powered by LeadingAge New York

Nursing Homes Are Reminded of Oct. 24th Effective Date for New RoPs Guidance

Nursing home members are reminded that on Oct. 24th, new guidance on the Requirements of Participation (RoPs) will become the standard by which surveyors will determine compliance with the regulations. Links to the revised guidance can be found in the Integrated Health Alerting and Notification System (IHANS) notice from the Department of Health (DOH) pasted below.

Members are advised to review their current policies and procedures to ensure that they align with the new guidance. Please be sure to review the resources on the LeadingAge NY and LeadingAge National websites.

The LeadingAge NY website contains a link to a series of Centers for Medicare and Medicaid Services (CMS)-produced training videos that cover, in depth, the changes to the survey guidance. Many of the guidance changes are significant, and the videos are particularly helpful in guiding staff through the changes.

In addition, LeadingAge National has compiled a wealth of resources for members, including policies and procedures, competency tools, and checklists that should facilitate the transition to the newly issued guidance.

On Oct. 13th, DOH distributed through IHANS the following information:

Attn: Nursing Homes

IMPORTANT NEW INFORMATION: On June 29, 2022, CMS issued QSO-22-19-NH (PDF) Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide

The Revised Long-Term Care Surveyor Guidance can be found at QSO-22-19-NH (PDF) and the following links to the changes are noted below:

Memorandum Summary

  • Revised Surveyor Guidance: CMS is releasing the following guidance and associated training for nursing home surveyors:
    • Phase 2 and 3 Requirements: Clarifications and technical corrections of Phase 2 guidance issued in 2017, and new guidance for Phase 3 requirements which went into effect in November 28, 2019.
    • Arbitration Requirements: Guidance on the new requirements which became effective September 16, 2019.
  • Effective Date: Surveyors will begin using this guidance to identify noncompliance on October 24, 2022.
  • Training Resources: Training on guidance for surveyors and providers will be available upon release of this memorandum.
  • Complaint and Facility Reported Incidents (FRIs): CMS revised the guidance in Chapter 5 and related exhibits of the State Operations Manual (SOM) to strengthen the oversight of nursing home complaints and FRIs. CMS also revised its guidance for all Medicare-certified provider/supplier types to improve consistency across the State agencies in their communication to complainants.
  • Psychosocial Outcome Severity Guide: CMS revised guidance to clarify the reasonable person concept and examples across the different severity levels.


For survey process questions, contact CMS at NHSurveyDevelopment@cms.hhs.gov.

For questions on regulations and interpretive guidance, contact CMS at DNH_TriageTeam@cms.hhs.gov.

Previously issued memos:

Contact: Elliott Frost, efrost@leadingageny.org, 518-441-8761