Using CMS Survey Tools and QAPI Principles to Evaluate Regulatory Compliance

      The June 29, 2022, release of QSO-22-19-NH from the Centers for Medicare & Medicaid Services announced significant revisions to surveyor guidance, which affected 62 regulations within 19 of the 21 regulatory groups (see Changes to component(s) of the intent, interpretive guidelines, investigative procedures, probes, key elements of noncompliance, deficiency categorizations, and additional tags for investigation have necessitated a wide range of practice changes for skilled nursing facilities.
      Providers were stocking up on highlighters and trying to make time for the ever-expanding “to be read” pile as additional key releases followed the memo in rapid succession. For example, changes to the Five-Star Quality Rating System methodology for staffing resulted in additional technical guidance and, consequently, an overwhelming majority of SNFs losing one or more stars.
      Soon after the revision of the surveyor guidance, CMS also updated the Prospective Payment System (PPS) Final Rule, SNF Quality Reporting Program (QRP), the SNF Value-Based Purchasing (VBP) Program, and the draft MDS Nursing Home Comprehensive (NC) Item Set for FY23. Many of the regulatory updates, changes to quality measurement, and payment adjustments are tied to the pandemic aftermath and the Biden-Harris administration’s aims for nursing home reform.
      With the deluge of new information, providers sprinted to integrate the changes into their daily practices and educate staff before October 24, 2022, when the new guidance went into effect. Now that the finish line is behind us, is your facility prepared for a survey?

      How to Understand and Effectively Utilize Appendix PP

      The volumes of summaries, tip sheets, webinars, and other curated materials from well-meaning, trusted professional associations can leave operators feeling information overload. Although these are helpful when digesting the needed changes, too much information can lead to long-term comprehension difficulties, delayed decision making, and ineffective action.
      During this time of information overload, “Appendix PP: Guidance to Surveyors for Long Term Care Facilities” of the State Operations Manual (SOM) ( may be the most comprehensive resource for evaluating the effectiveness and sustainability of the quickly implemented system changes. Understanding how to interpret and assimilate the regulatory content in the SOM is foundational to using the resource effectively.

      The level of detail may vary, but most regulations have similar components.

      • The Intent section succinctly states the purpose of the guidance and can be used internally for action plan goals or training objectives.
      • The Guidance section, also known as the interpretive guidelines, is designed to assist providers and surveyors in understanding the requirements to apply the regulation consistently.
      • The Summary of Investigative Procedure and Probes guide surveyors in identifying compliance or lack thereof by providing prompts to compare the observed practices to the standard. Conversely, the prompts are a valuable tool for providers to audit and evaluate their systems and care delivery.
      • Key Elements of Non-Compliance list what a facility has failed to do that substantiates the deficient practice. After we remove the “failed to” rhetoric, this section provides a ready-made checklist of necessary outcomes. The case studies can be valuable tools for SNF leaders and educators to assist direct care staff in conceptualizing the participation requirements and the potential consequences for noncompliance.
      • The Deficiency Categorization section of the regulation aids in determining the severity of noncompliance but can also be used as examples during training.
      The categorization also forewarns how to determine harm beyond actual or potential physical harm with the “Psychosocial Outcomes Severity Guide” (Oct. 2022, The guide and illustrations within the SOM can assist us in applying the new concept of quantifying psychosocial impact to our quality assurance, performance improvement practices, and adverse event reviews.

      Using Critical Element Pathways

      Critical Element Pathways are the tools used by the survey team to comprehensively assess whether care delivery systems accurately function consistently and incorporate evidence-based practice standards. Each tool outlines prompted observations, resident interviews, resident representative interviews, staff interviews, and medical record review elements to evaluate the care system as a whole rather than as individual F-tags.
      Answering “No” to any of the Critical Element Decisions will specify which F-tag(s) should be cited as a result of noncompliance. Quite literally, each pathway gives SNFs the questions and answers to their final exam. A few of the over 40 pathways are vital to evaluating the newly implemented guidance, including Abuse, Neglect, Infection Prevention, QAPI (Quality Assurance Performance Improvement), Sufficient and Competent Staffing, and Unnecessary Medications.
      Critical Element Pathways and many other helpful resource documents can be found in the Survey Resources folder on the CMS Nursing Homes website (

      Incorporating QAPI Principles

      The SOM revisions have heightened the emphasis on and outlined how one’s QAPI program must design systems to obtain data, incorporate feedback, track adverse events, identify opportunities, prioritize improvement activities, implement corrective and preventive actions, and conduct performance improvement projects.
      An example of QAPI in action is performing Plan, Do, Study, Act (PDSA) cycles. By incorporating the tools available to your survey team, SNFs can evaluate their Plan to implement the regulatory updates, follow that plan (Do), then Study what was done by monitoring the outcomes obtained through feedback and evaluating the data systems to perform a Five Whys assessment. After a root cause has been established, an interdisciplinary performance improvement project team can be chartered and prepare to Act again!
      Bringing the process back to the QAPI principles will allow the committee to analyze the cycle and repeat until sustained achievement is evident. SNFs should memorialize good faith attempts and implementation of the QAPI plan, which could support past noncompliance should the system be evaluated during the survey process.
      Ms. Hill is a Registered Nurse and the Director of Quality at Westminster Canterbury on Chesapeake Bay. She is also a Quality and Regulatory Compliance Consultant pursuing her Doctor of Nursing Practice at Virginia Commonwealth University.
      Did you know that training resources for surveying the updated regulations, selecting the survey sample, conducting survey procedures, and investigating complaints are available to the public? Visit for more information.