On March 24, 2025, new and revised surveyor guidance, as well as revised critical element pathways, will go into effect during survey, according to the Jan. 16, 2025 Quality, Safety, and Oversight memo QSO-25-12-NH, which revises and replaces the Nov. 18, 2024 memo QSO-25-07-NH. These revisions to Appendix PP of the State Operations Manual and the survey tools are extensive and numerous.
The following series of charts can help the director of nursing services (DNS) and other nurse leaders better understand the scope of the updates as they prepare:
18 F-tags With Unique Substantive Revisions Not Related to Use of MDS Section GG
Note: The following key updates are highlights and not meant to be comprehensive summaries of all changes in each F-tag.
F605* (Right to Be Free From Chemical Restraints/Unnecessary Psychotropic Medications), which combines the current F605 with the current F758 Key updates:
| F620*** (Admission Agreement), which is currently called Admissions Policy Key updates:
|
F627!, *** (Inappropriate Transfer or Discharge), which combines components of the current F622, F624, F626, F660, and F661 Key updates:
| F628!, *** (Transfer/Discharge Process), which combines components of the current F622, F623, F625, and F661 Key updates:
|
F641* (Accuracy/Coordination/Certification of Assessments), which combines the current F641 with the current F642 Key updates:
| F658* (Services Provided Meet Professional Standards) Key updates:
|
F678^ (Cardio-Pulmonary Resuscitation (CPR)) Key updates:
| F697 (Pain Management)** Key updates:
|
F725 (Sufficient Nursing Staff) Key updates:
| F727 (RN 8 Hrs/7 Days/Wk, Full Time DNS) Key updates:
|
F732 (Posted Nurse Staffing Information) Key updates:
| F757* (Drug Regimen Is Free From Unnecessary Medications) Key updates:
|
F841* (Responsibilities of Medical Director) Key updates:
| F851 (Payroll-Based Journal) Key updates:
|
F867 (QAPI/QAA Improvement Activities) Key updates:
| F880 (Infection Prevention and Control) Key updates:
|
F887 (COVID-19 Immunization) Key updates:
| F918 (Bedrooms Equipped/Near Lavatory/Toilet) Key updates:
|
! New F-tag
* Covered in the training “Chemical Restraints, Unnecessary Psychotropic Medications, Accuracy of Assessment, and Professional Standards” in the Long-Term Care Appendix PP Regulatory and Interpretive Guidance Updates – Effective February 2025 course available free with e-mail registration at the CMS Quality, Safety, and Education Portal (QSEP).
** Covered in the training “Pain Management” in the QSEP course.
*** Covered in the training “Admission, Transfer and Discharge” in the QSEP course.
^ Also see the below chart “F-tags With Revised Instructions for Surveyors Related to Psychosocial Harm.”
9 Removed/Depopulated F-tags
F622 (Transfer and Discharge Requirements) | Regulatory requirements relocated to F627 and F628. |
F623 (Notice Requirements Before Transfer/Discharge) | Regulatory requirements relocated to F628. |
F624 (Preparation for Safe/Orderly Transfer/Discharge) | Regulatory requirements relocated to F627. |
F625 (Notice of Bed Hold Policy Before/Upon Transfer) | Regulatory requirements relocated to F628 |
F626 (Permitting Residents to Return to Facility) | Regulatory requirements relocated to F627. |
F642 (Coordination/Certification of Assessment) | Regulatory requirements relocated to F641. |
F660 (Discharge Planning Process) | Regulatory requirements relocated to F627. |
F661 (Discharge Summary) | Regulatory requirements relocated to F628 and F627. |
F758 (Free from Unnecessary Psychotropic Meds/PRN Use) | Regulatory requirements relocated to F605. |
F-tags With Substantive Revised Guidance Related to the Transition to MDS Section GG (Functional Abilities)
F604 (Right to Be Free From Physical Restraints) | A deficiency categorization example of Severity Level 4 noncompliance (immediate jeopardy to resident health or safety) is updated to note that the resident required substantial/maximal assistance. |
F637 (Comprehensive Assessment After Significant Change) | An example of decline is updated to use section GG language to show when a decline in at least one ADL physical functioning area counts toward a significant change in status. In addition, an example of improvement is updated to use section GG language to show when an improvement in at least one ADL physical functioning area counts toward a significant change in status. |
F676 (Activities of Daily Living (ADLs)/ Maintain Abilities) | Revisions at F677 apply. |
F677 (ADL Care Provided for Dependent Residents) | The terms that surveyors will use to evaluate a resident’s ADLs and determining whether a resident’s abilities have declined, improved, or stayed the same within the last twelve months are updated to be consistent with section GG. |
F700 (Bedrails) | A deficiency categorization example of Severity Level 4 noncompliance (immediate jeopardy to resident health or safety) is updated to note that the resident required substantial/maximal assistance. |
Note: Some of these F-tags have additional minor revisions (e.g., a changed F-tag in a reference) or nonsubstantive revisions.
F-tags With Revised Instructions for Surveyors Related to Psychosocial Harm
Revised note: In addition to actual or potential physical harm, always observe for visual cues of psychosocial distress and consider whether psychosocial harm has occurred when determining severity level (See guidance on Severity and Scope Levels and Psychosocial Outcome Severity Guide located in the Survey Resources zip file located at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes) |
F678 (CPR) |
F684 (Quality of Care) |
F686 (Treatment/Services to Prevent/Heal Pressure Ulcers) |
F688 (Increase/Prevent Decrease in ROM/Mobility) |
F690 (Bowel/Bladder Incontinence, Catheter, UTI) |
F692 (Nutrition/Hydration Status Maintenance) |
F693 (Tube Feeding Management/Restore Eating Skills) |
F756 (Drug Regimen Review, Report Irregular, Act On) |
F761 (Label/Store Drugs & Biologicals) |
F849 (Hospice Services) |
Revised note: Always observe for visual cues of psychosocial distress and consider whether psychosocial harm has occurred when determining severity level (See guidance on Severity and Scope Levels and Psychosocial Outcome Severity Guide located in the Survey Resources zip file located at https://www.cms.gov/medicare/provider-enrollmentand-certification/guidanceforlawsandregulations/nursing-homes). |
F695 (Respiratory/Tracheostomy Care and Suctioning) |
F698 (Dialysis) |
Note: Among these F-tags, F678 is the only citation with significant substantive revisions other than this note update. (See above chart “15 F-tags With Unique Substantive Revisions Not Related to Use of MDS Section GG.”) The rest have minor revisions (e.g., a changed F-tag in a reference) or nonsubstantive revisions.
F-tags With Minor or Nonsubstantive Revisions
F550 (Resident Rights/Exercise of Rights) | F560 (Right to Refuse Certain Transfers) |
F562 (Immediate Access to Resident) | F621 (Equal Practices Regardless of Payment Source) |
F689 (Free of Accident Hazards/Supervision/Devices) | F726 (Competent Nursing Staff) |
F728 (Facility Hiring and Use of Nurse) | F729 (Nurse Aide Registry Verification, Retraining) |
F730 (Nurse Aide Performance Review – 12Hr/Year Inservice) | F731 (Waiver‐Licensed Nurses 24Hr/Day and RN Coverage). Note: The regulation text does include substantive changes to make Appendix PP consistent with the updated regulatory language in §483.35(f) and §483.35(g) required by the 2024 Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule. However, there are no substantive changes anywhere in the guidance itself. |
F740 (Behavioral Health Services) | F741 (Sufficient/Competent Staff‐Behavioral Health Needs) |
F743 (No Pattern of Behavioral Difficulties Unless Unavoidable) | F744 (Treatment/Service for Dementia) |
F771 (Blood Blank and Transfusion Services) | F772 (Lab Services Not Provided On‐Site) |
F776 (Radiology/Other Diagnostic Services) | F779 (X‐Ray/Diagnostic Report in Record‐Sign/Dated) |
F812 (Food Procurement, Store/Prepare/Serve ‐ Sanitary) | F826 (Rehab Services ‐ Physician Order/Qualified Person) |
F836 (License/Comply w/Fed/State/Local Law/Prof Standards) | F842 (Resident Records ‐ Identifiable Information) |
F843 (Transfer Agreement) | F845 (Facility Closure‐Administrator) |
F846 (Facility Closure) | F847 (Enter Into Binding Arbitration Agreements) |
F911 (Bedroom Number of Residents) | — |
Revised Critical Element Pathways
Pathway | F-tags at Risk |
Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) Review | QAPI Program Policies & Procedures, Activities, Analysis and Action: F867 Investigation of Identified Non-Compliance at the Systems Level: F865 F841 QAA Committee: F868 QAPI Program, Plan, Disclosure, and Governance and Leadership: F865 |
Pain Recognition and Management Critical Element Pathway | Critical Element Decisions: F697 F655 F636 F637 F641 F656 F657 Other Tags, Care Areas (CA), and Tasks (Task) to Consider:Advance Directives (CA), Choices (CA), Notification of Change F580, Accommodation of Needs (Environment Task), Abuse and Neglect F600, Professional Standards F658, Related Quality of Care (e.g., Dental, Hospice, Pressure Ulcers, Positioning/Mobility/ROM), Unnecessary Medications (CA), Physician Supervision F710, Pharmacy Services F755, Medical Director F841, Resident Records F842. |
Respiratory Care Critical Element Pathway | Critical Element Decisions: F695 F826 F715 F880 F655 F636 F637 F641 F656 F657 Other Tags, Care Areas (CA), and Tasks (Task) to Consider:Dignity (CA), Right to be Informed and Make Treatment Decisions F552, Notification of Change F580, Physician Delegation to Therapist F715, Accommodations of Needs (Environment Task), Choices (CA), Right to Refuse F578, Pressure Ulcer (CA), Nutrition (CA), Hydration (CA), Sufficient and Competent Staffing (Task), Rehab Services-Physician Order/Qualified Person F826, Facility Assessment F838, Medical Director F841, QAA/QAPI (Task), Maintenance of and safe operating equipment F908. |
Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway | Critical Elements Decisions: F757 F605 F756 F881 F552 F841 F655 F636 F637 F641 F656 F657 F658 Other Tags, Care Areas (CA), and Tasks (Task) to Consider: Notification of Change F580, , Choices (CA), Activities (CA), Social Services F745, Admission Orders F635, Pain (CA), General Pathway (CA) for Diabetic Management, Dementia Care (CA), ADLs (CA), Urinary Incontinence (CA), Behavioral-Emotional Status (CA), Nutrition (CA), Hydration (CA), Sufficient and Competent Staffing (Task), Physician Services F710, F711, Pharmacy Services F755, Medical Director F841, Antibiotic Stewardship Program (Infection Control Task), QAPI/QAA (Task). |
Hospitalization Critical Element Pathway | Critical Element Decisions: The relevant outcome tag in Quality of Life, Quality of Care, or if no specific outcome tag, F684 F627 F628 F655 F636 F637 F641 F656 F657 Other Tags, Care Areas (CA), and Tasks (Task) to Consider: Advance Directives (CA), Notification of Change F580, Dignity (CA), Informed Treatment Decisions F552, Choices (CA), Accommodation of Needs (Environment Task), Admission Orders F635, Professional Standards F658, QOL F675, Behavioral-Emotional Status (CA), Nutrition (CA), Hydration (CA), Sufficient and Competent Staffing (Task), Physician Services F710, Medical Director F841, Infection Control (Task), Facility Assessment F838, Resident Records F842, QAPI/QAA (Task). |
Accidents Critical Element Pathway | Critical Element Decisions: F689 F700 F909 F655 F636 F637 F641 F656 F657 Other Tags, Care Areas (CA) and Tasks (Task) to Consider: Smoking Policies F926, Notification of Change F580, Restraints (CA), Abuse (CA), Right to be Informed F552, Choices (CA), Right to Participate in Planning Care F553, Environment Task, Admission Orders F635, Professional Standards F658, General Pathway (CA), ADLs (CA), Behavioral-Emotional Status (CA), Physician Supervision F710, Unnecessary Medications (CA), Sufficient and Competent Staffing (Task), Physical Environment F906, F907, F909 thru F918, F920, F922, F925, Dementia Care (CA), Rehab and Restorative (CA), QAPI/QAA (Task). |
Resident Assessment Critical Element Pathway | Critical Element Decisions: F641 F636 F638 F640 |
Discharge Critical Element Pathway | Critical Element Decisions: F627 F628 F579 Other Tags to Consider: Participate in Care Plan F553, Notification of Change F580, Medicaid/Medicare Coverage/Liability Notice F582, Professional Standards F658, Medically Related Social Services F745, Resident Records F842. |
Sufficient and Competent Nurse Staffing Review Critical Element Pathway | PART I Mandatory Submission of Staffing Information: F851 RN Serving as Full-time Director of Nursing: F727 RN and LN Coverage: F725 for LN F727 for RN PART II Staff Sufficiency/Staff Competency: F725 F726 F727 PART III Observations: F732 Record Review: F838 Director of Nursing and/or Administrator Interviews: F725 F727 Nurse Aide Training and Competency Evaluation: F728 F729 F730 F947 Other Care Areas to Consider: Pressure Ulcer/Injury, Bowel or Bladder, Dental, Positioning/Mobility/ROM, Accidents, Nutrition, Catheter/UTI, Tube Feeding, Respiratory, ADLs, Environment, Abuse, Neglect, Physical Restraints, Quality of life, Quality of Care, Unnecessary Medications, and Behavioral-Emotional Status. |
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