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In November 2024, the Centers for Medicare and Medicaid Services (CMS) released Revised Long-Term Care (LTC) Surveyor Guidance. The memo included significant changes to guidance in Appendix PP. On Friday, March 7th CMS released QSO-25-14-NH. This memo updates the previously released guidance from November 18, 2024, and January 15, 2025, which included significant updates to surveyor guidance across several regulatory areas. Also contained in the memo, CMS pushed the effective date from March 24, 2025 to April 28, 2025.
The memo outlines CMS updated Guidance for investigations using the Payroll Based Journal Staffing Data Report. This report will be used as one of the sources of information indicative of potential noncompliance.
CMS also added to the guidance:
- Instructions specific to staff interviews, observations, key elements of noncompliance, and deficiency categorization.
- Instructions to surveyors based on whether or not the report identified concerns.
- Investigative probes for the Director of Nursing requirements and deficiency categorization examples.
- Investigative procedures for evaluating compliance with the submission of direct care staffing information and payroll using the Payroll Based Journal Staffing Data Report.
CMS added/updated the following definitions under F725 as follows:
“Licensed Nurse” means any nurse that requires the successful completion of a National Council Licensure Examination (NCLEX-PN or NCLEX-RN). At a minimum, this would include a Licensed Practical Nurse (LPN) or a Registered Nurse (RN).
“Charge Nurse” is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.
“Scope of Practice” describes the services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license.
The facility assessment is a key factor in determining sufficient nursing staff. CMS expanded upon the guidance under F725, with heavy ties to the requirements and guidance for the facility assessment under F838. They note that the assessment of the resident population contributes to the identification of staffing decisions and informs the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served on any given day.
The facility is required to provide licensed nursing staff 24 hours a day, along with other nursing personnel, including but not limited to nurse aides. The facility must also designate a licensed nurse to serve as a charge nurse on each tour of duty.
CMS expanded the guidance to include more details about RNs and the Director of Nursing (DON). For example, when CMS notes RN responsibilities in the guidance, they added developing and evaluating plans of care. CMS also formally separated and added to investigative procedures under F727, directing surveyors to follow the Sufficient and Competent Nurse Staffing Critical Element Pathway in addition to the guidance. During the annual survey entrance conference, the State Survey team will request confirmation of a full-time DON. If, at any time during the survey, the team identifies concerns with the availability of a full-time DON, further investigation would be warranted.
Additional information can be found in AHCA’s Action Tool F725 and F727. This action tool includes information regarding PBJ reporting and action items to ensure your facility’s compliance.
As a result of the updated CMS memo, additions and extending the effective date for the Appendix PP changes have been made to AHCA’s webinar, AHCA Education: Preparing for Upcoming CMS Guidance Changes: Key Updates and Action Items for Compliance. This webinar is on demand and available free to AHCA/NCAL members and $65 non-members. Remember if you are a member of Washington Health Care Association, you are also a member of AHCA and take advantage of this free resource. Please send questions to regulatory@ahca.org, and email educate@ahca.org if you need assistance with registering.
Thank you to AHCA for the development of the information contained within this communication and the associated tools. If you have questions, please contact Elena Madrid, Executive Vice President of Education and Regulatory Affairs.
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