CMS Official: Focus on Intent of New SNF Regulations

Skilled nursing providers are trying to understand the details of sweeping new Medicare requirements and survey process changes. But SNFs should not get so preoccupied with the finer points that they lose sight of the fundamental goals that the Centers for Medicare & Medicare Services (CMS) intends to achieve with the updates.

“The main point we try to stress in talking about the new survey process … is focus on the intent, that’s the start,” said Evan Shulman, CMS deputy director in the division of nursing homes. He spoke Tuesday at the American Health Care Association (AHCA) annual conference in Las Vegas.

Shulman ran through several of the topics that have drawn questions from SNF operators. He laid out CMS’ basic aims to help focus operators’ compliance efforts, as Nov. 28 draws near. This is the effective date for Phase 2 of the so-called “Mega Rule,” updating the requirements that SNFs must meet to participate in Medicare and Medicaid.


Baseline care plan

When the November deadline hits, skilled nursing facilities will be required to create baseline care plans with 48 hours of patient admission. These plans need to include a variety of information, such as patient goals and physician orders.

“Step away from [those specific requirements] for a moment to say: What is the intent of this?” Shulman said. “The underlying intent of this requirement is to determine what a resident needs until a comprehensive assessment can be done.”


In other words, the starting point for compliance should be getting the information to provide the highest quality care right out of the gate, not gathering information for its own sake. In any case, the baseline care plan will vary on a person-by-person basis, given that not every patient is going to be coming in with the same sets of orders and needs, Shulman said.

Notice of transfer

When a resident is discharged or transferred, the SNF now must notify the state ombudsman’s office, providing information such as whether the discharge was facility-initiated or resident-initiated.

There have been numerous questions related to this requirement, particularly because “no one wants to go the hospital,” so it’s difficult to classify these as resident-initiated versus facility-initiated transfers, Shulman said.

“The intent behind this regulation is if there’s a disagreement, the ombudsman has an opportunity to help the resident and inform them of their rights,” he said. “The starting point for this is, is there a disagreement? That should be the first place that we look.”

Shulman went on to say the agency is “sensitive” to the fact that if a SNF is simply providing notice of every single discharge or transfer, that might “dilute” the ability to zero in on cases of disagreement.

Reporting of crimes and abuse

CMS gets a lot of questions about F-tags 608 and 609, concerning reporting of reasonable suspicion of a crime and reporting of alleged violations. Depending on whether the suspected crime involves serious bodily injury or abuse, there are different requirements for how quickly reporting needs to be done.

“Trying to distill this intent, it struck me in the airport this morning—if you see something, say something,” Shulman said. “That’s what we’re talking about here.”

He referred providers to a table in the F608 section of the updated State Operations Manual for more specifics on reporting requirements and timelines.

Facility assessment

More than any other new regulation, CMS is getting questions about facility assessment, Shulman said.

“I can sum up the intent of facility assessment: Who are our residents, what are their needs and do I have what it takes to meet their needs?” he said. “That’s what to focus on. Start there.”

SNFs should rest assured that the facility assessment is not meant to be a “gotcha” tool for surveyors.

“[There is] no intent for the surveyors to look at the facility assessment and say, well, I see you marked this down here, but I don’t see it in the facility over there,” Shulman said.

Rather, the facility assessment aims to put more emphasis on a SNF’s overall systems and how they interact. Focusing on this should drive more meaningful change and improvement over the long run, rather than “picking over deficiencies,” Shulman said.

With this in mind, the facility assessment and documents such as the QAPI and emergency prep plans should not exist in isolation from each other. The documents can include references to each other and not duplicate large blocks of text, for example.

Shifting to a more systemic approach is driving the SNF regulatory update as a whole, Shulman emphasized.

“The intent of the overhaul is a system of safety,” he said.

Written by Tim Mullaney

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