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In November 2024, the Centers for Medicare and Medicaid Services (CMS) released Revised Long-Term Care (LTC) Surveyor Guidance. The memo included significant changes to guidance in Appendix PP. On Friday, March 7th CMS released QSO-25-14-NH. This memo updates the previously released guidance from November 18, 2024, and January 15, 2025, which included significant updates to surveyor guidance. Also contained in the memo, CMS pushed the effective date from March 24, 2025 to April 28, 2025.
The memo outlines new CMS guidance incorporating health equity data into Quality Assurance and Performance Improvement. F867 has been modified to include a definition for health equity. “Health equity” refers to the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.”
Additional Key Takeaways:
- Facilities must collect feedback on concerns related to health equity.
- Within their data collection and monitoring systems, facilities must incorporate the review and analysis of data on the outcomes of sub-populations to address health equity issues.
- When analyzing data on medical errors and adverse events, facilities should evaluate factors that impact health equity, such as race, sexual orientation, socioeconomic status, or preferred language.
- When establishing priorities for performance improvement activities, consideration should be given to factors that impact health equity.
- The updated critical elements pathway removes the section where surveyors assess the policies and procedures. Instead, if surveyors find a concern related to the practice of the QAPI team, they are advised to review the policies and procedures.
- Surveyors must now ask the medical director if they are aware of each systems-level area of non-compliance identified.
Additional information can be found in AHCA’s Action Tool Quality Assurance and Performance Improvement. This action tool includes information and action items to help ensure your facility’s compliance.
As a result of the updated CMS memo, additions and extending the effective date for the Appendix PP changes have been made to AHCA’s webinar, AHCA Education: Preparing for Upcoming CMS Guidance Changes: Key Updates and Action Items for Compliance. This webinar is on demand and available free to AHCA/NCAL members and $65 non-members. Remember if you are a member of Washington Health Care Association, you are also a member of AHCA and take advantage of this free resource. Please send questions to regulatory@ahca.org, and email educate@ahca.org if you need assistance with registering.
Thank you to AHCA for the development of the information contained within this communication and the associated tools. If you have questions, please contact Elena Madrid, Executive Vice President of Education and Regulatory Affairs.
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