The Centers for Medicare & Medicaid Services (CMS) recently released updated surveyor guidance in Appendix PP of the State Operations Manual to be effective March 24, 2025. For further details, visit the official CMS page on the State Operations Manual here. These changes have introduced new expectations and standards aimed at enhancing the quality of care in nursing homes. For administrators, directors of nursing (DONs), and staff, understanding and implementing these updates is crucial to ensuring compliance, maintaining certification, and improving resident outcomes. Below, we’ll explore how these updates will affect nursing home operations and offer strategies for adapting to the changes effectively.

Key Changes in Appendix PP Guidance

The updated Appendix PP guidance emphasizes several areas, including, but not limited to:

1. Chemical Restraints/Unnecessary Psychotropic Medications: Psychotropic medication guidance was moved from F-758 and incorporated into F-605 along with updated language about chemical restraints and the use of psychotropic medications for staff convenience or discipline. Facilities must ensure that prior to initiating or increasing a psychotropic medication, they provide documentation addressing the risks and benefits of these medication and alternatives to the medication, allowing the resident or their representative the right to consent or refuse. Additionally, facilities must attempt non-pharmacological behavioral interventions prior to using psychotropic medications, unless these interventions are clinically contraindicated.
2. Admission, Transfer and Discharge: F-622 through F-626 and F-660 and F-661 were removed and the guidance moved into two new tags, F-627 and F-628. Guidance was updated to address inappropriate discharges, as well as successful appeals on discharges. The terms “facility-initiated” and “resident-initiated” were removed from the guidance as well.
3. Nurse Staffing: Surveyor guidance was added on use of the Payroll Based Journal Staffing Data Reports as an additional source of information for surveyors to indicate if noncompliance is occurring with sufficient nurse staffing.
4. MDS Accuracy, Professional Standards of Care, and Medical Director Responsibilities: Accuracy in MDS coding will be scrutinized more when it comes to coding mental illness, especially with the diagnosis of schizophrenia and its related forms. Practitioners will have to ensure that they are adhering to professional standards of practice when it comes to diagnosing schizophrenia by providing evidence-based criteria and documentation to support the diagnosis and any indications for use of a psychotropic for schizophrenia. Medical directors will have to ensure that they and other practitioners adhere to these professional standards when it comes to diagnosing and prescribing medications. Without appropriate documentation, and inaccurate MDS coding, facilities could be cited for noncompliance.
5. Infection Control and Prevention: CMS incorporated language and guidance on Enhanced Barrier Precautions and multidrug resistant organisms (MDROs) based on current CDC guidance.

Implications for Nursing Home Administrators and Directors of Nursing (DONs)

The new guidance places significant responsibility on administrators and directors of nursing to ensure their facilities are not only compliant but also proactive in implementing the updates. Key implications include:

1. Increased Administrative/Nursing Oversight: Administrators and DONs must ensure that policies and procedures align with the updated guidance. A helpful starting point is the CMS Facility Assessment Tool, which provides a checklist for aligning policies and procedures. 
2. Enhanced Training Requirements: Staff education is a cornerstone of compliance. Administrators and DONs will need to provide regular, targeted training sessions to ensure all personnel understand the new standards and can apply them in daily operations.
3. Documentation and Audits: The updated guidance underscores the importance of thorough documentation and auditing of resident medical records. Administrators and DONs must ensure that records reflect adherence to the documentation standards based upon professional standards of care and the needs of the residents. Surveyors will likely scrutinize these records during inspections.
4. Risk Management: Administrators must adopt a proactive approach to identifying and mitigating risks. This includes regular internal audits to assess compliance and address potential issues by utilizing the Quality Assurance Process Improvement (QAPI) program before surveyors identify them.

Implications for Nursing Home Staff

For nursing home staff, the updated guidance will likely lead to changes in daily routines, workflows, and responsibilities. Key implications include:

1. Expanded Roles and Responsibilities: Staff may need to take on additional duties and responsibilities, including additional documentation and increased scrutiny of documentation present in resident medical records.
2. Increased Training and Education: Staff will require ongoing education to understand and implement the updated standards. Training topics may include chemical restraints/psychotropic medication use, infection prevention and control, and transfer and discharge.
3. Focus on Resident Engagement: Direct care staff will need to prioritize meaningful interactions with residents, implement non-pharmacological behavioral interventions where indicated, and support the residents’ overall goals and preferences for care and services.
4. Collaboration and Communication: Effective implementation of the guidance will require strong collaboration among interdisciplinary teams. Staff will need to communicate regularly and effectively to coordinate care and address resident needs comprehensively.

Strategies for Adapting to the Changes

Successfully navigating the updated guidance will require a coordinated effort from administrators, DONs, and staff. Here are some strategies to consider:

1. Conduct a Gap Analysis: Identify areas where current practices fall short of the new standards. Use this analysis to prioritize changes and allocate resources effectively.
2. Invest in Training Programs: Provide comprehensive training tailored to different roles within the facility. Include practical scenarios and hands-on practice to reinforce learning.
3. Strengthen Quality Assurance Processes: Establish robust quality assurance and performance improvement (QAPI) programs to monitor compliance and drive continuous improvement.
4. Engage Residents and Families: Involve residents and their families in care planning and decision-making. Solicit their feedback to ensure care plans align with their expectations, goals, and needs.
5. Enhance Communication Channels: Create opportunities for staff to share concerns, report challenges, and suggest improvements. Regular team meetings can help address issues promptly and foster a collaborative environment.
6. Stay Informed: Regularly review updates from CMS and attend industry conferences or webinars to stay abreast of best practices and regulatory changes.

Conclusion

The updated surveyor guidance in Appendix PP represents a significant shift in the regulatory landscape for nursing homes. While the changes pose challenges, they also present an opportunity to enhance the quality of care and improve resident outcomes. By proactively addressing the new requirements, nursing home administrators and staff can foster a culture of excellence and ensure their facilities remain compliant, effective, and compassionate.

The Compliance Store offers all the tools your facility needs to stay abreast of these changes, encourage and support their implementation, and provide the necessary training your staff will need to continue providing the level of care your residents expect and deserve. Contact us online or by calling 1-877-582-7347 to learn how The Compliance Store can put you in the driver’s seat to the best practices in long term care!