The release of QSO-22-19-NH has the skilled nursing industry abuzz with all the revisions to the Surveyor Guidance affecting Phases 2 and 3 of the Requirements of Participation (ROP).

The original release of Phase 2 dates to 2017 and Phase 3 to 2019. Shortly after the release of Phase 3, the global pandemic caused the health care industry as a whole to focus on many operational adjustments to continuously align best practices and recommendations around COVID-19. Today we shift our focus back to overall operations and the State Operations Manual (SOM), with the biggest topic of conversation being the release of this memo, where we find numerous language and interpretation guidance changes in Appendix PP.

We have broken down the changes by “F tag” into two posts. Read on for Part 1 of our comprehensive summary of these changes and what you should do to prepare for them.

F600—Freedom from Abuse, Neglect, and Exploitation


There are a lot of new examples provided for surveyors and providers to better understand what constitutes abuse and neglect, including a reminder that not all resident-to-resident altercations result in abuse. It also clarifies that a required step of protecting residents from sexual abuse includes evaluating whether the residents have the capacity to consent to sexual activity.

The guidance now specifically reminds that a community must revise the resident’s care plan if the resident’s medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Neglect is more specifically defined as “indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress,” with a new example of neglect being “failure to implement an effective communication system across all shifts for communicating necessary care and information between staff, practitioners and resident representatives.” New specific examples of sexual abuse, mental abuse, physical abuse, and neglect are now available within the scope and severity section of F600, guiding surveyors to what scope and severity abuse and neglect deficiencies can be cited.

Regarding the Psychosocial Outcome Severity Guide, substantial new information can now be found related to applying use of the “reasonable person concept,” meaning to what degree of actual or potential harm one would expect a reasonable person in the resident’s similar situation to suffer as a result of the noncompliance which has been identified. This plays a significant role in applying the psychosocial outcome severity guidelines because the true psychosocial result or outcome as a result of abuse may not be evident at the time of an investigation. Therefore, Immediate Jeopardy (IJ) or Actual Harm could be cited when applying the psychosocial outcome severity guidelines, utilizing the reasonable person concept, without any observed or documented negative outcome at the time of the investigation.

What You Should Do

Educate your team members using the new examples specifically noted in Appendix PP. Update your Abuse, Neglect, and Exploitation (ANE) policy to ensure the new language on coordination of allegations of abuse and Quality Assurance and Performance Improvement (QAPI), as well as the reporting obligations for annual notification of “covered individuals,” are included. Ensure that the care plan has been updated for any resident for whom medical, nursing, physical, mental, or psychosocial needs or preferences changed as a result of an incident of abuse, as this will be reviewed by surveyors upon investigation of any allegation of abuse. Review and understand the Psychosocial Outcome Severity Guide and how it applies to allegations of abuse and neglect. When doing internal investigations of any allegation of ANE, ensure you consider the reasonable person concept to understand your potential scope and severity of the issue prior to a surveyor’s investigation. This can help you ensure all measures are put into place to mitigate further concern and help put your community in a position of past non-compliance for any potential deficient practice you identified.

F607—Develop and Implement Abuse, Neglect, and Exploitation Policy


Definitions have been added to this section for covered individual, crime, law enforcement, serious bodily injury, and criminal sexual abuse. The policy must now include the requirement to post and inform employees of their right and how to file a complaint with the State Survey Agency if they believe the facility has retaliated against them for reporting a suspected crime.

Previously, the ANE policy had seven required sections: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. A new, eighth section of the policy must now be included, titled “Coordination with QAPI.” This section will outline how the staff will communicate and coordinate situations of abuse, neglect, and exploitation with the QAPI program and tracking by the Quality Assessment and Assurance (QAA) committee.

What You Should Do

Review your ANE policy to ensure the Reporting/Response section includes that you must post a conspicuous notice of employee rights to file a complaint with the State Survey Agency for retaliation and then ensure this posting can be found in the community in a conspicuous place where other mandatory employment posters are found. Update your ANE policy to include the required section titled “Coordination with QAPI.”

F609—Reporting of Alleged Violations


A clarified definition of the requirement of annual notification of covered individuals regarding their obligation to report, and when to report alleged acts of ANE has been added. New examples of what and when a covered individual must report and what and when a facility must report are given. Because of the responsibility of each covered individual to ensure that his/her individual reporting responsibility is fulfilled, more clear guidance advises that any multiple-person report from a community should include identification of all individuals making the report.

In addition, a community cannot prohibit or circumscribe a covered individual from reporting directly to law enforcement even if it has a coordinated internal system. It is also recommended that each community work with local law enforcement on an annual basis to more fully understand what constitutes a crime and what their definition of each type of crime is, in order to ensure proper reporting of reasonable suspicion of a crime.

New examples of what would require reporting and what would not need reporting are now included for staff to resident abuse, resident to resident altercations, mental/verbal conflict, sexual contact, physical altercations, injuries of unknown source, neglect, misappropriation of resident property, and exploitation.

What You Should Do

Educate your team on the new examples of what and when a covered individual and a facility must report. For all Facility Reported Incidents, identify all individuals making the report to ensure the covered individuals are included.

Make arrangements to work with local law enforcement on an annual basis to understand what constitutes a crime in your greater community/county and what law enforcement’s definition of each type of crime is to ensure proper reporting of a reasonable suspicion of a crime is done at the time it is suspected or identified. Your law enforcement agencies will appreciate this proactive approach to collaborate and build a positive relationship with them.



New guidance related to how to manage residents with mental health needs and substance use disorder have been included. This guidance clarifies the need for education on signs and symptoms of possible substance use and how to manage in emergencies in which these may be a factor. It is important to ensure that in meeting the special needs of these residents, your policies and procedures do not conflict with resident rights.

What You Should Do

Provide your team with education on the signs and symptoms of possible substance use and how to manage in those emergencies. Also educate on non-pharmacologic interventions for alternative approaches to care for residents with mental health and substance use disorders. Ensure care plans are up to date and include these interventions.

F656—Comprehensive Care Plans


New language was included that allows for a failure to address culturally competent care needs within the care plan to rise to an IJ level deficiency. The example being given is a failure to address the dietary restrictions of a specific religion which does not allow for consumption of pork to be included in the plan of care and leading to a resident eating pork at mealtime and becoming distressed. By employing the psychosocial outcome severity guidelines, this could now be an IJ level deficiency.

What You Should Do

Use of culturally competent care results in more resident participation and engagement, fostering respect and improved understanding, which can lead to increased resident safety and improved outcomes. Educate all members of your team on culturally competent care. Audit care plans to ensure the cultural needs of your residents are addressed and that the team is meeting these needs as you have identified them through the care plan.

F725—Nursing Services/Sufficient Staff


Surveyors will now utilize Payroll Based Journal (PBJ) data in determining compliance with requirements for sufficient staff, use of a RN eight consecutive hours per day, and licensed nursing 24 hours a day. This database will sync with the surveyor software program during investigations to alert surveyors to specific dates to focus their investigation on to determine if your community is out of compliance.

What You Should Do

Ensure your PBJ data is complete and accurate and includes all nursing hours worked by agency, leadership nursing, and PRN staff, filling in those holes in the schedule in order to ensure compliance with sufficient staff, use of a RN eight hours per day, and licensed nursing 24 hours a day.

F880—Infection Prevention and Control


Many small and insignificant additions or clarifications to verbiage can be found here. However, you will also find entirely new sections that discuss water management and Legionella as well as multidrug-resistant organisms (MDROs) have been added to the infection prevention and control guidance.

What You Should Do

Ensure your infection preventionist (IP) and team are aware of water management and Legionella, as well as MDROs, and have a plan to address both in the event they are identified in your community.

F882—Infection Preventionist


In Phase 2 of the ROP from 2017, we first saw language included in Appendix PP requiring an IP. The new language defines time-on-site requirements, knowledge, and training around the role that previously had not been provided.

What You Should Do

Ensure your IP meets the requirements for the primary and specialized IP training, qualifications, hours worked, and is working on-site in your community. While the requirement states the IP must be at least part-time, it is also required that the Infection Prevention and Control Program be able to meet the needs of the community. Review your annual assessment to ensure any special needs identified that require focused infection control can be covered by the time allotted to work by your IP.

Now that you have read about some of the bigger changes in Part 1 of this series, read part 2 for a summary of some of the smaller changes and what you should do to prepare.

How HDG Can Help You Prepare

As a national leader in senior care management and consulting services, Health Dimensions Group (HDG) is uniquely positioned to assist providers with operational, financial, and strategic issues.

We offer Positive Review and Evaluation Process (PREP) surveys to ensure readiness for recertification by state agencies. Our process reviews compliance of your community with all ROP guidelines and identifies areas of opportunity for process improvement before they can be cited as deficient practices through a state survey process. Let us perform a PREP survey in your community to ensure you are prepared for the changes identified in QSO-22-19-NH.

For more information on how HDG can help you, please contact us at or 763.537.5700.