Read Appendix PP: Here’s a Survey Study Guide

By Caralyn Davis, Staff Writer - August 09, 2017

“Quite a bit” of the regulatory requirements for survey won’t change with the Nov. 28, 2017, rollout of Phase 2 of the Reform of Requirements for Long-term Care Facilities (aka Mega-Rule), say officials with the Division of Nursing Homes in the Survey and Certification Group at the Centers for Medicare & Medicaid Services (CMS) during the video Appendix PP: Overview of Revised Interpretive Guidance.

“Most of the minimum quality standards that were in the regulation remain,” they explain. “There are still strong resident rights, use of the Minimum Data Set to do assessment and care planning based on the residents’ goals and preferences, and the input of the interdisciplinary team. There are still requirements for a medical director, a full-time licensed nurse, and requirements for medication review.”

However, while some of the regulatory underpinnings remain familiar, much of the subregulatory guidance found in the advance copy of the revised Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” in the State Operations Manual has changed significantly—even for regulations not specifically impacted by Phase 2, stresses Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, AADNS curriculum development specialist.

“For example, the only Phase 2 change associated with §483.12 (Freedom From Abuse, Neglect, and Exploitation) of the Code of Federal Regulations (CFR) is the requirement that providers report any reasonable suspicion of a crime in accordance with Section 1150B of the Social Security Act,” points out Stewart. “However, §483.12 (F600 – F610) in Appendix PP contains a multitude of revised guidance, including information about how position change alarms could be considered a physical restraint in F604 (Right to Be Free From Physical Restraints). In some states, directors of nursing services (DNSs) have encountered this, but in other states it will be completely foreign and new.”

In fact, Appendix PP contains so many changes identified in red that it’s practically brand-new, she notes. “Consequently, DNSs who don’t read the entirety of the new Appendix PP will be at a distinct disadvantage when state surveyors walk in the door after Nov. 28.”

Determining how to break down a 696-page document can be difficult. “It is hard to tailor it because everything is important,” stresses Stewart. However, here are two suggestions on where to start:


1. Use past and current problems to identify areas for review

“DNSs should look at issues they have been cited on in past surveys, as well as issues that they’ve seen happening recently in the facility,” suggests Stewart. “To find the new F-tags for issues from past surveys, use the crosswalk provided by CMS. Then read the new interpretive guidance for those issues. This will help DNSs be up-to-date on the areas where they have the highest probability of getting tagged.” Note: Need Excel viewer to use the crosswalk? Access it here.


2. Target areas where CMS is focusing education

CMS has developed a video education series for surveyors targeting nine areas of revised interpretive guidance—a sure sign that DNSs should highlight these areas as well in their survey preparation activities, says Stewart. The videos (and the related Appendix PP sections) are as follows:

·         Admission, Transfer, and Discharge Rights (§483.15, F620 – F626);

·         Behavioral Health Services (§483.40, F740 – F745);

·         Facility Assessment (§483.70(e), F838);

·         Freedom From Abuse, Neglect, and Exploitation (§483.12, F600 – F610);

·         Infection Control (§483.80, F880 – F883);

·         Person-Centered Care (§483.10, Resident Rights: F552 – F555, F557 – F559, F561, F563 – F565, F573, F576; §483.21, Comprehensive Person-Centered Care Plans: F655 – F657, F660 – F661; §483.24, Quality of Life: F675; §483.25, Quality of Care: F684; §483.60, Food and Nutrition Services: F800, F803, F809; and 483.70(e), Facility Assessment: F838);

·         Quality Assurance and Performance Improvement: The Basics (§483.75, F865, F867, F868);

·         Quality of Life and Quality of Care (§483.24, F675; §483.25, F684) Note: F684 is F309 in the current survey process; and

·         Nursing Services (§483.35, F725 – F726, F729 – F730).

Why watch the videos and read the interpretive guidance? Appendix PP contains details that can’t be included in videos that range from 10 to 30 minutes long. “For example, there are some examples of deficiency categorizations in the Resident Rights section that DNSs will want to be familiar with,” says Stewart.


How to read Appendix PP: Critical element pathways and more

In the Overview video, CMS officials describe how the revised Appendix PP is structured and how providers can use that structure to understand more about the survey process. All F-tags will still begin with the regulatory citation and the exact regulatory language in bold. Then they follow this structure:

* Intent. This section “offers additional information and key context for the regulation,” say officials. “What is the purpose? What is the intended quality issue that this addresses?”

* Definitions. “These definitions come from a couple of places. In some cases, they come directly from 483.5, which is the Definitions section of the regulation. In other cases, we added definitions that are relevant for that regulatory section,” say officials. “For example, in the Admission Transfer, and Discharge interpretive guidance [at F622], we define facility-initiated [transfer or] discharge vs. a resident-initiated [transfer or] discharge. We have added this definition because it is important to understanding compliance with that particular requirement.”

* Interpretive Guidance. “This section is the primary component where CMS describes what is compliance with that particular section. We may reference important concepts related to compliance, may establish frameworks that allow facilities to think about different aspects of compliance, and reference standards of practice,” say officials. “As a reminder, surveyors must cite to the regulations themselves and not to the interpretive guidance.”

* Investigative Summary / Investigative Summary and Probes / Procedures and Probes / Investigative Protocol. “This section may be called any of these items. The reason they can be called a few different headings is that this will guide you in understanding whether or not there are other survey documents called critical element pathways or CE pathways that are used by surveyors in determining compliance,” say officials.

“In general, this section is intended to tell the reader how compliance with that section will be investigated or evaluated. There are three sources of information: interview, observation, and record review,” they explained. “This section will describe exactly what will be reviewed if there are concerns identified.”

If Investigative Summary is the section heading, “there is a specific critical element pathway or facility task that the surveyor would use to investigate that area,” say officials. “What is in Appendix PP is a high-level summary of that CE pathway [or task]. Investigation of subjects like assistance with activities of daily living, personal funds, and sufficient staffing are covered in a facility task or a critical element pathway. In these cases, we refer the surveyor to those documents to avoid duplication and confusion.”

Note: CMS is currently revising and expanding the CE pathways and facility tasks used in the Quality Indicator Survey to meet the needs of the new national survey process. Stay tuned for links to these important documents. (See a list of CE pathways and facility tasks currently mentioned in the revised Appendix PP at the end of this article.)


* Key Elements of Noncompliance. “This is a new section that we have added to certain tags,” say officials. “[W]ithin all the guidance, we didn’t want the key points to be lost, and we didn’t want to just restate the regulation. Our goal was to try and summarize the key elements and make it as clear as we could, and share with the surveyor what the main points to focus on include.”

To develop the Key Elements of Noncompliance, “in many cases we looked at the case law to determine what was needed and what wasn’t needed to have a deficiency,” say officials. “For example, in the area of sufficient staffing [F725], there was the belief that, to cite a sufficient staffing tag, resident outcomes needed to be explicitly tied back to the resident’s care plans in all cases. Based on our review, that does not need to be the case where there are certain basic needs like perhaps being fed or having assistance with activities of daily living. The surveyor [doesn’t] have to have an explicit care plan reference for those areas.”


* Deficiency Categorization. “This section is intended to provide examples of level 1, 2, 3, and 4 deficiencies. These are examples to help identify the types of noncompliance that rise to [each] level of deficiency,” say officials. “In some cases, depending upon the tag we have indicated that severity level 1 would not apply for that particular regulatory requirement. These examples are those cases where any level of noncompliance with that has the potential to result in more than minimal harm.”

For example, all of the F-tags in §483.12 (Freedom From Abuse, Neglect, and Exploitation) that include deficiency categorization examples have no level 1 examples, points out Stewart. “They’re severity level 2 and above.”


* Potential Tags for Additional Investigation. “When surveyors have finished their investigation, “there may be related systems or processes or outcomes that may also have noncompliance. This section identifies the major tags,” say officials. “As a reminder, these are not automatic citations for other areas, and there must be an independent investigation of those tags before cross-referencing. It is not just a copy and paste of the same evidence.”


What to do with what you learn

DNSs should start now reviewing key F-tags with staff, suggests Stewart. “For example, once a week or even daily during the stand-up meeting, they should share some of the changes. It needs to be done on a routine basis because it’s going to take a lot of time to get through them all.”




Critical element pathways and facility tasks discussed in the advance copy of Appendix PP


· Abuse Critical Element Pathway (Form CMS-20059)

· Neglect Critical Element Pathway (Form CMS-20130)

· Physical Restraints Critical Element Pathway (Form CMS-20077)

· Critical Element Pathway for Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review (Form CMS-20082)

· Critical Element (CE) Pathway for Hospitalization

· General Critical Element Pathway

· Community Discharge Critical Element (CE) Pathway

· Activities of Daily Living Critical Element (CE) Pathway

· Activities Critical Element pathway

· Hospice and End of Life Care and Services CE Pathway

· Communication-Sensory Critical Element (CE) Pathway

· Pressure Ulcer Critical Element (CE) Pathway

· Positioning, Mobility & Range of Motion (ROM) Critical Element (CE) Pathway

· Accidents Critical Element (CE) Pathway

· Bladder and Bowel Incontinence Critical Element (CE) Pathway

· Urinary Catheter and UTI CE Pathway

· Nutrition and Hydration Critical Element (CE) Pathway

· Tube Feeding Critical Element (CE) Pathway

· Respiratory Care Critical Element (CE) Pathway

· Pain Recognition and Management Critical Element (CE) Pathway

· Dialysis Critical Element (CE) Pathway

· Sufficient and Competent Staffing Critical Element Pathway

· Behavioral and Emotional Status Critical Element Pathway (CMS-20067)

· Dementia Care Critical Element Pathway (CMS-20133)

· Medication Administration Observation and the Medication Storage and Labelling Critical Element Pathway

· Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway

· Dental Care Area Pathway

· Hospice and End of Life Care and Services Critical Element (CE) Pathway

· Medication Administration Observation Facility Task

· Facility Task Pathway for Quality Assurance and Performance Improvement (QAPI) Plan and Quality Assessment and Assurance (QAA) Review

· Infection Control Facility Task

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