State Operations Manual Updates Affect Nursing Home Surveys

CMS has issued revisions to Chapters 5 and 7 of the State Operations Manual (SOM) that affect how nursing homes are surveyed, cited, and revisited for compliance. Read the DSHS Dear Provider Letter (DPL) here.

Chapter 5 updates include revised examples for determining Immediate Jeopardy (IJ) in nursing homes and clarification on when and how off-site investigations may be used.

Chapter 7 contains more significant operational and enforcement changes. CMS has moved guidance on nurse staffing waivers and resident room variances from Appendix PP into Chapter 7 and clarified that this process is separate from the survey process. The chapter also clarifies expectations for on-site versus off-site revisits, updates how surveyors identify and clear Immediate Jeopardy, and provides additional direction on when IJ severity may be lowered after removal.

CMS also clarified what constitutes an acceptable plan of correction, revised civil money penalty (CMP) enforcement guidance to reflect current practices and annual inflation adjustments, and aligned enforcement policy with the FY 2025 SNF payment rule—strengthening CMS’ ability to impose CMPs for health and safety deficiencies. In addition, the guidance clarifies how CMP reinvestment funds may be used, how applications are reviewed, and notes that state CMP fund balances will be publicly posted.

Finally, CMS aligned Informal Dispute Resolution (IDR) procedures with the Independent IDR (IIDR) process and added new guidance on how deficiencies under dispute are recorded in CMS systems to improve transparency. Additional technical and reference updates were also made, including moving content previously found in Appendix P into Chapter 7.