The Centers for Medicare and Medicaid Services (CMS) on Friday issued a memo with new instructions and guidance in the State Operations Manual (SOM) to explain specific federal requirements and clarify how surveyors should cite non-compliance.

“CMS has updated Chapters 5 and 7 of the SOM to align instructions and guidance with current policies in QSO memos and established practices,” the agency said.

The following guidance is in Chapter 5 of the SOM:

• Revisions to Immediate Jeopardy (IJ) Priority Definition examples for Nursing Homes; and

• Clarification of Off-site investigations.

CMS has updated and revised guidance in Chapter 7 of the SOM that includes:

• Survey Team Composition, Survey Procedures, Plans of Correction, Verifying Corrections, Survey Revisit and Offsite Revisit Paper Review, Off-hours Survey, Enforcement, Nurse Staffing Waivers, Disposition of Civil Money Penalties (CMP), Federal Civil Penalties Inflation Reduction Act, Informal Dispute Resolution (IDR), and Independent Informal Dispute Resolution (IIDR);

• Additionally, guidance previously found in Appendix P of the State Operations Manual has been added to Chapter 7; and

• Technical changes that include updates for accurate references.

Prior Approval for Off-Site

CMS said Chapter 5 updates include that the oversight and investigations of alleged non-compliance are thorough and consistent across the country.

“They also clarify that off-site investigations must be approved by CMS in advance to ensure uniform application. The revisions also expand examples of intakes that warrant immediate jeopardy prioritization, such as discharging a resident to an unsafe setting,” the memo said.

The revisions to Chapter 7 standardize oversight, investigation procedures, enforcement actions, and the Civil Money Penalty Reinvestment Program (CMPRP). “The revisions update a wide variety of survey guidance, such as survey team composition, resident privacy and confidentiality, photography during survey, off-hours survey, past non-compliance, severity and scope of deficient practices, and conducting exit conferences,” CMS said.

The agency also incorporated instructions previously outlined in Appendix P of the SOM, which was removed when the Long Term Care Survey Process (LTCSP) launched in 2017.

Key Revisions include:

• Nurse Staffing Waivers and Resident Room Variances: This section of guidance simply provides a process for nursing homes to obtain a waiver and is not related to the survey process. Therefore, CMS is moving this guidance from Appendix PP to Chapter 7.

• Onsite vs. Off-site Revisits: Clarifies procedures for conducting revisits after surveyors identify non-compliance.

• IJ: Updated guidance on identifying immediate jeopardy, determining when it has been removed, and outlining conditions for lowering the severity level once IJ has been removed.

• Acceptable Plan of Correction: Addresses an OIG recommendation to clarify areas related to the acceptable plans of correction after a facility was found to be non-compliant with the requirements for participation.

• Enforcement Guidance: Revises policies for CMP to align with current practices, including use of the CMP Analytic Tool and the annual adjustment of CMP amounts according to the Annual CMP Inflation Adjustment Act of 2015. Updates also reflect changes to the CMP policy that align with the Fiscal Year 2025 Skilled Nursing Facilities Prospective Payment System (SNF PPS) final rule (89 FR 64048, Aug. 6, 2024), which expands CMS’s ability to impose per instance and per day CMPs to promote sustained correction of health and safety deficiencies.

  “These revisions will be reflected in the CMP Analytic Tool for all enforcement cycles starting on and/or after March 31, 2026. Per-Instance CMPs will be displayed on Nursing Home Care Compare beginning June 24, 2026,” CMS said.

• Civil Money Penalty Reinvestment Program: The updated guidance clarifies the allowable and non-allowable uses of CMP funds, the current application review process, and reporting requirements for project results. Additionally, the updates clarify that State CMP Fund Balances from the State Plan will be publicly posted.

• Survey Expectations: The updated guidance clarifies the minimum amount of time the survey team should be onsite on the first day of a survey, and the minimum amount of consecutive days that the survey team should be onsite for standard and abbreviated surveys.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.