In 2025, CMS has highlighted critical focus areas for surveyors conducting health inspections in Long-Term Care (LTC) facilities. These priorities emphasize improving care quality, enhancing regulatory compliance, and ensuring resident well-being.
I read the recently released CMS 2025 Mission & Priorities document to summarize the key areas for focused review, provide you with best practices for each item and action opportunities with practical steps to help your facility prepare.
For 2025, CMS has focused on the following key areas for focused review during the standard health survey process relative to facility performance and practice:
- Facility Assessments and Staffing
- Nurse Staffing Requirements
- Compliance with PBJ Reporting
- Antipsychotic Medication Use
- Involuntary Discharges
- Infection Prevention and Enhanced Barrier Precautions (EBP)
- Compliance with Infection Prevention and Control (F880)
Let’s take a look at each of these in regard to CMS expectations and best practices to avoid citations.
Facility Assessments and Staffing: Aligning Resources with Resident Needs
What CMS Expects:
In a nutshell, facilities must conduct thorough assessments to ensure staffing levels and competencies align with resident needs. These assessments should also identify any additional resources necessary for care delivery.
Best Practices:
Regularly update staffing plans based on resident assessments and acuity levels. While the facility assessment is only required to be completed yearly, more frequent reviews of assessment data combined with staffing levels and competency training will allow you to adjust as needed to ensure resident needs are safely being met. Provide ongoing training to ensure staff competencies match resident care requirements.
Action Opportunity:
Leverage a solution that provides facility assessment resources that allow your team to conduct frequent facility assessments, like SHP’s Data Analytic Portal which provides a Facility Assessment Work Document and a Facility Assessment Data Report with many of the needed data points to quickly assess your facility and identify areas to address.
Nurse Staffing Requirements: Meeting Minimum Standards
What CMS Expects:
Facilities must maintain adequate staffing levels, ensuring alignment with resident care needs. While the federal minimum staffing mandate may be dead, the regulatory requirement for sufficient staffing is alive and well and not dependent on a number.
Best Practices:
Monitor staffing using payroll-based journal (PBJ) data to track and adjust staffing ratios. Recruiting qualified staff through attractive incentives is only half the battle – you must retain them. Being invested in the success of your new hires and engaging personally with staff goes a long way to building trust establishing improving staff retention.
Action Opportunity:
Leverage a solution that tracks staff hours and positions to include providing analytic software tools to your team, like SHP’s PBJ Manager which tracks staff hours to ensure compliance with CMS regulations.
Compliance with PBJ Reporting: Ensuring Accuracy
What CMS Expects:
Facilities must submit timely and accurate payroll-based journal data, detailing staff hours and roles. Failure to submit timely can significantly impact overall star ratings and the impact can be felt for up to 18 months.
Best Practices:
Don’t wait until the end of a quarter to begin evaluating your data. Utilizing analytic software monthly or even with completion of each payroll cycle gives valuable insight into performance and potential outcomes. Use software to minimize errors in PBJ submissions and cross-check PBJ data with timekeeping systems to ensure accuracy.
Action Opportunity:
Leverage a solution that scrubs your PBJ data for errors or audit risks, like SHP’s PBJ Manager which also tracks staff hours, scrubs for errors or risks, projects staffing star ratings and helps avoid penalties to protect your rates.
Antipsychotic Medication Use: Reducing Inappropriate Prescriptions
What CMS Expects:
Facilities must prioritize behavioral interventions and limit antipsychotic prescriptions to cases with appropriate diagnoses. CMS will continue to focus in this area, likely fueled in part by the number of facilities that failed the CMS schizophrenia audit.
Best Practices:
Conduct regular audits of medication records to identify and address inappropriate antipsychotic use and be aware of off-label use and its alignment with resident care plans. Diagnoses for antipsychotic medications should be well documented and established prior to implementation and the clinical record needs to reflect that to the best extent possible. Implement non-pharmacological interventions such as music therapy, sensory interventions, or environmental changes to manage behaviors.
Action Opportunity:
Leverage a data solution that provides easy access to list of residents using antipsychotic medication or residents coded with schizophrenia on the MDS, like SHP’s Clinical Systems Review Report which provides easy lists and drill down analysis to quickly find residents that you may want to audit prior to a CMS audit or survey.
Involuntary Discharges: Safeguarding Resident Rights
What CMS Expects:
Facilities must follow legal protocols for involuntary discharges, providing adequate notice and exploring alternatives.
Best Practices:
Strong communication and pre-admission screening is essential. Remember, once you accept and admit a resident to your facility, you are responsible for providing the necessary care and services, so ensure you can fully meet the resident’s needs before committing. When issues do arise post admission, engage families early to address concerns and prevent escalations. As always, document thoroughly. Maintain detailed records of efforts to resolve issues before resorting to discharge.
Action Opportunity:
Leverage a solution that allows you to evaluate involuntary discharge risks, like SHP’s Resident Risk and Hospitalization Reports which can help identify discharge risks and trending issues for implementation of preventative measures and staff education.
Infection Prevention and Enhanced Barrier Precautions (EBP): Protecting Resident Health
What CMS Expects:
Enhanced Barrier Precautions (EBP) must be applied to residents with chronic wounds, indwelling devices, or other risk factors for infection.
Best Practices:
Promote Hygiene: Conduct regular hand hygiene audits and provide refresher training on PPE use. Monitor Compliance: Use infection control rounds to ensure adherence to EBP protocols.
Action Opportunity:
Leverage a data solution that analyzes the resident’s infection risk based on their current acuity, like SHP’s Infection Risk Report which includes scoring methodology based on the residents known risk factors as well as infection guidelines from the CDC. This report creates a color-coded Risk Score to easily identify which residents are at a High, Moderate or Low Risk for Severe Outcomes from a potential infection.
Compliance with Infection Prevention and Control (F880): Strengthening IPCPs
What CMS Expects:
Facilities must enhance their Infection Prevention and Control Programs (IPCPs), emphasizing training, reporting, and outbreak management. Infection control practices were being expanded in the conditions of participation PRIOR to the pandemic and expectations remain high for compliance with implementing policies.
Best Practices:
Train Frequently to ensure all staff understand their role in infection prevention. Simulate scenarios and conduct drills for managing outbreaks or isolation procedures. Always audit for compliance with expectations and document all efforts.
Action Opportunity:
Leverage a solution that supports your ability to evaluate your facility performance on infection control issues and risks, such as SHP’s Viral Respiratory Infection – Resident
Risk Report as well as consolidated COVID19 NHSN Reports which consolidate risk data and relative performance for your organization as well as individual resident risk factors for mitigation.
Conclusion
CMS’s 2025 Mission & Priorities reflect a commitment to improving care quality and resident safety. Equipped with the insights I just shared, you can be prepared to reduce the risk of deficiencies and foster a culture of excellence in care.
Stay ahead of the curve by regularly reviewing your facility’s policies, training programs, and compliance records. With the right preparation, along with SHP’s Data Solutions, you can meet and exceed CMS’s expectations for 2025.
Prepare for CMS 2025 with Confidence—Transform Compliance and Care Today
Take the next step in safeguarding your facility’s success. Equip your team with the insights and tools needed to meet CMS’s 2025 priorities head-on. Schedule your free demo of SHP’s innovative data solutions today and see how we can help you enhance compliance, improve care quality, and optimize performance. Don’t wait—prepare now to lead with confidence!