Updated LTCSP Reports

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

On November 15, 2022, CMS quietly posted 2 Exhibits/Reports that have had placeholders in Chapter 9 (Exhibits) of the State Operations Manual. Chapter 9 shows a revision date of October 21, 2022.

If you access those hyperlinks on the last page of the current Chapter 9, there’s nothing to see.

Page 157 of the October 21, 2022 Appendix PP references these Exhibits:

Neither hyperlink provides the Exhibit identified. On November 15, 2022, CMS provided both exhibits separately on this landing page.  Both Exhibits carry the date of November 10, 2022.

  • Exhibit 358 is found here. This sample form can be used to ensure the reporting of reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Act; and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property. The information collected is critical in determining what may be occurring in a facility and the effect(s) that it may have on residents. The sample form is 7 pages in length.
  • Exhibit 359 is found here. This Follow-up Investigation Report is 6 pages in length. Within five (5) business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to, the following …

The most recent Revision History for LTC Survey Process Documents and Filesis dated October 26, 2022.  It’s prior to the November 10th date when the Exhibits were posted separately as PDFs.  There is no mention of either Exhibit in that Revision Hx. 

Please review both PDF documents/Exhibits. I’ll keep an eye on the online SOM, watching for the documents to be incorporated into Chapter 9.  When that’s available, I’ll post a blog to notify you.