CMS Updates SOM to Provide Further Guidance on Phase 3 Requirements

Regulations associated with the Phase 3 Requirements were formally implemented on November 28, 2019.  However, the State Operations Manual was not updated to reflect the Phase 3 Requirements at that time, and CMS advised that surveys to assess compliance with the Phase 3 Requirements would not start until the issuance of the updated State Operations Manual.  On June 29, 2022, CMS announced via a memorandum, QSO-22-19-NH QSO-22-19-NH (, that the long-awaited guidance updates to the State Operations Manual would be released on or about October 24, 2022, and that facilities should expect to be surveyed for compliance with the updated guidance starting on October 24, 2022.

Facilities should review the updated SOM and revise their policies and procedures in accordance with the new guidance.  Examples of some of the significant updates include:

  • 483.12 Abuse and Neglect
    • There are significant revisions to the guidance for Abuse/Neglect, which provide clarifications to surveyors regarding facility reportable incidents, including examples of cases of abuse and what information should be reported by facilities, and when the reports are required to be made.
  • 483.15 Admission, Transfer and Discharge
    • When a facility initiates a discharge while a resident is in the hospital following an emergency transfer, the facility must have evidence that the resident’s status, at the time the resident seeks to return to the facility, meets the criteria for discharge, not when they were transferred to the hospital.
    • The revisions provide clarifications to the notice requirements for transfer or discharge to ensure residents and their representatives receive complete and accurate information.
  • Mental Health(MH)/Substance Use Disorder (SUD)
    • CMS desires to improve the provision of care to residents with MH and SUD needs, without implementing policies and procedures that conflict with resident’s rights.
    • Facility staff should be trained and have knowledge regarding signs and symptoms of SUD and be prepared to address SUD emergencies.
    • CMS also is encouraging Facilities to utilize non-pharmacological interventions for residents dealing with MH needs and SUD.
  • 483.35 Payroll Based Journal/Nurse Staffing
    • Surveyors are now instructed to incorporate the use of the PBJ staffing data when investigating the potential noncompliance with staffing requirements.
  • Potential Inaccurate Diagnosis and/or Assessment
    • CMS has issued guidance to surveyors to investigate the potential for inaccurate diagnosis and/or prescription of psycho-tropic medication
    • Surveyors will be reviewing Resident Assessments to check for accurate diagnosis and prescription.
    • Residents with certain diagnosis, such as schizophrenia will likely be flagged for review (along with Residents with prescriptions for psycho-tropic medication) to ensure accurate diagnosis.
  • 483.10 Resident Rights
    • CMS has incorporated visitation guidance developed during the COVID-19 pandemic formally into the SOM.
    • The guidance also states that Facilities cannot search a Resident’s person or belongings without the Resident or Resident Representative’s consent.  If, for example, a facility suspects the Resident is in possession of an illegal item the Facility should immediately contact law enforcement to conduct any search.
  • 483.80 Infection Control
    • Facilities must have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the infection prevention and control program.
    • Facilities should regularly update their Infection and Control policies to include current information regarding best practices.
  • 483.95 Training
    • Surveyors will be closely reviewing Facility training programs.  Facilities should confirm that such programs are on-going and regularly updated.
    • Such reviews such include assessing whether the Facility makes efforts to ensure that the training program is effective, including conducting random spot checks to test staff knowledge.
    • CMS has listed a variety of topics to be addressed in training, including resident rights, abuse and neglect, Infection Control, MH and SUD.

Surveyors will be conducting surveys using the updated State Operation Manual SOM – Appendix PP ( starting October 24, 2022.  Facilities should immediately review and revise their policies and procedures as necessary to ensure that they are compliant with the new Guidance to avoid potentially issues during upcoming surveys.

If you have any questions regarding the revisions to the State Operations Manual and how to prepare for upcoming surveys, please do not hesitate to contact us.