Compliance & Enforcement

Regulatory

Regulatory Compliance & Enforcement

Surveyors are now using the below guidance and State Operations Manual updates to identify non-compliance that became effective on October 24, 2022:

Regulatory requirements and compliance

CMS memo detailing surveyor guidance clarifying specific regulatory requirements and provided information on how compliance will be assessed. In addition, CMS has revised its guidance to State agencies, to strengthen the management of complaints and facility reported incidents. Download the memo from CMS>

Download information from CMS:

QSO-22-19-NH: Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide.
State Operations Manual Chapter 5 – Complaint Procedures
State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities

Lastly, the LTCSP will assist the survey team in the identification of low staffing concerns by utilizing PBJ data. LTCSP Survey Resources.

The American Health Care Association (AHCA) has created this Detailed Overview to help members filter through the changes to the immense guidance document issued by CMS.

A-Z Resources
A	(here).DOJ abuse training video, curriculum and trainer materials. (2023) All Cause Harm Prevention in Nursing Homes (November 2018)
B	Bed Rails Safety Video Bed Rails: Informed Consent (2016) Bed Rails: Hospital Bed Entrapment Assessment Information
C	Contact Your District Office
D	3.5/2.4 Direct Care Service Hour Requirements (SB 97, Chapter 52, Statutes of 2017) SNF Change of Director of Nursing Application Packet
E	End of Life Act Guidelines (2016) End of Life Talking Points (2016)
F	Facility Assessment Tool (8/18/2017) Facility Assessment Data Collection (9/14/2017)
G
H	HIPPA (5/26/2016)
I	IDR Toolkit (08/04/2015) Identity Theft: LTC Template (2009) Identity Theft: LTC Red Flags (2009)
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K
L	Legionella: CDC Toolkit LGBT: Required Training (8/14/2019)
M	CMS Minimum Data Set (MDS 3.0) Information
N
O	Ombudsman: Directory of Local Ombudsman Programs Ombudsman: Transfer/Discharge Notices (10/2017) Ombudsman: Written Notice - Local Long-Term Care Programs and Websites (01/2023)
P	Pharmacy: 2020 Lawbook for Pharmacy Electronic Plan of Correction (ePOC) for Skilled Nursing Facilities
Q
R
S	SFF Posting with Candidate List - April 2022 (cms.gov) Schizophrenia Minimum Data Set (MDS) Audit (1/20/23)
T	Title 22 Workbook (2016) Title 22 Administrator Entrance Conference Worksheet (8/4/2009) Transfer/Discharge Assessment Form Transfer/Discharge Flow Chart Transfer and Discharge Guidelines (05/2011)
U
V
W	Workplace Violence (2017) COVID-19 Facility Waivers Waivers CDPH Webinar (Submitting Patient Needs Waivers and Workforce Shortage Waivers ) (2023)
X
Y
Z

Regulatory

Regulatory Compliance & Enforcement

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