After a period of pandemic-related forbearance, the Centers for Medicare & Medicaid Services (CMS) is “picking up its game” on survey enforcement, according to industry experts. The renewed focus signals a new era of scrutiny for nursing home operators, who are being cautioned to prioritize compliance and meticulous documentation to avoid significant financial and operational penalties.
The shift in regulatory climate was a key topic at Zimmet Healthcare’s annual user conference. Alicia Cantinieri, Zimmet Healthcare’s Director of Clinical Reimbursement & Regulatory Compliance for Healthcare, emphasized that CMS is now “in a heavy compliance era, more than usual,” and that a pause on auditing during the pandemic has given way to a concerted effort to “catch up.”
“For years, nobody was audited, and now they’re coming around and doing those audits. So things we might have thought were OK because our claims were being paid, they’re now coming back to us and saying, ‘No, that wasn’t compliant,’” Cantinieri told attendees. “Lots of dollars being recouped based on that.”
This heightened enforcement is not just about catching up; it’s about a fundamental shift in how CMS is approaching its oversight role. With the April 2025 activation of 900 pages of new surveyor guidance, regulators are focusing on several key areas, including assessment accuracy, staffing data, and the inappropriate use of antipsychotics.
Accuracy is Everything: A Closer Look at F-Tag 641
Central to the new enforcement push is F-Tag 641, which governs the accuracy of resident assessments. CMS is no longer just looking for isolated mistakes. The agency is now defining a “pattern” of inaccuracy as just three mistakes, a significant change that could lead to more serious consequences. Cantinieri warned that when these patterns are found, CMS is more likely to bypass the state office and refer problems directly to the Office of the Inspector General (OIG), triggering an investigation.
The penalties for these infractions have also been codified with specific “price tags.” An individual who “willfully and knowingly” certifies a false statement in a resident assessment could face a civil money penalty of up to $1,000 for each assessment. If that individual is found to be a “mastermind” who directed someone else to file falsely, the penalty jumps to $5,000 for each assessment, a stark reminder of the financial stakes involved.
Staffing and Antipsychotics Under the Microscope
Another major focus for surveyors is the data submitted through the Payroll-Based Journal (PBJ). CMS is leveraging this data to ensure facilities are meeting staffing requirements and that staffing levels are not tied to the misuse of medications. As Cantinieri pointed out, “There are penalties not just on survey for not submitting your PBJ data but there’s penalties in your Five Star. Everything is connected to each other.”
The use of antipsychotic medications is a particularly sensitive area that CMS is “not letting go.” The agency has been concerned that some nursing homes are misdiagnosing residents with schizophrenia to mask high antipsychotic use rates. In response, CMS has begun conducting off-site audits of schizophrenia coding and will adjust a facility’s quality measure star ratings if inaccurate coding is found. This targeted approach is part of a broader push to ensure that these powerful drugs are used only when medically necessary, not as a form of chemical restraint.
According to a 2021 report by the Office of the Inspector General (OIG), nearly one-third of residents reported in the MDS as having schizophrenia—a diagnosis that exempts them from CMS’s antipsychotic quality measure—did not have any Medicare service claims for that diagnosis. This statistic underscores the seriousness of CMS’s concern and the reason behind its renewed focus on these audits.
Surprise Inspections and Enhanced Precautions
Surveyors are also employing more aggressive tactics. Amy Greer, Zimmet’s Director of Quality Innovations, noted that some survey teams are skipping pre-conference meetings and heading straight for the kitchen in a “surprise attack” to check for infection control compliance. A single staff member without a hairnet or gloves can be an immediate citation. This shift, combined with new requirements for enhanced barrier precautions, indicates a more hands-on, unannounced approach to inspections.
The message for nursing home operators is clear: The regulatory landscape is changing, and the time for a thorough review of internal processes, from documentation to staffing, is now. In the coming months, a new wave of citations is expected as surveyors catch up on audits and begin to enforce these new guidelines with newfound vigor. The documentation is vital.
