The numerous changes to the Centers for Medicare & Medicaid Services (CMS) federal Requirements of Participation (ROP) for nursing homes, announced on June 29, 2022, in QSO-22-19-NH, will begin to be surveyed on October 24, 2022.

Phase 2 Adjustments

These rule changes revise ROP Phase 2 guidance to enhance quality and oversight of sensitive areas such as reporting of abuse and neglect, as well as conditions of admissions, transfers, and discharges. There is a revised focus on improving rights, protections, and management of residents with mental health and/or substance use disorders (MH/SUD). They include new close evaluation of the use of the diagnosis code for schizophrenia on the minimum data set (MDS) and add additional medications with potentially harmful extrapyramidal side effects to the list of psychotropics currently evaluated for dose reduction by pharmacists.

Additional infection control and prevention measures are added, which include hours assigned to an employee Infection Preventionist; assuring visitation is permitted within facilities, even during infectious disease outbreaks; and considerations of other physical changes that may reduce potential disease spread. There are clarifications in almost every care area. For example, changes to guidance around Payroll Based Journal (PBJ) submissions now allow surveyors to use this data to assess sufficient staffing. And, the regulatory groups of Quality of Life and Quality of Care, Food and Nutrition Services, Physical Environment, Trauma Informed Care, Compliance and Ethics, and Quality Assurance Performance Improvement (QAPI) all received guidance updates.

Guidance for Phase 3

Along with the Phase 2 changes, CMS provides additional guidance on implementing the requirements of Phase 3 and revises Chapter 5 of the State Operations Manual (SOM). Changes include new standards that eliminate state-by-state variations in Facility Reported Incidents (FRIs), including what must be reported and what forms must be used, with those changes occurring at the level of the State Survey Agency as well. There is new guidance on use of arbitration agreements in admission contracts, and CMS has developed the Psychosocial Outcome Severity Guide to assist providers in recognition (and surveyors in determination of appropriate scope and severity) in situations where the degree of emotional or psychosocial impact may not be obvious, but which would occur in a “reasonable person,” thus allowing surveyors to assign harm on that basis.

Pushing Double Occupancy

An important “recommendation” being made by CMS includes the number of beds permitted in a room. In 2016, ROP revisions stated, “For facilities that receive approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents.” Based on the Biden/Harris plan, Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes, dated February 28, 2022, CMS is “urging providers” to begin to work on physical environment changes with the intention of limiting bedrooms to no more than double occupancy. The purpose is clearly stated to promote resident privacy during care, create a more homelike setting, and improve infection control and prevention by reducing close contact. Other physical plant recommendations include complete review of heating and ventilation systems to maximize fresh air intake and reduce potential concentration of virus particles.

Let’s face it—it’s a lot. The following grid will assist in recognizing the need for policy updates, the use of new forms or documentation, and education and training of staff, residents, or families. Health Dimensions Group (HDG) recommends that you review your policies in comparison to the updated Appendix PP.[1] Changes to the ROP are noted in red. For every policy change—and in some cases, just to reinforce existing policies—staff training will likely be necessary.

Read part 2 now to complete this review.

F Tag #Policy Change RecommendedDocumentation/ Form ChangeTraining/Education Recommended
Respect and Dignity
In suspected substance possession or use and/or need to determine possession or source, new rules about search of person or belongings and notification requirements.Notification and documentation required, including the resident or representative providing informed consent as to reason for search/confiscation/action taken.Recognizing symptoms suggesting potential substance use or organic change; assure resident safety and condition. Requirement to notify supervisor, fully document objective observations and actions. When to involve law enforcement.
If facility policy changes to prohibit smoking, facility must notify current residents of the change and allow those who smoke to continue. Smoking location may be outside if in a safe, monitored location. New admissions must be fully informed of non-smoking status. Note requirements for a safe smoking area.Residents are fully informed of change through resident council and individually, especially smokers’ changes to smoking allowances. New admits receive written notification of facility non-smoking status.Staff in-serviced on policy changes and methods/systems and cautions/monitoring to be used to manage current smokers.
Right to Receive Visitors
1) Visitation Policy to be person-centered, considering psychosocial well-being and quality of life in balance with infection prevention precautions, which include screening, providing safe visiting spaces, signage about precautions, ample hand hygiene, etc. Clarification about visitation during infectious disease outbreak.

2) Policy for Visitation by an individual suspected of providing illegal substances to residents.

1) All infection control and prevention documents for screening and notification.

2) Documentation/notification and monitoring process for observation of behaviors and protection of resident suspected of using substances of abuse.

1) Staff to be trained in signs and symptoms of illness, prevention of illness, screening, testing, vaccination, and all internal systems to be used in managing COVID-19 and other infectious disease processes and illnesses.

2) See F557. If visitor is suspected of bringing in (current or history), requirement to monitor resident for safety and condition, notification of law enforcement, and rules around search of person or possessions.

Beneficiary Notification
Residents must be fully informed in advance when changes will occur with their bills. 1) Notice of Medicare Non-Coverage (NOMNC) requires two days’ advance notice of end of Part A stay or when Part B therapies are ending, except in specific circumstances. 2) Advance Beneficiary Notice (SNF ABN) must be provided under specific triggering events and with required timing.Develop process for notification, including designating person(s) responsible, backup plan, documentation to be provided, as well as internal documentation of notification.Train therapy staff, MDS, nursing and interdisciplinary team in process to be used to inform residents/ representatives of upcoming changes in treatment and impact on Medicare utilization, who and how notification is to be done.
Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect, and exploitation policy must now add an eighth element, coordination with QAPI. New guidance contains much interpretation of what constitutes abuse, neglect, and exploitation. For example, resident-to-resident conflicts that occur as part of everyday socialization may not be considered abuse. However, if either resident has impaired cognition or is a clear, repeated, or historic perpetrator, the situation may change. From a policy standpoint, every situation should be thoroughly investigated to rule out abuse and that investigation thoroughly documented. “Keeping each resident safe” includes ongoing tracking and monitoring to ensure situations do not intensify over time. To achieve a citation as past non-compliance, response  should include immediate safeguarding of each resident during and following investigation and assuring no further abuse can occur. Violations must be reported as required, an investigation must be thorough, and appropriate corrective action taken. The facility must continue to monitor that situation, as well as any similar situations that have been identified as creating similar risk. Follow the plan of correction format.

In the case of neglect, consider the nuance of indifference or disregard for resident care, comfort, or safety that results in physical harm, pain, mental anguish, or emotional distress. Note that a failure to implement appropriate communication between staff, shifts, etc., that results in harm, pain, or emotional distress can be considered neglect. The addition of the Psychosocial Outcome Severity Guide provides a way for surveyors to assign actual harm based on how a “reasonable person” would respond. Policy may include applying the Psychosocial Outcome Severity Guide tool to each situation to assure the facility response fully addresses the potential for psychosocial change or harm. With many new examples of non-compliance, a thorough reading of F600 is in order.

After a thorough policy review and revision and the addition of the eighth element to your policy, new assessment tools may be in order. Without question, the use of the Psychosocial Outcome Severity Guide should be incorporated into situations with a person with any level of cognitive impairment.Train staff to understand the potential for unrecognized harm per the Psychosocial Outcome Severity Guide. Abuse, neglect, and exploitation training of all staff at orientation, at least annually, with a recommendation for quarterly or monthly training for constant reinforcement of  policy elements, including screening, training, prevention, identification, investigation, protection, reporting/response, and coordination with QAPI.
Free from Restraints
New language: A bed rail is considered to be a restraint if “the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive ability to lower the bed rail independently.”Fully assess all bed rails in compliance with F700, including restraint assessments, safety checks, notification, consent, monitoring. Care plans must be updated.Train staff to avoid the use of bed rails, but if they are in place, to monitor for behaviors that might indicate the resident is not safe with the bed rail in place.
F606 Screening of Employees for Abuse PotentialAdd new definitions to policy which should require comprehensive screening of all “staff,” potential employees, contractors, volunteers, and students prior to contact with residents.

Develop and implement policies to prevent and prohibit abuse and neglect. Eight elements to be included: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting/Response, and Coordination with QAPI.

New FRI forms and requirements. Thorough documentation of each element to prevent and, in the event of an allegation, to investigate, protect, and respond completely.All staff should be thoroughly trained prior to contact with residents, periodically to enhance and refresh, and at any point where additional training may be warranted (a new problematic resident, heightened environmental stress such as burnout, etc.).
Transfer and Discharge
Distinguish a transfer from a discharge. Note a resident-initiated discharge versus a facility-initiated discharge and when each is permitted. Note specific language regarding investigating a resident leaving Against Medical Advice (AMA). (See F660 for additional details on AMA.) A Resident who is transferred to the hospital must be permitted to return except in very specific circumstances (See F626). Note transfer/discharge notification requirements.Review discharge and notification requirements as well as other tags cited to assure documentation is complete. Determine who in the facility is able to make a decision about whether or not to transfer or discharge a resident.Train staff to understand that a resident cannot be involuntarily discharged except in accordance with policy. Train staff to notify and manage AMA situations.
F623 Notice Before DischargeA facility-initiated discharge while a resident is hospitalized, or as an emergency transfer, requires notice of discharge to the resident and resident representative and the state LTC ombudsman before the discharge. Note requirements for such a notice. Note additional requirements for a resident with intellectual or developmental disabilities.

Note exceptions to requirement of 30-day notice prior to discharge or transfer requires notice made to resident, representative, and LTC ombudsman as soon as practicable before the transfer or discharge. A significant change, such as destination or reason for discharge, requires a new notice.

Review transfer and discharge process with primary and secondary person assigned as responsible. Review requirements by state LTC ombudsman for notice.Educate nurses, MDS, those responsible for transfer or discharge about criteria for transfer or discharge and notice requirements.
Permitting Residents to Return to Facility
Policy should reflect intent to allow residents, without regard for payment source, to return to facility after therapeutic leave or hospitalization. When a facility does not allow the resident to return, it is a facility-initiated discharge and must meet criteria in F623. Resident must be permitted to return to the facility and resume residence while an appeal is pending. Include specific criteria for not permitting return found in F626. Refer to previous discussion about AMA discharge.Review transfer and discharge policies to assure compliance. Review requirements for notification of transfer and discharge to LTC ombudsman.Educate nurses, MDS, those responsible for transfer or discharge about criteria for such transfer or discharge and notice requirements.
Accuracy of AssessmentsSee also F658
Diagnoses must be valid and verified by a licensed physician.A change in diagnosis cannot be made for the purpose of justifying the use or continued use of an antipsychotic.Instruct nursing, MDS, and physicians that a diagnosis that is consistent with allowing psychoactive drugs must be accurate and may be questioned if it is new or newly changed.
Comprehensive Care Plan
Add language requiring person-centered, culturally competent, and trauma-informed care. Assessment to be completed upon admission to identify individuals who have religious or cultural life patterns that may require special care. Identify individuals who may have experienced trauma and the care that should be avoided or utilized to improve a sense of well-being and safety.Include definitions of culturally competent and trauma-informed care.Educate all staff in person-centered care. Assure care plan staff, MDS nurses, and interdisciplinary teams understand the concepts and are able to determine when a resident requires culturally competent or trauma-informed care, and are able to create and implement a care plan with interventions which are sensitive to the resident’s history, preferences, practices, and needs.
Resident assessment should include understanding what gives an individual a sense of well-being, security, autonomy, growth, connectedness, identity, joy, and meaning, and activities that nurture this domain if well-being should be provided. Emphasis on person-centered care.Review resident activity assessment in use to assure this is being identified, honored, care planned, and implemented.Educate staff to understand the concept of well-being in person-centered care. How will this be communicated to staff and how can it be effectively implemented?
1) E-cigarettes/vape pens are not without risk and require oversight and management by staff. Residents who wish to use should be assessed for ability to use safety and facility determine where such devices can be used and stored to avoid any impact on those who prefer not to be exposed.

2) Staffing should reflect an awareness of residents with dementia, mental/psychosocial disorders, and SUD to assure sufficient staff.

3) Elopement: ”A situation in which a resident leaves the premises or a safe area without the facility’s knowledge and supervision, if necessary, would be considered an elopement.”

4) Safety of residents with SUD: SUD increases a risk of leaving the facility to satisfy an addiction and/or of illegal or prescription drug overdose.

5) Warning about the risk of asphyxiation due to bed rail/restraint use.

1) Determine how and when e-cigarettes/vape pens can be used, smoking assessment completed, and safety documented.

3) Complete wandering assessments to identify residents at risk and implement safety interventions.

2/4) Facilities are responsible for identifying resident risks and implementing interventions to reduce or eliminate the risks.

Instruct staff about policy on use of e-cigarettes and vape pens.

Assure staff is fully trained and prepared to identify and provide safety and assistance to residents who have dementia, or mental/psychosocial disorders or SUD.

Educate staff on definition of elopement to assure protections and reporting.


Parenteral Fluids
Facility must develop and implement resident care policies based on professional standards of practice for preparation, insertion, administration, maintenance, and discontinuance of an IV and must include procedures for care and use of all equipment such as pumps, tubing, syringes, fluids, etc.Develop documentation standards, assessment and monitoring systems to assure ongoing safety and evidence of care.Assign IV care to RNs or to LPNs who are competency evaluated if permitted by the state in which the facility operates.

Establish monitoring system to assure proper technique is used consistently.

Pain Management
Pain management policy should recommend a facility study patterns of pain, times of day, and non-medication strategies to reduce or prevent pain. The use of opioids should be reduced or avoided due to risk of addiction and overuse. If the decision is to use opioids, the facility should use a structured process of assessing for side effects, using the lowest dose which is effective, and requiring the oversight of a physician and/or pharmacist to effectively manage the use of opioids.Establish a system to minimize the use of opioid medications. For those residents who are prescribed opioid medications, dosage, effectiveness, and the potential for side effects should be closely monitored. Coordinate oversight with pharmacy and physician.Educate nurses to assess pain and the need for medication prior to administering medications, observe for side effects, and monitor for indication of overuse or abuse.
Trauma-Informed Care
The facility will assess each resident upon admission and as indicated to identify trauma survivors and assure they receive culturally competent, trauma-informed care in accordance with professional standard to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Cultural competencies aid in communication with residents and families and help provide care that is appropriate to the culture of the individual.

Assess for potential trauma history. Develop a plan of care which reduces the potential for re-traumatizing the resident. Document any signs or symptoms of distress. Inform the interdisciplinary team/ social worker of events which appear to cause distress and interventions which may be effective in reducing distress. Care plan to address past trauma. Care plan to address cultural needs/preferences/strategies.Train staff to recognize events which may trigger and signs and symptoms of being triggered by a situation or of emotional or psychosocial distress and a plan to intervene to protect the resident and reduce his/her distress.

Train staff to appreciate the unique aspects of an individual’s culture and heritage and to assist in communicating effectively and planning care that is consistent with personal preferences, beliefs, and history.

Bed Rails
The facility must attempt to use appropriate alternatives to installing side or bed rails due to a known risk of asphyxiation, entrapment, and other injuries. Facility will attempt to use alternative interventions to assist the resident in bed mobility and safety prior to considering the use of bed rails. Any bed rails installed must be assessed for resident risk of entrapment prior to installation and periodically thereafter, after informing the resident/representative of the alternatives tried, medical needs, potential risks and hazards and likely benefits and obtaining a signed informed consent. Facility will keep a record of beds with rails and the assessments.

Note: When considering potential for entrapment, address the use of air-filled mattresses and other specialty surfaces. In the case of low air loss systems, air pressure should be prescribed and monitored to assure a surface that is supportive but not over-inflated.

See this guide[2] for information to help assure mattress and rail fit is correct. Inspect every bed with a rail, grab bar, or alternative surface.

Monitor and document regularly (for example, monthly) and anytime there is a change.

Train staff in observing for the safe fit of surfaces, correct inflation of air-filled surfaces, and observation of the resident’s ability to safely benefit from bars, rails, and surfaces.
Frequency of Physician Visits
The rule still requires a physician visit at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. There is clarification on when telemedicine can replace an in-person visit and how a Non-Physician Practitioner (NPP) can be used. There is clarification on who can sign what orders and when.Use a system to assure compliance with physician, and/or NPP visits occur within 10 days of the calendar due date. Assure orders are signed on a timely basis.Educate the assigned individual(s) and a backup system to maintain compliance with this rule.
Sufficient Staff
Remember that CMS does not, at this time, state a required staffing ratio, but each state does. Sufficient staffing is determined by outcomes. Policy should state that the facility will meet state minimums and provide sufficient staff to meet the needs of care and safety of residents to meet their highest practicable level of physical, mental, and psychosocial well-being. It is highly recommended that facilities begin to work toward 24-hour RN presence, but no less than eight consecutive hours in any calendar day.Staff should be able to state confidently that they consistently have the time and the materials needed to safely and fully provide care. Outcome measures such as falls, wounds, weight loss, call-light wait time, and resident satisfaction should be tracked to demonstrate sufficient staff.Train staff to work in teams, provide assistance to each other, and be aware of resident needs. Remind staff to ask for help when needed and to follow safe patient handling rules at all times.
Registered Nurse
The facility will consistently use the services of an RN for at least eight consecutive hours a day, seven days per week (note, per PBJ, the eight hours must occur on the same calendar day). The facility will designate an RN to serve as the director of nursing on a full-time (40 hours a week) basis. The director of nursing may serve as the charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.RN staffing should be based on medical and psychosocial acuity such that all residents consistently receive the services needed to sustain highest practicable level of physical, mental, and psychosocial well-being. Person-centered care with quality outcomes.Train staff to understand the need to comply with this rule.
Nurse Staffing Information
Posting requirements have not changed, but guidance adds that a document that contains required staffing data must be posted in a prominent place that is readily accessible to residents and visitors and is presented in a clear and easy-to-read format. Staffing data should include all paid staff (employee or contract) and should include a) facility name, b) current date, c) total number and actual hours worked by each category of nursing staff (RN, LPN, and CNA) and d) census. This must be posted at the beginning of each shift. Data must be made available upon request and should be maintained for 18 months or greater (if required by state law).Create a form and a process to assure this is completed every shift and every day. Make it simple and straightforward and assign it to a specific staff position so it is always completed.Train staff to understand this form, where it is posted, and to provide a copy to an individual resident, family member, or member of the public upon request.

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How HDG Can Help

With an abundance of experience in long-term care and senior living, Health Dimensions Group is prepared to assist your community in drafting workable, user-friendly policies, as well as full implementation. We are actively assisting facilities in working through the workforce crisis while maintaining clinical and regulatory excellence, and in developing new strategies to sustain successful operations during this challenging period in the industry. To learn what we can do for your organization, please contact us at or 763.537.5700.