CMS Releases Updated Guidance for LTC Surveyors

On November 26, 2014, CMS issued revisions to State Operations Manual (SOM) Appendix PP for health and safety in long-term care facilities. The majority of the revisions were explained in advance guidance through survey and certification letters (S&C letters) released by CMS over the last decade. Previously addressed substantive changes include advance care planning, dementia care, NG tube care, pharmacy services, physician extender services, clinical records, food prep and handling, and infection control.

The S&C letters can be found at the CMS website. While none of this guidance is new, providers should review the revisions to dementia care at F-309, as the changes are substantial and CMS has stated that it will rely on this guidance for its new dementia care survey for nursing facilities. For more information about CMS’s focused dementia care surveys, please see the S&C letter released on this topic entitled “Focused Minimum Data Set (MDS) and Dementia Care Surveys,” released on April 18, 2014.

The most recent version of SOM Appendix PP also reflects revisions to compliance with laws that the S&C letters do not address. Notably, under F- 492, a facility may be cited with a deficiency related to a state or local law or regulation even if that law or regulation is stricter than the corresponding federal authority. The deficiency may only be cited, however, if the state or local authority has taken final adverse action and provided written confirmation to the facility. Final adverse action must be more than a corrective action plan or a civil monetary penalty and must not be under appeal or litigation. Examples of final adverse actions include a ban on admissions or suspension or loss of the facility license. In addition, the facility must be out of compliance with the state or local law or regulation at the time the deficiency is cited. If the facility was previously out of compliance with a state or local ordinance, but is compliant as of the on-site complaint or follow-up survey surveyors may not cite the deficiency.

Providers must ensure they are compliant with all applicable state and local laws, including state professional licensure practice acts and scope of practice regulations. Failure to comply with these standards may also result in an F- 492 deficiency if the state or local licensing board has taken a final adverse action against the facility or a facility employee.

Should you or your organization have any questions about the changes to SOM Appendix PP, please contact Peter Mellette ( or Harrison Gibbs (, or call Mellette PC at (757) 259-9200.

Categories: Client Advisory