CMS Updates Chapter 5 and 7 of the SOM Also Posts an Administrative Information Memorandum for States and Surveyors

Posted in INDUSTRY NEWS, Long-Term Care

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

Last Friday, February 10, 2023, CMS posted these Transmittals:

The 24 pages in the Chapter 5 Transmittal and the 84 pages in the Chapter 7 Transmittal are the changed pages for each Chapter.  The complete Chapters are found:

Also, on February 10, 2023, CMS posted Admin Info: 23-06-NH … State Operations Manual Chapter 5- Implementation Dates for Revised Guidance.  I encourage you/your team/colleagues to review this Administrative Memorandum as it applies to implementation of the revised guidance in Chapter 5 – Complaints.

Given how these revisions to Chapter 5 would impact state operations, CMS recognizes that state survey agencies will need time to prepare for full implementation. For example, some state survey agencies may need to hire and train additional surveyors; some state survey agencies may need to also hire staff to enter data into ACTS, or make adjustments to their tracking and data systems to accommodate CMS’ requirements. Since this may involve state employees and processes, the state survey agencies may need to request legislative and/or administrative approval for position authority, position development, recruitment and onboarding. In addition, due to suspending survey activities during the COVID-19 Public Health Emergency, the states are experiencing a backlog of surveys that need to be conducted. Therefore, CMS is expecting the state survey agencies to implement the following:

  • No later than October 1, 2023- Implementation of the maximum investigation timeframes, including the development and implementation of policies and procedures for complaints and facility-reported incidents (SOM Sections 5075 and 5310.2). 
  • No later than October 1, 2024- Implementation of data entry requirements into ACTS (SOM Section 5060).

[Note: Subscribers to Briggs 1766 – Survey Guide – Interpretive Guidelines for Long-Term Care and 1766E – Survey Guide – Interpretive Guidelines for Long-Term Care – eManual will receive the updated Chapters this week.]