assessments are more critical than ever.
  This change forces facilities to rethink how they approach assessments. Data validation processes, staff training, and regular audits should become routine to ensure compliance.
• Infection Prevention and Control: With the introduction of Enhanced Barrier Precautions (EBP), infection control efforts have become more structured. Proper implementation requires coordinated staff training and continuous monitoring to minimize multi-drug-resistant organism (MDRO) risks.

Facilities must create a culture of vigilance, where every staff member understands their role in preventing infections.

PointClickCare is actively evaluating additional ways to support our partners and customers in navigating these updates. Beyond the existing tools like our psychotropic medication dashboard and MDS data validations, we’re exploring new solutions to address the heightened compliance requirements. For example, our Infection Prevention and Control module has been updated to allow for evidence-based practice (EBP) alerting and tracking.

Looking Ahead

While these changes may seem overwhelming, they also offer an opportunity to strengthen our compliance efforts and enhance resident care. The revised guidance is a call to action, urging facilities to build resilient processes that stand up to the highest scrutiny. Let’s use this moment to elevate our standards, ensuring a safer, higher-quality experience for the residents we serve.