The Centers for Medicare & Medicaid Services has released comprehensive updates to the State Operations Manual Appendix PP, which provides guidance to state survey agencies on evaluating nursing home compliance with Medicare and Medicaid requirements. The updates, effective immediately, incorporate recent regulatory changes and clarify enforcement expectations across multiple compliance areas.
Key Updates
The revised guidance addresses several areas where surveyors and facilities had sought clarification. Notable updates include: revised interpretive guidance on the “sufficient staffing” requirement following repeal of numeric minimums; updated infection control survey protocols incorporating lessons from respiratory illness seasons; clarified expectations for emergency preparedness documentation and testing; and new guidance on evaluating compliance with health information transfer requirements.
The guidance also updates civil monetary penalty amounts for inflation, with per-day penalties now ranging from $71 to $23,607 and per-instance penalties up to $78,689.
Staffing Evaluation
With the repeal of federal minimum staffing ratios, the updated guidance provides detailed criteria for surveyors evaluating whether facilities have “sufficient nursing staff.” Factors include: resident acuity and care needs; facility census and layout; staff competencies and skill mix; and evidence of care failures attributable to staffing levels.
Surveyors are instructed to cite staffing deficiencies based on demonstrated harm or potential for harm to residents, rather than comparison to numeric thresholds.
Implementation
State survey agencies are expected to implement the updated guidance immediately, though CMS has indicated a 90-day transition period during which surveyors will provide education and technical assistance on new expectations before citing deficiencies.
Industry groups have welcomed the clarifications while requesting additional training opportunities to ensure consistent interpretation across state survey agencies.