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Appendix PP Revisions in the State Operations Manual: Breaking Down Key Changes

On June 29, the Centers for Medicare & Medicaid Services (CMS) issued a major update to surveyor guidance via Quality, Safety and Oversight (QSO) memo QSO-22-19-NH to strengthen the implementation of the already-in-effect Phases 2 and 3 of the 2016 Reform of Requirements for Long-Term Care Facilities, as well as to update some guidance in response to stakeholder feedback and questions.

The wide-ranging update provides both revised guidance to surveyors (substantive as well as technical revisions) and new guidance to surveyors in the following areas of Appendix PP in the State Operations Manual:

§483.10 (Resident Rights): training video and slides. This includes significant revisions to four F-tags:

  • F557 (Respect, Dignity/Right to Have Personal Property): Clarifies how facilities should handle incidents involving mental health and substance use disorders, including the need to obtain consent for staff searches of a resident’s body or personal possessions; referrals to law enforcement; and staff training requirements on the signs, symptoms, and triggers of potential substance use.
  • F561 (Self-Determination): Includes inadvertently deleted guidance on facility smoking/nonsmoking policies, particularly the transition from a smoking to a nonsmoking facility.
  • F563 (Right to Receive/Deny Visitors): Clarifies visitation rules during communicable disease outbreaks (i.e., the need to adhere to the core principles of infection prevention while enabling maximum visitation), as well as guidance on denying access or providing supervised visitation to people who historically have brought illegal substances into the facility, including staff searches, referrals to law enforcement, and staff training requirements.
  • F582 (Medicaid/Medicare Coverage/Liability Notice): Revises guidance for two Medicare beneficiary notices, specifically the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN; form CMS‐10055) and the Notice of Medicare Non-Coverage (NOMNC; form CMS‐10123), consistent with existing Medicare Claims Processing Manual instructions.

§483.12 (Freedom From Abuse, Neglect, and Exploitation): training video and slides. This includes significant updates to five F-tags:

  • F600 (Free From Abuse and Neglect): This update addresses the following main areas:
    • Resident-to-resident abuse: Clarifies that not every resident-to-resident altercation is a case of abuse because disagreements occur in social interactions, so surveyors must determine on a case-by-case basis whether the incident meets the definition of abuse.
    • Sexual abuse: Removes the sentence, “Residents without the capacity to consent to sexual activity may not engage in sexual activity,” because it might unintentionally convey that physical intimacy is not allowed for all residents without the capacity to consent. However, it also adds that a facility must take steps to ensure that residents are protected from abuse, including evaluating the resident’s capacity to consent to sexual activity, any time that the facility has reason to suspect that the resident may lack the capacity to consent.
    • Past abuse noncompliance: Clarifies the rules for surveyors to use in determinations of past noncompliance, as well as the additional F-tags that could be cited if the facility didn’t take all appropriate remedial steps for the immediate protection of residents.
    • Neglect: Adds language to better define neglect as “the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress” and explains the circumstances that indicate when neglect has occurred vs. when it hasn’t (e.g., noncompliance under §483.25 (Quality of Care) does not automatically mean that there is neglect under F600).
    • Abuse or neglect citation templates: Adds templates for surveyors to use for the deficient practice statement for F600.
  • Psychosocial Outcome Severity Guide: training video and slides. While not part of Appendix PP, this revised guide helps surveyors consider the impact of a facility’s noncompliance on the resident’s psychosocial outcome, and how to apply these principles to cases of abuse at F600 in order to categorize a deficiency at the appropriate severity level.
  • F604 (Right to Be Free From Physical Restraints): Clarifies that “a bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently.”
  • F607 (Develop/Implement Abuse/Neglect, etc. Policies): This update includes two key areas:
    • QAPI: Adds new guidance that providers must include QAPI coordination in policies and procedures for prohibiting abuse and neglect and that these policies and procedures should direct staff how to share information with the Quality Assessment and Assurance (QAA) committee so that the QAA committee can effectively oversee facility processes and determine the need for additional systemic actions.
    • Moved citations: Adds citations (from the deleted F608) and the investigative protocol related to the failure to develop and implement written policies and procedures for posting conspicuous notice of employee rights, as well as prohibiting and preventing retaliation.
  • F608 (Reporting of Reasonable Suspicion of a Crime): Deleted. Citations previously issued under this F-tag (and their associated investigative protocols) have been moved to F607 and F609.
  • F609 (Reporting of Alleged Violations): This update provides several significant revisions, including:
    • Moved citations: Adds citations (from the deleted F608) and the investigative protocol related to the failure to ensure that suspected crimes are reported and that covered individuals are notified about their reporting responsibilities. Includes standardized language that surveyors must use to cite the failure to ensure the reporting of crimes in the deficient practice statement.
    • Reporting of suspected crimes: Updates what the facility’s policies and procedures should address with examples (e.g., orienting new staff to the reporting requirements and assuring that covered individuals are annually notified of their responsibilities in a language they understand). Also guides surveyors to investigate and document the facility’s failure to develop and/or implement policies and procedures for reporting suspected crimes, as well as what should happen if the covered individual refused to report a suspected crime to law enforcement, or the surveyor cannot verify that the report was done. 
    • Reporting of alleged violations: Clarifies reporting requirements with additional guidance on what needs to be reported and what doesn’t, including examples of each type of alleged violation, for staff-to-resident abuse; resident-to-resident altercations, including three new categories: mental/verbal conflict, sexual contact, and physical altercations; injuries of unknown source; neglect; and misappropriation of resident property and exploitation.

§483.15 (Admission, Transfer, and Discharge Rights): training video and slides. This includes revisions to the following F-tags related to facility-initiated discharges:

  • F622 (Transfer and Discharge Requirements): Clarifies specific situations, illustrating both psychosocial and physical harm, for transfers and discharges, including the facility’s responsibility:
    • When a resident is admitted for short-term skilled rehabilitation therapy services under Medicare but doesn’t feel ready to leave the facility following completion of rehab.
    • When Medicare coverage has ended but the resident continues to need long‐term care services.
    • To permit the resident to return to the facility when they are emergently transferred to acute care, including the documentation requirements if the facility instead initiates a discharge while the resident is hospitalized.
  • F623 (Notice Requirements Before Transfer/Discharge): Provides guidance on giving residents a notice of transfer or discharge prior to the transfer or discharge, including a clarification that the notice should have the specific transfer or discharge location (e.g., the new provider’s name or the residential address)—and that a change in transfer or discharge location could require the issuance of a new notice with new appeal rights.
  • F626 (Permitting Residents to Return to the Facility): Clarifies that facility policies on bed‐hold and permitting residents to return after hospitalization or therapeutic leave “apply to all residents, regardless of payment source.” Also updates the investigative procedure section of the guidance for situations when a facility does not permit a resident to return because there is no available bed or the facility says it cannot meet the resident’s needs.
  • F622, F623, and F626: Adds language to all three F-tags about against medical advice (AMA) discharges, which may be facility‐initiated discharges and will be investigated by surveyors, as appropriate, to ensure that neither the resident nor the resident representative was forced, pressured, or intimidated into leaving the facility.

§483.24 (Quality of Life): training video and slides. This removes language that suggested surveyors should automatically cite F675 at the immediate jeopardy (IJ) level, directing surveyors to consider the impacts on the resident and to review Appendix Q, “Determining Immediate Jeopardy,” for potential IJ-level concerns.

§483.25 (Quality of Care): training video and slides, including new guidance for trauma-informed care: separate training video and slides. Updated F-tags include the following:

  • F686 (Treatment/Services to Prevent/Heal Pressure Ulcers): Changes the rules for when pressure ulcer risk assessments should occur: upon admission, weekly for the first four weeks, and then quarterly (instead of monthly to reflect the current accepted standard of practice), or when a change in condition occurs.
  • F687 (Foot Care): Clarifies the need to follow proper infection prevention and control practices for foot care equipment.
  • F689 (Free of Accident Hazards/Supervision/Devices): Updates guidance in two key areas:
    • The use of electronic cigarettes (e‐cigarettes), including the need for facilities to oversee use and to address them in smoking policies, e.g., how staff will supervise resident use of e‐cigarettes, how batteries and refill cartridges will be handled, and how the facility will keep residents safe, including protecting residents who want to avoid exposure to second‐hand aerosol.
    • Safety for residents with substance use disorder, including documentation requirements if the resident leaves the facility and the facility knows about the departure. (If the resident leaves the facility without the staff’s knowledge, it’s an elopement.) Also requires the facility to assess the resident’s risk for using illicit substances in the facility, to train staff on the signs and symptoms of possible substance use, and to train staff to be prepared to address related emergencies (e.g., know how to administer opioid reversal agents like naloxone, initiate CPR as appropriate, and contact emergency medical services timely).
  • F690 (Bowel/Bladder Incontinence, Catheter, Urinary Tract Infection (UTI)): Clarifies that this tag is specific to bowel incontinence and that bowel management issues, such as constipation or impaction, fall under F684 (Quality of Care). Also makes a technical correction to the first criteria for initiating antibiotics for a UTI, changing the number 105 to 10 to the fifth power.
  • F694 (Parenteral/IV Fluids): Adds new guidance on the frequency of assessment for parenteral and IV fluids, indicating that an exact assessment timeframe is not specified but providing factors that could impact what frequency of assessment is needed (e.g., the resident’s ability to report symptoms such as pain or redness, the type of infusion, and the location of the IV on the resident’s body). Also adds information on proper infection control practices when accessing or using a resident’s IV (e.g., the use of appropriate antiseptic to scrub IV ports, needleless connectors, and hubs prior to access or use), as well as requiring facility policies and procedures to address documentation of why an IV catheter continues to be needed when it is no longer being used for IV fluid or medication.
  • F695 (Respiratory/Tracheostomy Care and Suctioning): Clarifies that the mechanical ventilation guidance in this F-tag only applies to facilities that offer this service.
  • F697 (Pain Management): Updates the guidance to address the use of opioids to meet residents’ pain needs in light of the ongoing national opioid crisis, adding definitions for medication-assisted treatment and opioid use disorder; providing strategies and resources for the use of opioids for pain management; instructing facilities to assess residents for a history of addiction or past or ongoing treatment for opioid use disorder and to evaluate for potential drug diversion if a resident reports or has signs of increased pain; and describing opioid side effects and the need for facilities to have a written policy addressing opioid overdoses.
  • F699 (Trauma-Informed Care): Adds new guidance to ensure that facilities deliver care and services that not only meet professional standards, but also use culturally competent approaches that account for resident experiences and preferences, and meet the needs of trauma survivors by minimizing triggers and/or re-traumatization (i.e., culturally competent, trauma-informed care). Key components of the new guidance include the following:
    • Definitions of key terms, including culture, cultural competency, trauma, and trauma-informed care.
    • Approaches for assessing a resident’s history of trauma and cultural preferences, including examples of trauma survivors (e.g., military veteran, history of homelessness or imprisonment, abuse survivor, etc.).
    • The requirement for the facility to identify triggers that may prompt the resident to recall the previous traumatic events and particularly triggers that may cause re-traumatization.
    • Care planning to address past trauma, including the need for the facility to collaborate with the resident, their family and friends as appropriate, and additional healthcare professionals (e.g., psychologists or other mental health professionals), as well as the need for trigger-specific interventions, including examples of what those include.
    • Surveyor use of the facility assessment to identify the facility’s resident populations with unique cultural characteristics (e.g., language, religious or cultural practices, values, and preferences). Four key elements will determine compliance with this F-tag. Did the facility:
      • Identify the cultural preferences of residents who are trauma survivors?
      • Identify a resident’s past history of trauma?
      • Identify triggers that cause re‐traumatization?
      • Use approaches that are culturally competent and/or are trauma‐informed?
  • F656 (Develop/Implement Comprehensive Care Plan): While this F-tag falls under §483.21 (Comprehensive Resident-Centered Care Plan), CMS links the training to F699 because the agency is adding a new guidance to ensure that a resident’s comprehensive care plan includes approaches to address the resident’s cultural preferences and reflects trauma‐informed care when appropriate. Care planning to address a resident’s history of trauma should show evidence that the facility collaborated as needed to understand the resident’s trauma experience, including developing trigger-specific interventions. Care planning to address cultural needs and preferences may need to consider communication, food preparation, clothing preferences, physical contact or provision of care by a person not of the same sex, and cultural etiquette (e.g., voice volume and eye contact). When investigating culturally competent, trauma-informed care, surveyors will address concerns as follows:
    • F656: The development or implementation of culturally competent and/or trauma-informed care plan interventions;
    • F699: Outcomes or potential outcomes to the resident related to culturally competent and/or trauma-informed care;
    • F726: The knowledge, competencies, or skill sets of nursing staff to provide care or services that are culturally competent and trauma-informed.
    • F742: Treatment and services for residents with a history of trauma and/or history of post-traumatic stress disorder (PTSD).
  • F700 (Bedrails): Clarifies that facilities should attempt to use alternatives prior to the use of bed rails, not just prior to the installation of bed rails. Updates include the following:
    • Includes links to resources and guidance on appropriate alternatives (e.g., roll guards, foam bumpers, and lowering the bed and using concave mattresses to reduce rolling off the bed).
    • Makes an allowance for when no alternative exists, indicating what information must be documented in the medical record (e.g., purpose of bedrail and notation that no appropriate alternative exists; an entrapment risk assessment of the resident and the bedrail; and an assessment of the risks vs. benefits that is reviewed with the resident and resident representative, who must give informed consent).
    • Emphasizes that facilities must have a process for assessing whether beds (and their rails) are appropriate for the residents using them.
    • Clarifies that bedrails aren’t required to be removed or disabled when not in use. “However, if bed rails are not appropriate for the resident and the facility chooses to keep the bed rail on the bed, but in the down position, raising the rail even for episodic use during care would be considered noncompliance if all of the requirements (assessment, informed consent, appropriateness of bed, and inspection and maintenance) are not met prior to the episodic bedrail use for the resident,” says CMS.

§483.30 (Physician Services): training video and slides. This updates the table in F712 (Physician Visits—Frequency, Timeliness, Alternate Non-Physician practitioners (NPPs)) to make it easier to understand what NPPs can—or cannot do—in terms of the initial comprehensive visit, admission orders, other required visits and orders, other medically necessary visits and orders, and Medicare Part A certifications and recertifications.

§483.35 (Nursing Services): training video and slides. This revises the following F-tags, particularly to assist surveyors to use PBJ data to identify low staffing concerns for deeper investigation:

  • F725 (Sufficient Nursing Staff): Instructs surveyors to access the PBJ Staffing Data Report, which contains information about overall direct-care staffing levels, including nurse staffing, from the Certification and Survey Provider Enhanced Reports (CASPER) reporting system and use it to identify sufficient nursing staff concerns. If concerns are identified, surveyors will investigate using the Sufficient and Competent Staffing Critical Element Pathway and updated probes included in F725.
  • F727 (RN 8 Hours/7 Days/Week, Full-Time Director of Nursing (DON)): Instructs surveyors to use the PBJ Staffing Data Report to determine whether facilities have an RN onsite each day. If concerns are identified, surveyors will investigate using the Sufficient and Competent Staffing Critical Element Pathway and updated probes included in F727. Note: Due to the way the report is structured, CMS training documents carry over previous guidance that facilities that report the absence of an RN for four or more days in a quarter will be cited at F727. However, this is not included in the draft Appendix PP guidance, and CMS notes that it expects that surveyors will consider issuing a citation “when a minimum of one day is identified to not meet the nurse staffing requirement for both a Registered Nurse and licensed nursing staff.”
  • F729 (Nurse Aide Registry Verification, Retraining): Updates the survey procedure to instruct surveyors to review at least five nurse aide personnel files, if concerns are identified with nurse aide services at F725 and F726 (Competent Nurse Staff), including any specific staff members with whom concerns were identified.
  • F732 (Posted Nurse Staffing Information): Adds new survey procedures and probes, requiring surveyors to use observations and record reviews to ensure compliance, as well as adding a new key element of noncompliance: failure to make daily staffing available to the public upon request.

§483.40 (Behavioral Health Services): training video and slides. This includes significant changes to two F-tags:

  • F740 (Behavioral Health Services): Changes include the following:
    • Updates the definitions of mental disorder and substance use disorder.
    • Ties the behavioral health care needs of residents with a substance use disorder or other serious mental disorder to the facility assessment.
    • Adds a reference to Preadmission Screening and Resident Review (PASARR) requirements.
    • Adds new language regarding the use of behavioral contracts, including examples of issues that they may address.
    • Provides updated or new clinical information about depression, anxiety and anxiety disorders, schizophrenia, and bipolar disorder. The schizophrenia information includes the requirement that “schizophrenia must be diagnosed by a qualified practitioner, using evidence-based criteria and professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders – Fifth edition (DSM-5), and documented in the resident’s medical record.”
    • Adds resources related to behavioral health care and services.
  • F741 (Sufficient/Competent Staff—Behavioral Health Needs): Changes include the following:
    • Adds residents with a history of trauma and/or PTSD to the requirement that facilities ensure that they have sufficient staff members who possess the basic competencies and skills sets to meet the behavioral health needs of residents for whom the facility has assessed and developed care plans. This requirement already included residents with mental or psychosocial disorders and substance use disorders.
    • Updates the definition for mental disorder and adds definitions for substance use disorder, trauma, and PTSD.
    • Adds guidance related to how residents with a substance use disorder or other serious mental disorder must be part of the facility assessment.
    • Adds examples of nonpharmacological interventions for residents diagnosed with mental health and/or substance use disorders.

§483.45 (Pharmacy Services): training video and slides. This includes significant updates to three F-tags:

  • F755 (Pharmacy Services/Procedures/Pharmacist/Records): Revises guidance about the disposal of fentanyl transdermal patches.
  • F757 (Drug Regimen Is Free From Unnecessary Drugs) and F758 (Free From Unnecessary Psychotropic Medications/PRN Use): Updates the key elements of noncompliance for both sections to direct surveyors to consider whether a facility is compliant with F881 (Antibiotic Stewardship Program) if there is evidence of unnecessary antibiotic use.
  • F758 (Free From Unnecessary Psychotropic Medications/PRN Use): Updates include the following:
    • Revises the definitions for dose, duplicate therapy, and excessive dose.
    • Adds information about using a facility’s QAPI program to potentially track the facility’s use of certain classes of medications, such as antipsychotics, through reports from the long-term care pharmacist to identify trends and reduce adverse events.
    • Clarifies that the “use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented.” Psychotropic medication requirements apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety, and hypnotic) listed in §483.45(c)(3) without exception because the risks associated with psychotropic medications are present regardless of the indication for use (e.g., nausea, insomnia, itching).
    • Clarifies that other medications not classified as anti-psychotic, anti-depressant, anti-anxiety, or hypnotic medications can also affect brain activity and should not substitute for a psychotropic medication “unless prescribed with a documented clinical indication consistent with accepted clinical standards of practice and in accordance with §483.45(d)(4).” These other medications include antihistamines, anti-cholinergic medications, and central nervous system agents used to treat conditions such as seizures, mood disorders, pseudobulbar affect, and muscle spasms or stiffness. When the documented use for these other medications appears to be as a substitution for a psychotropic medication rather than for the original or approved indication, the psychotropic medication requirements apply.
    • Instructs facilities to monitor residents who take these other medications for any adverse consequences, specifically increased confusion or over-sedation.
    • Updates the language for gradual dose reductions to indicate that reduction should occur in modest increments over a period of time that is adequate to minimize withdrawal symptoms and to monitor for symptom recurrence.
    • Adds language to address the potential misdiagnosis of residents with a condition for which antipsychotics are an approved use, such as a new diagnosis of schizophrenia—a diagnosis that excludes the resident from the long‐stay antipsychotic quality measure. Investigation of a potential misdiagnosis will include a review of F658 to determine if the practitioner’s diagnosing practices meet professional standards and F641 to determine if the facility completed an assessment that accurately reflects the resident’s status. Language in these F-tags was added to align with this update to F758. 
    • Directs surveyors to evaluate if a resident experienced psychosocial harm related to medication side effects of medications, as well as to look at whether side effects such as sedation, lethargy, agitation, mental status changes, or behavior changes affected the resident’s abilities to perform activities of daily living (ADLs), to maintain usual social patterns, and/or to think or concentrate.

§483.60 (Food and Nutrition Services): training video and slides. This includes the following updates to F812 (Food Procurement, Store/Prepare/Serve—Sanitary):

  • Addresses concerns related to culture change in nursing homes, particularly dining practices.
  • Reorganizes and updates key guidance, including:
    • Separates food distribution and food service operations in the guidance.
    • Clarifies the definitions of food distribution and food service.
    • Provides details on staff hair restraint use and staff glove use.

§483.70 (Administration): arbitration training video and slides, and PBJ data submission separate training video and slides. This updates the following F-tags:

  • F847 (Enter Into Binding Arbitration Agreements) and F848 (Select Arbitrator/Venue, Retention of Agreements):Updates requirements that a facility must comply with if it chooses to ask a resident or their representative to enter into an agreement for binding arbitration. This includes prohibiting facilities from requiring that residents sign a binding arbitration agreement as a condition of admission or as a requirement to receiving continued care at that facility.
  • F851 (Payroll-Based Journal): Updates the guidance to make failure to submit the required staffing information based on payroll data in a uniform format a key element of noncompliance. The facility’s failure to submit PBJ data as required will be reflected on its CASPER report and will result in a deficiency citation.

§483.75 (Quality Assurance and Performance Improvement (QAPI)): training video and slides. This includes new and revised guidance for the following F-tags:

  • F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt): Adds new requirements for the QAPI plan and program to ensure that nursing homes (including multi-unit chains) implement a comprehensive QAPI program that addresses all of the care and unique services that a facility provides. Changes include the following:
    • Adds definitions for governing body, indicators, QAPI, and QA.
    • Details minimum program requirements, including the need to:
      • Address all care and management systems.
      • Include clinical care, quality of life, and resident choice concerns.
      • Use the best available evidence to define measure indicators of quality and facility goals that reflect care processes and facility operations that are demonstrated to predict desired outcomes for residents.
      • Reflect the complexities, unique care, and services that the facility provides.
    • Defines governorship and leadership requirements for the program.
    • Provides examples of when disclosure of information may be needed for surveyors to determine compliance.
    • Instructs surveyors to use the QAPI and QAA Review facility task plus the Appendix PP guidance to investigate concerns and determine compliance.
    • Updates the facility elements of noncompliance.
  • F866 (QAPI/QAA Data Collection and Monitoring): Relocates the requirements from this tag into F867 (QAPI/QAA Improvement Activities).
  • F867 (QAPI/QAA Improvement Activities): Add requirements that address how a facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects. This includes the following:
    • Updates multiple definitions, including adverse event, high-risk areas, incidence, indicator, medical error, near miss, prevalence, systematic, and systemic.
    • Addresses the role of feedback as a data source.
    • Requires that the facility:
      • Collect and monitor data reflecting its performance.
      • Address how data will be identified, as well as the frequency and methodology for collecting and using data from all departments.
      • Establish priorities for performance improvement activities that focus on resident safety, health outcomes, autonomy, choice, and quality of care, as well as high‐risk, high‐volume, and/or problem‐prone areas.
      • Have policies and procedures in place for developing, monitoring, and evaluating performance indicators, including how and with what frequency that will be done.
      • Have systems in place and implement actions to improve performance, including implementing corrective actions, measuring the success of these actions, and tracking their performance. This should include changes at the systems level to prevent quality of care, quality of life, or safety problems.
      • Develop and implement policies and procedures addressing the use of systematic approaches to assist in determining underlying causes of problems that impact larger systems (e.g., root cause analysis, reverse tracker methodology, or healthcare failure and effects analysis).
      • Track medical errors and adverse resident events; analyze the cause of identified errors or events; implement corrective actions, including the education of staff, residents, resident representatives, and family members; and monitor to ensure that the desired outcome has occurred and is maintained.
      • Conduct at least one improvement project annually that focuses on high‐risk or problem‐prone areas, identified by the facility through data collection and analysis.
    • Instructs surveyors to use the QAPI and QAA Review facility task plus the Appendix PP guidance to investigate concerns and determine compliance.
  • F868 (QAA Committee): Identifies the infection preventionist as a required active member of the facility’s QAA committee who must report on the infection prevention and control program (e.g., facility process and outcome surveillance, occupational communicable diseases, or the antibiotic stewardship program), as well as on infections identified under the program (e.g., healthcare‐associated infections). The IP should attend each QAA meeting, and if they can’t, another staff member should report on their behalf.

§483.80 (Infection Control): training video and slides. This addresses significant changes at the following F-tags:

  • F880 (Infection Prevention and Control): Adds guidance that facilities must demonstrate measures (e.g., a documented water management program) to minimize the risk of Legionella and other opportunistic waterborne pathogen outbreaks in building water systems.
  • F881 (Antibiotic Stewardship Program): Removes the provision of feedback to prescribing practitioners regarding antibiotic resistance data, their antibiotic use, and their compliance with facility antibiotic use protocols as a required element for compliance.
  • F882 (Infection Preventionist Qualifications/Role): Changes include the following:
    • Requires that facilities designate one or more people as the infection preventionist who is responsible for meeting the regulatory requirements of the infection prevention and control program, including assessing, developing, implementing, monitoring, and managing the program.
    • While there is no specified number of hours that the IP must work, they are required to work at least part-time onsite at the facility.
    • Sets professional training requirements for the infection preventionist, as well as requirements for specialized training in infection prevention and control.

§483.85 (Compliance and Ethics Program): training video and slides. This establishes new program requirements in F895 (Compliance and Ethics Program), including a new intent statement and definitions; requirements for all facilities and additional requirements for operating organizations with five or more facilities; and training requirements.

§483.90 (Physical Environment): training video and slides. This updates F919 (Resident Call System) to require that residents be able to access the communication system from the bedside, the toilet, or bathing facilities and either directly call a staff member or call a centralized staff work area.

In addition, CMS is making new recommendations—but not requirements—for resident rooms under §483.90. Currently, bedrooms in facilities that receive approval of construction or reconstruction plans by state and local authorities or are newly certified after Nov. 28, 2016, must accommodate no more than two residents, while older facilities can have up to four residents per room. However, CMS is now “urging providers to consider making changes to their physical environment to allow for a maximum of double occupancy in each room,” says the agency. “Additionally, we encourage facilities to explore ways in which they can allow for more single occupancy rooms for residents.”

§483.95 (Training Requirements): training video and slides. This adds a wealth of significant new training guidance under the following F-tags:

  • F940 (Training Requirements—General): Requires that facilities develop, implement, and maintain effective training programs for all new and existing staff (including contract workers and volunteers), as well as determine the amount and types of training necessary based on the facility assessment.
  • F941 (Communication Training): Requires that facilities provide mandatory training for direct-care staff.
  • F942 (Resident’s Rights Training): Specifies that facilities must develop and implement an ongoing education program related to resident rights and facility responsibilities, supporting current scope and standards of practice and ensuring that all facility staff understand and foster the rights of each nursing home resident.
  • F944 (QAPI Training): Requires that facilities conduct mandatory training for all staff on the facility’s QAPI program, including the goals and various elements of the program, the staff’s role in the program, and how to communicate concerns, problems, or opportunities for improvement to the QAA committee. Training should be updated as needed, and staff participation in training should be tracked.
  • F945 (Infection Control Training): Mandates that facilities develop, implement, and permanently maintain an effective training program for all staff. Training should address the standards, policies, and procedures for the infection prevention and control program, and training needs may change due to changes to the facility’s population, community infection risk, national standards, staff turnover, physical environment, or facility assessment. All training curricula should detail learning objectives, performance standards, and evaluation criteria, and address potential risks to residents, staff, and volunteers if procedures are not followed. Facilities should track staff participation in and retention of training.
  • F946 (Compliance and Ethics Training): Requires that each facility’s operating organization (the individual or entity that operates the facility) provide a training program or another practical way to effectively communicate the standards, policies, and procedures of the compliance and ethics program to all staff. Facilities should track staff participation in the required trainings, and annual staff training must be conducted by operating organizations that operate five or more facilities.
  • F947 (Required Inservice Training for Nurse Aides): Mandates that all facilities develop, implement, and permanently maintain an inservice training program for nurse aides. The program must be appropriate and effective as determined by nurse aide performance reviews and the facility assessment, and when able, each nurse aide should be evaluated based on individual performance.
  • F949 (Behavioral Health Training): Specifies that facilities must develop, implement, and maintain behavioral health training for all staff. The training, which must be appropriate and effective as determined by staff need and the facility assessment, should include competencies and skills necessary to provide the following:
    • Person‐centered care that reflects the resident’s goals for care.
    • Interpersonal communication that promotes mental and psychosocial well‐being.
    • Meaningful activities that promote engagement and positive relationships.
    • An environment or atmosphere that promotes mental and psychosocial well‐being.
    • Individualized, nonpharmacological approaches to care.
    • Care tailored to the individual needs of residents diagnosed with a mental, psychosocial, or substance use disorder; a history of trauma and/or post‐ traumatic stress disorder; or other behavioral health condition.
    • Care specific to the individual needs of residents diagnosed with dementia.

Surveyors will begin using the updated Appendix PP and the revised Psychosocial Outcome Severity Guide to determine compliance beginning Oct. 24, 2022, and CMS will release updated critical element pathways and survey task tools by that date as well.

CMS is also revising Chapter 5, “Complaint Procedures,” of the State Operations Manual, as well as the related Exhibit 23, to clarify the timeliness of state investigations and requirements for the state to communicate with complainants. CMS will assess the survey backlog and establish a target implementation date for meeting these new investigation timelines.

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