The Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2025 Mission and Priority Document (MPD) on January 13. This document, released annually, directs and prioritizes work for the year, reflecting regulatory changes, adjustments to budget allocations, new initiatives, and new statutory requirements. This year’s MPD reviews updates to guidance for various CMS-certified settings, survey activity prioritization, and ongoing CMS initiatives. Find updates below for LeadingAge members.

Nursing Homes

CMS reviewed updates to surveyor guidance, including the June 2024 release of memo QSO-24-13-NH that outlines surveyor guidance for the new facility assessment requirements implemented in August 2024 and significant revisions to Appendix PP of the State Operations Manual (SOM) in November 2024 that incorporated guidance for the use of enhanced barrier precautions, previously released in March 2024.

CMS provided guidance to state survey agencies for prioritizing survey activities. Standard recertification surveys remain in the top tier of importance, along with complaints triaged at immediate jeopardy (IJ) level and initial certification surveys exceeding 150 days. CMS directed state agencies to prioritize off-hours surveys (surveys that begin before 8 a.m., after 6 p.m., or on weekends) as tier 2, noting that off-hours surveys should continue to account for at least 10% of all surveys. Non-IJ high complaints are also prioritized at tier 2, with non-IJ low and medium, initial certifications not exceeding 150 days, and Medicaid-only recertifications prioritized at tiers 3 and 4. Facility-reported incidents and complaints should also be managed according to the revisions to Chapter 5 of the State Operations Manual released in June 2022.

New initiatives outlined in the MPD include the testing of the Risk-Based Survey, which focuses survey time and resources for higher-performing nursing homes, and the Nursing Home Staffing Campaign. CMS is investing more than $75 million to support staffing in nursing homes by making it easier for individuals to enter careers in the nursing home workforce. This includes increasing awareness of nursing home careers and financial incentives such as tuition reimbursement for new nurses.

Ongoing efforts include timely recertification surveys, timely surveys of Special Focus Facilities, and state-level support for Minimum Data Set (MDS) assessments. States must continue to maintain a nurse aide training registry and to review requests for waiver of nurse aide training program prohibitions. States must update and maintain Civil Money Penalty (CMP) reinvestment programs consistent with programmatic changes announced in September 2023 and should continue to transfer all cases that require CMP enforcement to the CMS location. Other areas of focus include inappropriate antipsychotic usage, inappropriate discharge, and nurse staffing and payroll-based journal data submission.

Anticipated regulatory changes for nursing homes in the Unified Agenda include four new rules. Healthcare System Resiliency and Modernization has been under review with the Office of Management and Budget since October 2023 and will be boosted by Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers II. These two proposed rules will be combined to update emergency preparedness requirements for all providers and will include elements of coordination with federal, state, tribal, regional, and local emergency preparedness systems and preparedness against cyberattacks. Reporting Crimes Occurring in Federally Funded Long Term Care Facilities and Enforcement Under Section 1150B of the Social Security Act will include requirements for reporting reasonable suspicion of crimes committed against individuals receiving care from long-term care facilities and will implement requirements to notify individuals of reporting obligations. The rule will also establish procedures for imposing civil money penalties and exclusion from participation in federal health care programs for violating these obligations, and hearings and appeals processes related to these penalties. This rule is expected in April 2025, along with the annual Skilled Nursing Facility (SNF) Prospective Payment System (PPS) proposed rule.

Hospice

Updates to hospice survey guidance in 2024 included a memorandum, QSO-25-02-Hospice, which outlines the hospice special focus program (SFP) criteria and the roles and responsibilities for CMS, the SAs, and the accrediting organizations (AOs). The first SFP cohort was selected on December 20, 2024, and surveys, which will be conducted by a contracted surveyor, will begin in January 2025. LeadingAge has created a serial post to track the implementation of this program. When the hospice program completes the SFP and elects SA oversight (as opposed to an AO), the state is required to conduct a survey within one-year post-SFP completion, which will start a new standard 36-month survey cycle. CMS also published updates to survey guidance regarding the development and implementation of enforcement remedies for noncompliant hospice programs in Chapter 10 of the SOM.

CMS provided guidance to survey agencies to prioritize survey activities. Standard recertification surveys remain in the top tier of importance, along with complaints prioritized at IJ level and initial certification surveys with a CMS determined access to care issue (which is the responsibility of the hospice to provide in their application). For tier 2, surveyors were directed to prioritize complaint investigations as non-IJ high and initial certification surveys exceeding 150 days. All other initial certifications fall into tier 3.

New initiatives include ensuring consistency of hospice survey results by developing processes to facilitate consistency across surveying entities (CMS, states, accrediting organizations). CMS is also asking that SAs conduct a review of their hospice complaint hotline information in the Hotline Directory on CMS.gov on a monthly basis. Specifically, SAs are requested to test links and phone numbers to ensure accuracy, and email their CMS location point of contact if information needs to be corrected. Finally, states will continue to be responsible for conducting substantial allegation complaint surveys for deemed hospices. However, in 2025, states will not be conducting representative sample validation surveys. SAs are asked to include a sample of multiple locations in the survey process and this sample should be included minimally in the record reviews and onsite visits when possible.

Anticipated regulatory changes for hospices in the Unified Agenda include three new rules. In addition to the FY2026 Hospice Wage Index, which will include more updates to the Hospice Quality Reporting Program, the Healthcare System Resiliency and Modernization has been under review with the Office of Management and Budget since October 2023 and will be boosted by Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers II. These two proposed rules will be combined to update emergency preparedness requirements for all providers and will include elements of coordination with federal, state, tribal, regional, and local emergency preparedness systems and preparedness against cyberattacks. In 2024, CMS issued a proposed rule for updating CMS oversight of AOs which LeadingAge commented on, however, no final rule has been issued and it is no longer on the Unified Agenda.

Home Health

CMS is delayed in revisions to SOM Appendix B to include updates based on several final rules that amended home health Conditions of Participation (CoPs), including the acceptance to service policy. CMS did release conforming revisions to the regulatory tags and interpretive guidelines in March 2024. CMS combined survey protocol and interpretive guidelines into a single document, updated Level 1 tags, and made clarifications and technical corrections to other guidance based on stakeholder feedback. CMS also published updates to survey guidance regarding the development and implementation of enforcement remedies for noncompliant hospice programs in Chapter 10 of the SOM.

CMS provided guidance to survey agencies to prioritize survey activities. Standard recertification surveys remain in the top tier of importance, along with complaints triaged at IJ level, substantiated allegation validation surveys at the IJ level, and initial certification surveys with a CMS determined access to care issue (which is the responsibility of the home health to provide in their application). For tier 2, surveyors were directed to prioritize complaint investigations as non-IJ high and initial certification surveys exceeding 150 days. All other initial certifications fall into tier 3. In tier 4, surveyors are directed to conduct any additional surveys (beyond tiers 1-3) done based on state judgment regarding agencies most at risk of providing poor care, so that all agencies are surveyed on average every 24 months. This is to optimize the unpredictability of surveys. Finally, in tier 4, surveyors are directed to prioritize surveys of HHAs de-activated by their Medicare Administrative Contractor (MAC) for failure to bill Medicare for 12 consecutive months.

At this time, QSOG will continue to fund OASIS education coordinators (OEC) and OASIS automation coordinators (OAC). The OECs will provide technical assistance to the HHA providers in the administration of the OASIS data set. The OACs will provide technical assistance to the HHA providers on the transmission of OASIS data.

Anticipated regulatory changes for hospices in the Unified Agenda include three new rules. In addition to the CY2026 Home Health Prospective Payment System Rate Update, the Healthcare System Resiliency and Modernization has been under review with the Office of Management and Budget since October 2023 and will be boosted by Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers II. These two proposed rules will be combined to update emergency preparedness requirements for all providers and will include elements of coordination with federal, state, tribal, regional, and local emergency preparedness systems and preparedness against cyberattacks. In 2024, CMS issued a proposed rule for updating CMS oversight of AOs which LeadingAge commented on, however, no final rule has been issued and it is no longer on the Unified Agenda.