CMS Releases Revised Appendix PP with Renumbered F Tags

The Centers for Medicare and Medicaid Services (CMS) has released a new Survey & Certification letter, S&C: 17-36-NH, detailing revisions to the State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag revisions, and related issues. revisions will be effective on November 28, 2017. Specifically, the letter covers the following:

Revised Interpretive Guidance
In September 2016, the Centers for Medicare & Medicaid Services (CMS) released revised Requirements for Participation under the Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities rule (RoPs). As a result of the changes effected by the RoPs, CMS has released revised Interpretive Guidance to be effective November 28, 2017. Additionally, CMS noted that many standards have remained unchanged since the early 1990s. For these areas, CMS reviewed the existing Interpretive Guidelines and updated where necessary to ensure that the standards and examples were clear. CMS also added a section in some areas to the Interpretive Guidance titled “Key Elements of Noncompliance.” This is intended to guide surveyors and nursing facilities about the key behaviors and practices identified in the regulation. LeadingAge is reviewing and analyzing the Interpretive Guidance and will be providing a summary in the coming days.

Revised F Tags
The revisions to the regulations caused many of the prior regulatory citations to be re-designated. As such, CMS was required to re-number the F-Tags used to identify each regulatory part. CMS has provided a crosswalk for the F-Tags to assist surveyors and providers with understanding the changes.

Notification about Training Resources
CMS is providing several training resources available to the public:

- A Medicare Learning Network (MLN) Call on July 25th from 1:30 to 3:00 pm to discuss the Interpretive Guidance and Survey Process. Questions can be submitted in advance to this email address. The call information will also be posted on the registration website when registration opens.

- The Integrated Survey Training website will also host the following in the coming months:

  • Training videos by CMS staff to review highlights of 11 key topics for the Interpretive Guidance including, for example, person-centered care, sufficient and competent staff, pharmacy services and infection control. These videos will review key components of the requirements;
  • Self-paced, online training describing the survey process changes to the Regional Office and State staff (which will also be made available publicly); and
  • Provider-specific training that will focus on those elements needed for the LTC survey process (e.g., materials to be requested during the entrance conference, etc.).

Enforcement Considerations
To address concerns related to the scope and timing of the changes, CMS will be providing limited enforcement remedies for certain Phase 2 provisions. CMS will provide a one- year restriction of enforcement remedies for specific Phase 2 requirements. The listing of specific Phase 2 requirements associated with enforcement delays will be shared at a later date. CMS will not utilize civil money penalties, denial of payment, and/or termination should a facility be found to be out of compliance with these new requirements beginning in November of 2017. Rather, CMS will use the year-long period to educate facilities about certain new Phase 2 quality standards by requiring a directed plan of correction or additional directed in-service training. Enforcement for other existing standards (including Phase 1 requirements) will follow the standard process. CMS warns, however, that the one-year period is not a change in the required implementation date for Phase 2 provisions.

Nursing Home Compare Considerations
CMS will be holding constant the Nursing Home Compare health inspection rating for one year for any surveys conducted after November 28, 2017. CMS previously done this as new requirements are being phased-in. To address the concern that serious quality concerns will not be known, CMS will separately flag those nursing facilities to ensure public transparency. CMS will provide more detailed methodology information at a later date.