Federal regulators are ramping up scrutiny of nursing homes in 2026, and while individual policy updates may appear modest, together they signal a broader push toward tighter oversight and stronger accountability.
At the center of the shift is the Centers for Medicare & Medicaid Services’ growing use of a “hybrid method” to calculate quality measures. The approach combines Minimum Data Set (MDS) information with Medicare claims data — a move designed to close reporting gaps identified in federal watchdog reviews.
According to industry consultant Pat Newberry of SimpleLTC, more hybrid measures are likely on the way.
“We’re not through with these new hybrid claims measures,” Newberry said during a recent presentation. “We’re going to start seeing these become more and more prevalent.”
Antipsychotic Use Under the Microscope
The antipsychotic medication quality measure has already undergone significant revisions. A 2021 Office of Inspector General report found discrepancies between MDS coding and the number of residents receiving antipsychotic drugs.
In response, CMS rolled out changes in phases. Survey updates and new F-tags were introduced in 2022. A focused audit on schizophrenia diagnoses followed in 2023, affecting many facilities’ Five-Star ratings. By 2025, the agency consolidated and updated enforcement tags tied to antipsychotic oversight.
Now, the hybrid method allows CMS to identify antipsychotic use through pharmacy or physician claims — even if the medication wasn’t captured on the MDS. Facilities must also ensure that exclusion diagnoses, such as schizophrenia, appear in both claims and MDS records to qualify.
Newberry emphasized that accurate reporting will require coordination across nursing, admissions, billing teams, physicians, and hospital partners.
Falls Measure Gets Hybrid Treatment
The falls with major injury quality measure is also shifting to hybrid data collection under the Skilled Nursing Facility Quality Reporting Program. Federal reviewers previously found that a significant share of serious fall injuries documented in hospital or physician claims were not reflected on the MDS.
Going forward, CMS will rely on hospital and emergency department claims, along with ICD-10 diagnosis and external cause codes, to identify qualifying injuries. Facilities may need to update assessments if hospital records confirm a major injury after initial documentation.
In addition, falls now factor into selection criteria for the Special Focus Facility program, adding another quality-related indicator to the review process.
Deadlines Still Matter
CMS pulls MDS data on the last Sunday of the month following each quarter’s end. Corrections must be submitted before that date to affect public quality measure calculations. Later changes may be required for compliance but won’t alter published results.
Taken together, the updates suggest a clear message from regulators: more data cross-checking is coming — and facilities will need to be ready.
