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The State Operations Manual (SOM) contains the primary survey and certification rules and guidance from the Centers for Medicare and Medicaid Services Internet-Only Manual System for LTC providers. The entire manual can be accessed online here.
Chapter 1, "Program Background and Responsibilities," explains the basic role of certification and recertification in ensuring that healthcare providers meet the Medicare/Medicaid conditions of participation. It outlines CMS' role in the process, as well as the responsibilities of the state survey agencies.
Chapter 2, "The Certification Process," reviews the requirements for initial certifications, the rules for approval or denial, and procedures for reconsideration; issues involving change of ownership and voluntary terminations from Medicare; readmission criteria after involuntary terminations from Medicare or Medicaid; and timing requirements for resurveys.
Chapter 3, "Additional Program Activities," explains the rules involving adverse actions, including initial denials of Medicare provider requests for program participation and the basis for terminating provider participation; the role of documentary evidence in determining noncompliance, and documentation and notice requirements for terminations; the procedures for reconsideration, hearings, and appeals; and the impact of changes in provider status or services, including the requirements for distinct-part certifications for skilled nursing facilities, changes in designated bed sizes/locations, and changes in ownership.
Chapter 4, "Program Administration and Fiscal Management," explains the core roles and responsibilities of the federal government and the state survey agencies throughout the survey-and-certification process. For example, this chapter includes information about the Quality Indicator Survey training process for surveyors, as well as federal minimum qualification standards for surveyors. Other sections cover the deeming and waiver of nurse aide training and competency evaluation requirements, as well as curriculum requirements for those programs; nurse aide registries; and Resident Assessment Instrument specifications, including state-specified RAI requirements.
Chapter 5, "Complaint Procedures," reviews the purpose of the complaint/incident process; how state agencies should manage the intake of complaints; how state agencies should prioritize complaints as immediate jeopardy—high, medium, or low, administrative review/offsite investigation, referral—immediate or other, or no action necessary; and maximum time frames for onsite investigations. Specific sections related to nursing homes include: investigation of complaints for nursing homes; action on complaints of resident neglect and abuse, and misappropriation of resident property; reporting findings of abuse, neglect, or misappropriation of property to the nurse aide registry; reporting abuse to law enforcement and the Medicaid fraud control unit; and post-survey certification actions for nursing homes.
Chapter 7, "Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities," is the core "how to" chapter of the State Operations Manual for nursing home surveys and enforcement actions by state agencies. The chapter opens with definitions of a skilled nursing facility and a nursing facility, and explains special waivers that may apply to SNFs and NFs, such as a waiver of the seven-day RN Requirement for SNFs. In addition, this chapter covers:
The survey process. Topics in these sections include but are not limited to:
The enforcement process. Topics in these sections include but are not limited to:
Remedies. Topics in these sections include but are not limited to:
Civil money penalties. Topics in these sections include but are not limited to:
Program management. Topics in these sections include but are not limited to:
Disclosure. Topics in these sections include but are not limited to:
Appendix I, "Survey Procedures for Life Safety Code Surveys," reviews the six survey tasks for surveyors during a life safety code survey: offsite survey preparation, entrance conference/onsite preparation, orientation tour, information gathering, information analysis and decision-making, and the exit conference. This section also addresses complaint investigations and survey revisits.
Appendix P, "Survey Protocol for Long-term Care Facilities – Part I," spells out the exact survey process for the two types of standard survey: the Quality Indicator Survey (QIS) and the traditional survey. QIS topics include the QIS standard survey, the QIS extended survey, the QIS post-survey revisit, and QIS complaint survey procedures.
Traditional survey sections review all seven surveyor tasks:
Other traditional survey topics include the traditional extended survey and partial extended survey; the traditional post survey revisit; the traditional abbreviated standard survey; complaint investigations; substantial changes in a facility's organization and management; writing the statement of deficiencies; deficiency categorization; confidentiality and respect for resident privacy; and information transfer.
Appendix PP, "Guidance to Surveyors for Long-term Care Facilities," contains the relevant sections of the Code of Federal Regulations (42 CFR 483), the corresponding F-tags (F150 - F522), and the interpretive guidelines that surveyors are expected to use in assessing nursing facility compliance with the Medicare/Medicaid conditions of participation. These instructions cover the full range of operational, physical plant, and quality issues that surveyors assess. For example, sections include:
Please note, the Advance Copy Revisions to State Operations Manual (SOM), Appendix PP-Revised Regulations and Tags was released on November 9, 2016.
Appendix Q, "Guidelines for Determining Immediate Jeopardy," provides surveyors with detailed steps for determining whether an immediate jeopardy exists. These instructions include triggers for further review, examples of immediate jeopardy, and procedures to follow when immediate jeopardy is cited.