Understanding the 2025 Survey & Enforcement Changes for Skilled Nursing Facilities

The Centers for Medicare & Medicaid Services (CMS) has released QSO-25-14-NH, which provides important updates to surveyor guidance effective April 28, 2025. While the underlying regulations remain unchanged, these clarifications help skilled nursing facilities better understand how surveyors will interpret compliance requirements.

Admission, Transfer, and Discharge Updates

CMS has reorganized its approach to resident transitions by consolidating several existing tags. The guidance now prohibits admission agreements requesting third-party payment guarantees and eliminates the distinction between "facility-initiated" and "resident-initiated" transfers. Two new tags have been created: F627 addressing inappropriate transfers/discharges and F628 covering the transfer/discharge process. Tags F622-F626 and F660-F661 have been deleted as part of this reorganization.

Refined Staffing Oversight

Surveyors will now incorporate Payroll Based Journal Staffing Data Reports into their investigations, providing additional context for staffing assessments. The guidance includes more detailed processes for staff interviews and observations, with specific attention to Director of Nursing requirements and compliance standards for submitting direct care staffing information.

Medication Management Clarifications

The guidance has integrated unnecessary psychotropic medication regulations (previously F758) into chemical restraints guidance (F605), refining the definition of "convenience" regarding medication use. Additional requirements have been established for resident notification and consent before initiating or increasing psychotropic medications. F757 (Unnecessary Medications) now applies specifically to non-psychotropic medications.

Professional Standards and Medical Director Role

Medical directors will find clarification regarding their responsibilities in implementing resident care policies. The guidance provides more specific investigative procedures for situations where residents are diagnosed with conditions without sufficient documentation, and outlines expectations for physician adherence to facility policies on diagnosing and prescribing.

Assessment and Quality Improvement

CMS has updated guidance for MDS assessment accuracy and moved Coordination/Certification requirements (F642) into Accuracy of Assessment (F641). The QAPI guidance now incorporates health equity considerations, and infection control standards have been updated to include enhanced barrier precautions for multidrug-resistant organisms and integration of COVID-19 immunization education requirements.

For SNF providers looking to maintain compliance and prepare for upcoming surveys, understanding these interpretive changes is an important part of operational readiness. Rolf Martin Lang LLP will be hosting a panel session on 2025 Survey & Enforcement Updates at the upcoming OHCA conference to help facilities navigate these clarifications.