Regulatory Update

CMS Revised Surveyor Guidance

Polaris Group Profile
Polaris Group
June 30, 2022
March 14, 2023
Polaris Group Profile
Polaris Group
March 14, 2023

Surveyors will be using new CMS Phase 2 and Phase 3 guidance to identify non-compliance as of October 24th, 2022.

Download PDF
Download icon

CMS clarified their Phase 2 and Phase 3 guidance from 2017 and 2019 respectively.  Surveyors will be using this new guidance to identify non-compliance as of October 24th, 2022.  

Phase 2 guidance surrounds enhancing quality and oversight in the areas of abuse and neglect, admission, transfers, discharges and improving care for individuals with mental health or substance use disorder needs. Surveyors will be using the Payroll Based Journal staffing data to inform surveyors of potential staffing concerns.  The revisions also include CMS expectations for ensuring visitations can occur while preventing community-associated infection or the spread of communicable disease.  This phase also includes assistance in investigations of misdiagnosed or coded residents with schizophrenia.  

Phase 3 guidance surrounds ensuring facilities have assigned an Infection Preventionist and prohibition of requiring residents sign binding arbitration agreements as a condition of admission or continued stay in the facility.

CMS has also revised Chapter Five of the State Operations Manual related to investigating complaints and facility reported incidents.  The Government Accountability Office reported variations among state in the processing and tracking of abuse/neglect reports and investigating complaints timely.  

The last revision is in the Psychosocial Outcome Severity Guide.  This revision will assist surveyors in applying the guidance and categorizing a deficiency at the appropriate severity level.

All the revisions can be reviewed at QSO-22-19-NH (  

CMS is also updating other survey documents, including the Critical Element (CE) Pathways, which are used for investigating potential care areas of concern. CMS will update these documents found in the “Survey Resources” link in the Downloads Section of the CMS Nursing Homes website, by October 24, 2022. Lastly, the LTCSP will assist the survey team in the identification of low staffing concerns by utilizing PBJ data.

CMS has included guidance training that will explain the updates and changes of the regulations and guidance. Surveyor training on the updated LTCSP software is forthcoming in QSEP in September 2022.

continue reading

Sign-up for the Polaris Pulse Newsletter

We filter out the noise and provide you the information you need to keep you informed.

I want to subscribe to...
Great– your all set!
You will start receiving our Polaris Pulse Newsletter in your inbox.
Oops! Something went wrong while submitting the form.