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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. The memo was updated January 16, 2025, to include additional changes to the guidance. The changes will be effective and surveyors will begin surveying based on the revised guidance, on March 24, 2025. Note: The effective date was delayed from the original memo.
On a quarterly basis skilled nursing facilities are required to submit staffing data to CMS through the Payroll Based Journal (PBJ). In the memo, CMS provides information on the updates made to the guidance for F851. Prior to the facility visit, surveyors are instructed to review the most recent quarterly data from the PBJ Staffing Data Report and confirm that PBJ data was submitted by the facility. The PBJ Staffing Data Report found in CASPER will highlight “Failed to Submit Data for the Quarter” if the provider has failed to submit this data. In these cases, CMS directs the surveyors that they must cite F851 at an F scope and severity.
Additional takeaways include but are not limited to the following:
Surveyors will review the PBJ Staffing Data Report to evaluate if the facility failed to do any one of the following:
- Submit the required staffing information based on payroll data in a uniform format
- Complete data for the entire reporting period, such as hours paid for all required staff
- Provide accurate data
- Provide data by the required deadline
Failure to submit PBJ will result in a deficiency citation under F851 at an F scope and severity. In extremely rare cases, the surveyors may contact CMS if the PBJ Staffing Data Report indicates that the facility failed to submit data, and the surveyors believe the facility should not be cited. If the surveyor identifies concerns related to the federal registered nurse (RN) coverage requirements of eight hours a day, licensed nurse (LN) coverage 24 hours a day, or sufficient staffing, surveyors are directed to investigate these concerns using the Sufficient and Competent Staff Critical Element Pathway, and guidance at §483.35 Nursing Services (F725 & F727).
For additional information AHCA’s F851 Action Tool-Mandatory Submission of Staffing Information contains action items and a check list which can assist your facilty with regulatory compliance.
AHCA has also developed an on-demand webinar that walks learners through each of the changes to guidance, the updates to the Critical Element Pathways (CEP), and some tips/action items necessary in order to be compliant ahead of the effective date. 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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