QSO-22-19-NH: What Changed in Appendix PP & How to Prepare - Part 2

QSO-22-19-NH: What Changed in Appendix PP and How to Prepare. Part 2 of 2

The release of QSO-22-19-NH has the skilled nursing industry abuzz with all the updates 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.

You read about some of the bigger changes in Part 1 of this series, now read on for a summary of some of the smaller changes and what you should do to prepare.

F557 Respect and Dignity


New information around search of a resident’s body or possessions when it is suspected the resident may have obtained illegal substances state you must have obtained expressed consent of the resident or responsible party (as legally defined). Only items or substances which pose a risk to resident health or safety, and are in plain view, may be confiscated.

What You Should Do

Educate your team to have knowledge of signs, symptoms, and triggers of possible illegal substance use (changes in behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and/or loss of consciousness). Team members should understand when it is appropriate to simply ask residents who appear to have used an illegal substance (e.g., cocaine, hallucinogens, heroin) if they have used or are in possession of an illegal substance. They can provide education to the resident on why this is of concern and the risk factors of this action or behavior, document this education and the resident’s response, and adjust the care plan accordingly. Policies should be reviewed and updated as necessary.

F561 Self-Determination


Smoking must be allowed to continue in a safe manner for residents who already reside in a community after it changes its policy to non-smoking. Consideration must be taken for quality of life and safety for smokers and non-smokers alike.

What You Should Do

Ensure new residents are informed prior to admission and educated upon admission that you are not a smoking property. It will be important for them to understand that while residents who resided in the community prior to the change in policy are still permitted to smoke under specific circumstances, no one admitted after the date of the policy change is permitted. Be prepared to provide alternatives, such as smoking cessation, nicotine patches, gum, or lozenges for those new admissions.

F563 Right to Visitation


Guidance on how to manage visitation during a communicable disease outbreak has now been included under the visitation regulation. While this is specific to infection control, the adherence to the core principles of infection prevention is critical to ensure we reduce the risk of transmission of any infectious disease during visits to the community by family and loved ones.

What You Should Do

While the addition of this information in Appendix PP is new, the content is not new to us. This is simply the visitation practices we have been following through the pandemic. So, nothing new to do here, unless of course you haven’t gone back to allowing visitors into your community, in which case you will want to do so immediately. The key here is notifying visitors of the risk of visiting during an outbreak, especially if their intent is to visit a resident in isolation, and to allow for safe visits by providing proper PPE when needed, ensuring they have access to hand hygiene supplies, and using signage that provides instruction on proper infection control measures expected of a visitor.

F582 Beneficiary Notices


Clarified language is now included as to when a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice of Non-Coverage (ABN) should and should not be issued to residents.

What You Should Do

Ensure your team understands not only when, but when not, to issue a NOMNC or ABN to a resident. The new language in Appendix PP is clear and concise with examples that you should be familiar with and understand.

F622 Transfer and Discharge


There are clarifications on resident-initiated versus facility-initiated discharge, leaving against medical advice, and emergency transfers to acute care. For acute care transfers, there is now clear guidance that these transfers are not considered “discharges” and that the residents must be evaluated at the time they are ready to return to the community for the ability to meet their needs and be re-admitted, versus at the time and in the state in which they were transferred. The new examples of scope and severity take into consideration the Psychosocial Outcome Severity Guide.

What You Should Do

Ensure that you provide education to your team that with transfers to acute care emergency departments, these do not meet the requirement for discharge from the community. For residents to be considered for discharge, you must have evidence that the requirements for discharge are met based on the resident’s needs, behaviors, and status at the time of return to the community from the hospital, and not at the time the resident was transferred out to the hospital.

F641 Accuracy of Assessments, F658 Professional Standards, and F758 Unnecessary Use of Psychotropic Medication


Use of the diagnosis of “Schizophrenia” eliminates the requirement for gradual dose reduction and may artificially improve the long stay quality measure for antipsychotic use. Surveyors are provided regulatory guidance to investigate situations where this may be happening. F758 additionally has new guidance that specifically states that in instances where a psychotropic medication has been ordered, substitutions from other classifications, such as antihistamines, anti-cholinergic medications, and central nervous system agents, which can also affect brain activity, should not be used. If their documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication, then requirements pertaining to psychotropic medications will apply. Additional guidance for gradual dose reduction (GDR) attempts has also been added, giving guidance on what meets the criteria for attempting a GDR in an adequate amount of time.

What You Should Do

Ensure that each use of an antipsychotic medication is justified by an appropriate indication for use. Audit specifically for the use of the diagnosis of schizophrenia to ensure it has not been inaccurately used by the practitioner or on your minimum data set (MDS) assessment. Obtain clarification from physicians if necessary and update your indication for use and MDS if needed.

F847 Entering into Binding Arbitration Agreements


A new section covering arbitration has been included and prohibits communities from requiring residents to sign binding arbitration agreements as a condition of admission or continued care.

What You Should Do

If you find a need for an arbitration agreement to resolve a dispute, ensure you are familiar with all the requirements of F847, so the resident and/or representative can be fully informed of their rights and choices surrounding their care, health, safety, and welfare.

F868 QAA Committee


While it is not new for the infection preventionist to participate on the Quality Assessment and Assurance (QAA) committee, new language requires the infection preventionist to report on a regular basis, which is defined as reports occurring with the same frequency as the QAA committee meetings.

What You Should Do

Ensure your infection preventionist participates on the QAA committee with each meeting.

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 ensure you are survey ready, please contact us at info@hdgi1.com or 763.537.5700.

Authored by:

Kim Barnes, RN
Vice President, Clinical Operations


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