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Draft Appendix PP Revisions: A REVISED Overview

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:  
  • Clarifies the role of staff convenience in psychotropic medications serving as a chemical restraint

  • Addresses the resident’s right to be informed of the benefits, risks, and alternatives before a psychotropic medication is initiated or increased

  • Discusses the documentation required to support a diagnosed mental disorder
F620*** (Admission Agreement), which is currently called Admissions Policy  

Key updates:  
  • Clarifies prohibition of language in admission agreements that specifically requests or requires a third party to personally guarantee facility payment

  • Provides examples of noncompliant admission agreement language
F627!, *** (Inappropriate Transfer or Discharge), which combines components of the current F622, F624, F626, F660, and F661  

Key updates:  
  • Identifies scenarios when evidence suggests a facility should not have transferred or discharged a resident at the time of discharge, or at all

  • Clarifies the need for an assessment of the resident’s status at the time of their proposed return for discharge when needs cannot be met, or when safety or health of individuals is endangered

  • Adds guidance for successful appeals on discharges
    Updates documentation requirements, as well as Against Medical Advice (AMA) guidance

  • Removes facility- and resident-initiated language
F628!, *** (Transfer/Discharge Process), which combines components of the current F622, F623, F625, and F661  

Key updates:  
  • Updates Intent section to state, “The intent of this tag is to ensure the facility adheres to all of the applicable components of the process for transferring or discharging a resident which include documentation and information conveyed to the receiving provider, the notice of transfer or discharge, notice of bed-hold policy, and completing the discharge summary.”

  • Removes facility- and resident-initiated language
F641* (Accuracy/Coordination/Certification of Assessments), which combines the current F641 with the current F642  

Key updates:  
  • Addresses inaccurate diagnosis coding for schizophrenia but also “for any new diagnosis,” including:

    • What counts as a pattern of inaccurate coding

    • The documentation required to support a diagnosed mental disorder

  • Adds new Investigative Procedures that address the surveyors’ role to investigate MDS coding accuracy and to make a referral to the Office of Inspector General if a pattern (i.e., three or more residents) of inaccurate MDS coding is identified and there are indications or concerns that the individual who completed the section(s) in question knew the coding was inaccurate
F658* (Services Provided Meet Professional Standards)  

Key updates:  
  • Revises Intent section to “assure that ALL services, as outlined by the comprehensive care plan, being provided meet professional standards of quality.”

  • Addresses the documentation required to support the diagnosis of a mental disorder:

    • Provides examples of insufficient documentation

    • Explains what the documentation does not contain when it’s insufficient

  • Describes diagnostic criteria for schizophrenia, schizophreniform disorder, and schizoaffective disorder

  • Updates Survey Probes and Deficiency Categorizations
F678^ (Cardio-Pulmonary Resuscitation (CPR))  

Key updates:  
  • Revises CPR certification training requirements to note that:

    • Training should include “a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards”

    • Training that may not meet “accepted professional standards” could be investigated under F659 (Qualified Persons) and/or F836 (License/Comply w/Fed/State/Local Law/Prof Standards)
F697 (Pain Management)**  

Key updates:  
  • Provides new definitions from the Centers for Disease Control and Prevention (CDC) for acute, chronic, and subacute pain

  • Updates guidance on the use of opioids for pain management:

    • Opioid treatment should be appropriately assessed and individualized for each resident

    • Prescribers may consider immediate-release opioids instead of extended-release and long-acting opioids when starting opioid therapy for acute, subacute, or chronic pain

  • Refers surveyors to F552 (Right to be Informed/Make Treatment Decisions) for concerns related to informing the resident or resident representative of the risks of opioid use for pain

  • New resource links
F725 (Sufficient Nursing Staff)
 
Key updates:
  • Adds definitions for licensed nurse, charge nurse, and scope of practice

  • Substantially expands the surveyor guidance, including a discussion of how “Concerns such as falls, weight loss, dehydration, pressure ulcers, elopement and resident altercations can also offer insight into potential insufficient numbers of staff available in the facility.”

  • Significantly expands the Investigative Procedures, including instructions for how surveyors should use the PBJ Staffing Data Report, as well as enhancing staff interviews and observations

  • Updates the Key Elements of Noncompliance to stress that surveyors must use the PBJ Staffing Data Report to check that the facility has ensured licensed nurse coverage 24 hours a day, except when waived. “If the facility triggers on the report under the category of ‘No Licensed Staff,’ a citation at F725 should be issued at a minimum severity and scope of ‘F’”

  • Updates the Deficiency Categorization examples
F727 (RN 8 Hrs/7 Days/Wk, Full Time DNS)
 
Key updates:
  • Adds a definition for scope of practice

  • Updates the surveyor guidance to emphasize the RN’s role in developing and evaluating the plan of care and that some facilities may need more than minimum RN coverage due to a facility population that requires “more frequent assessment, as well as care plan development and evaluation of interventions that may not be delegated to the LPN or other healthcare professional.”

    • Also specifies that hours worked by “any RN or multiples of RNs,” including the DNS, can contribute to meeting the requirement to have an RN providing services at least 8 consecutive hours a day, 7 days a week

  • Adds new Investigative Procedures that specify step-by-step how the surveyors must use the PBJ Staffing Data Report, as well as staff interviews that should be completed

  • Updates the Deficiency Categorization examples
F732 (Posted Nurse Staffing Information)  

Key updates:  
  • Adds that facility staffing data must be readily accessible to staff, as well as residents and visitors
F757* (Drug Regimen Is Free From Unnecessary Medications)  

Key updates:  
  • Addresses unnecessary medications, excluding unnecessary psychotropic medications

  • Discusses the requirements for a comprehensive assessment, including:

    • Reasons not to initiate or change a medication

    • Circumstances that warrant evaluating the resident’s underlying medical condition and medication

  • Provides information on:

    • Determining the necessity for use of medications

    • The resident’s right to be informed

    • Dose and duration

    • Monitoring and adverse consequences
F841* (Responsibilities of Medical Director)  

Key updates:  
  • Addresses the medical director’s:

    • Role in the implementation of resident care policies, including facility policies on diagnosing and prescribing medications

    • Responsibility for intervening when medical care is inconsistent with current professional standards of care, including adding an example of when “physicians assigning new psychiatric diagnoses and/or prescribing psychotropic medications without following professional standards of practice”

    • Responsibility to address issues related to the coordination of medical care and implementation of resident care policies identified through the facility’s quality assessment and assurance committee and other activities

    • Need to be actively involved in the process of conducting the facility assessment

    • Role in administrative decisions, including recommending, developing, and approving facility policies related to resident care

  • Adds a new example of a Severity Level 2 (no actual harm, with a potential for more than minimal harm, that is not immediate jeopardy) deficiency citation that involves the medical director’s role in a resident’s new diagnosis of schizophrenia
F851 (Payroll-Based Journal)
 
Key updates:

  • Substantially revises the Investigative Procedures to incorporate the PBJ Staffing Data Report

  • Adds the facility’s failure to “submit the required staffing information based on payroll data in a uniform format” as a new Key Element of Noncompliance
F867 (QAPI/QAA Improvement Activities)  

Key updates:  
  • Adds a new definition for health equity

  • Directs facilities to:

    • Consider feedback related to concerns about health equity

    • Collect and monitor data related to the outcomes of subpopulations to address health equity issues

    • Give consideration to factors that affect health equity and outcomes (depending on the resident population) when establishing priorities for performance improvement

    • Include an evaluation of factors known to affect health equity, such as race, sexual orientation, socioeconomic status, or preferred language in data analysis for preventing medical errors and adverse resident events
F880 (Infection Prevention and Control)  

Key updates:  
  • Adds a new definition of enhanced barrier precautions and new guidance for using enhanced barrier precautions to reduce transmission of multidrug-resistant organisms (MDROs). This guidance is based on the March 20, 2024 QSO memo QSO-24-08-NH. However, there are some new additions, including:

    • A listing of four situations when contact precautions should be used for residents infected or colonized with MDROs

    • Adds deficiency categorization examples of Severity Levels 4, 3, and 2 involving COVID-19 transmission
F887 (COVID-19 Immunization)  

Key updates:  
  • Adds F887 guidance, originally created as a new tag back in 2021 via QSO memo QSO-21-19-NH, to Appendix PP for the first time. While the guidance is largely the same as in the memo, there are changes, including:

    • An updated Investigative Procedure that instructs surveyors on how to determine whether the scope of noncompliance is isolated, a pattern, or widespread

    • A revised resource list
F918 (Bedrooms Equipped/Near Lavatory/Toilet)  

Key updates:  
  • Adds guidance specifying that each resident bedroom is required to have its own bathroom consisting of at least a sink and commode/toilet and that each resident bedroom should accommodate no more than two residents per bedroom in facilities that meet specific criteria

! 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

PathwayF-tags at Risk
Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) ReviewQAPI 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 PathwayCritical 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 PathwayCritical 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 PathwayCritical 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 PathwayCritical 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 PathwayCritical 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 PathwayCritical Element Decisions:
F641
F636
F638
F640
Discharge Critical Element PathwayCritical 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 PathwayPART 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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