Survey Preparedness

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Skilled nursing centers and nursing facilities are required to follow extensive rules in the Requirements of Participation (ROP) to receive payment under the CMS Medicare or Medicaid programs. These requirements are contained in the Federal Regulations for Nursing Facilities, which also state each center must comply with all applicable Federal, State, and local laws, regulations, and codes with accepted professional standards. The AHCA regulatory team provides members with guidance and resources to help them understand the survey process and implement the requirements.  

Need help locating a specific resource? Download the AHCA Regul​a​tory Resources Guide​, which provides direct links to all available tools to help you prepare for surveys.

 SURVEY TIPS to Maintain Compliance

The AHCA regulatory team is developing survey tips to assist in maintaining compliance with skilled nursing regulations, as well as preparing for surveys. The team will review trends for citations and provide tips for staying in compliance with these regulatory areas.​​​

 

 

CMS Rescinds Memo QSO-23-03-ALLhttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Rescinds-Memo-QSO-23-03-ALL-.aspxCMS Rescinds Memo QSO-23-03-ALL3/25/2025 4:00:00 AM<p>​<span style="font-size:11pt;">On March 14, the Centers for Medicare and Medicaid Services (CMS) <a href="https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/importance-timely-use-covid-19-therapeutics" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">rescinded QSO-23-03-All – The Importance of Timely Use of COVID-19 Therapeutics</a>. The memo was referenced in <a href="https://www.federalregister.gov/documents/2021/01/26/2021-01858/improving-and-expanding-access-to-care-and-treatments-for-covid-19" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Executive Order (EO) 138997- Improving and Expanding Access to Care and Treatments in COVID-19</a>. EO 13997 was rescinded in <a href="https://www.govinfo.gov/content/pkg/FR-2025-01-28/pdf/2025-01901.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">EO 14148 – Initial Rescissions of Harmful Executive Orders and Actions</a>. According to CMS, this QSO memo was effective January 20, 2025, when EO 14148 was issued.   </span></p><div><span style="font-size:11pt;">The original memo did not reflect new or changed survey guidance nor policy but was considered to be a reference memo only.  </span></div><div><br></div><div><strong>What does this mean for nursing homes?  </strong></div><div><br></div><div>Since the original memo did not change regulations or survey guidance, there are no changes to regulations or guidance resulting from its rescission. <br></div><div><ul><li><span style="font-size:11pt;">Regulations and guidance related to <a href="https://www.cms.gov/files/document/qso-21-19-nh.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">COVID-19 vaccination</a> and <a href="https://www.cms.gov/files/document/qso-25-11-nh.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">NHSN reporting</a> remain unchanged.  </span></li><li><span style="font-size:11pt;">Current <a href="https://www.cdc.gov/covid/treatment/index.html" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">practice guidelines</a> for the testing and treatment remain unchanged.  </span></li></ul></div><div><br></div><div>Questions may be sent to <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org​</a>.   <br></div><p>​</p>On March 14, CMS rescinded QSO-23-03-All – The Importance of Timely Use of COVID-19 Therapeutics.
CMS Further Delays Implementation of Surveyor Guidance Changeshttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Further-Delays-Implementation-of-Surveyor-Guidance-Changes.aspxCMS Further Delays Implementation of Surveyor Guidance Changes3/10/2025 4:00:00 AM<div>The Centers for Medicare and Medicaid Services (CMS) released <a href="https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/policy-memos/policy-memos-states-and-cms-locations/revised-revised-long-term-care-ltc-surveyor-guidance-significant-revisions-enhance-quality-and-0" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">QSO-25-14-NH​</a> earlier today, March 7. The memo updates previously released guidance from November 18, 2024, and January 15, 2025 which included significant updates to surveyor guidance across several regulatory areas.</div><div><br></div><div>In today’s memo, CMS pushed the effective date from March 24, 2025 to April 28, 2025. CMS also noted that revised surveyor resources will be released on April 28, 2025.</div><div><br></div><div>The AHCA Regulatory team is reviewing the memo and will provide additional information once the full review is complete. For questions please email <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org</a>.​<span style="font-size:11pt;">​</span></div>CMS released QSO-25-14-NH​ earlier today, March 7. The memo updates previously released guidance from November 18, 2024, and January 15, 2025.
Dementia Care Training and Certification Research Studyhttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/Dementia-Care-Training-and-Certification-Research-Study.aspxDementia Care Training and Certification Research Study2/20/2025 5:00:00 AM<p><span style="font-size:11pt;">A</span><span style="font-size:11pt;">s assisted living communities have become more popular, they have become the largest residential provider of long term care for people with dementia. Often, these residents need special help with daily tasks, including bathing, dressing, and eating. Training can help staff problem-solve the challenging situations that arise when caring for persons with dementia. </span></p><div><span style="font-size:11pt;">There are two online programs developed by the Alzheimer’s Association that offer education and aim to better inform staff how to provide care. They are being offered at no cost to selected assisted living communities. </span></div><div><span style="font-size:11pt;"><br>A research study funded by the National Institute on Aging is evaluating the two programs. Led by the University of North Carolina at Chapel Hill, in partnership with the Alzheimer’s Association, the study will work with 126 assisted living communities to evaluate the essentiALZ and Project ECHO training. It will determine whether these trainings help staff feel better trained and result in better outcomes for both residents and staff. </span></div><div><span style="font-size:11pt;"><br></span></div><div><span style="font-size:11pt;">Learn more about this no-cost opportunity at <a href="http://www.dementiacaretraining.org/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">dementiacaretraining.org​</a>.</span></div><p>​</p>As assisted living communities have become more popular, they have become the largest residential provider of long term care for people with dementia.
CMS Releases Revised Guidance for Federal Monitoring Surveyshttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Releases-Revised-Guidance-for-Federal-Monitoring-Surveys-.aspxCMS Releases Revised Guidance for Federal Monitoring Surveys1/21/2025 5:00:00 AM​<span data-contrast="auto" lang="EN-US" style="font-size:11pt;">On January 17, 2025, the Centers for Medicare and Medicaid Services (CMS) released a revised </span><a href="https://www.cms.gov/files/document/admin-info-25-06-nh.pdf" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="font-size:11pt;"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">Admin Memo: 25-06-NH</span><span data-ccp-charstyle="Hyperlink"> </span></span></a><span data-contrast="auto" lang="EN-US" style="font-size:11pt;">related to guidance for Federal Monitoring Surveys (FMS). According to the memo, FMS are performed each fiscal year to validate the State Survey Agency’s performance. In the Fiscal Year (FY) 2025 FMS memo, CMS notes FMS will only consist of Resource and Support Surveys (FSS) and Health Comparatives. CMS will not conduct any Focused Concern Surveys (FCS) in FY 2025. In addition, CMS reports RSS will be conducted throughout the year. Previously, they were conducted in the first six months of the year. </span><span data-ccp-props="{}" style="font-size:11pt;"> </span><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">CMS also notes that a Health Comparative survey may now follow a standard or complaint survey. Previously they only followed standard surveys. These surveys should be conducted within 60 calendar days of the State Agency’s survey exit.</span><span data-ccp-props="{}"> </span></div><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">CMS did add a type of Emergency Preparedness (EP) and Life Safety Code (LSC) FMS. Previously there were four types, and now there are five. The types of EP/LSC FMS include the following:</span><span data-ccp-props="{}"> </span></div><div><ol role="list" start="1"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="1" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Resource and Support Survey</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="2"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="2" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Comparative</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="3"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="3" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Revisit Resource and Support Survey</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="4"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="4" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Revisit Comparative</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="5"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="5" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">NEW: An EP/LSC Desk Audit</span><span data-ccp-props="{}"> </span></li></ol></div><div><span data-contrast="auto" lang="EN-US">CMS Reports that the new type of survey, the EP/LSC Desk Audit, is a desk review conducted by a Federal Surveyor after the State Agency has conducted the facility’s recertification survey. The purpose is to monitor the State Agency’s performance.</span><span data-ccp-props="{}"> </span></div><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">Please send any questions to </span><a href="mailto:regulatory@ahca.org" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">regulatory@ahca.org</span></span></a><span data-contrast="auto" lang="EN-US">.</span><span data-ccp-props="{}"> </span></div>CMS released a revised Admin Memo: 25-06-NH related to guidance for Federal Monitoring Surveys

 ‭(Hidden)‬ Toolkit

HealthCap Risk Manageme​​nt Services has released the 2022 Elopement ​Prevention & Management Toolkit.

 Focus F-Tags: Guidance

On November 18, 2024, the Centers for Medicare and Medicaid Services (CMS) released Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC Survey Process.​ The memo included significant changes to guidance in Appendix PP related to the updated regulatory areas.​ The changes will be effective, and surveyors will begin surveying based on the revised guidance, on April 28, 2025.  ​

Please refer to Appendix PP Gu​​idance to Surveyor for Long Ter​m Care Facilities​​​ for the most up to date regulations and guidance.​​ ​

 F-Tag Action Briefs & Much More on ROP

Additional resources and tools to help you navigate the ROP are available on ahcancalED, including F-Tag Action Briefs, which complement the sum​m​a​ries above and highlight implementation strategies and tips​.  

 ‭(Hidden)‬ Blue Quick Links ‭[1]‬

 ‭(Hidden)‬ Blue Quick Links ‭[2]‬

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Phase 3 Interpretive Guidance – Delayed

Phase 3 of the Requirements of Participation (RoP) went into effect on November 28, 2019. However, as the Centers for Medicare & Medicaid Services (CMS) announced in a memo (QSO-20-03-NH) released on November 22, 2019, CMS will not be releasing the interpretive guidance (IG) for Phase 3 until the second ​quarter of 2020.  Read More>>​