3.3 State Operations Manual (SOM) Appendix PP & Survey Process

3.3 State Operations Manual (SOM) Appendix PP & Survey Process

Quick Answer: The State Operations Manual (SOM) Appendix PP contains the federal guidelines used by state surveyors to evaluate facility compliance. In the current Long-Term Care Survey Process (LTCSP), surveyors utilize the Activities Investigation Pathway (Form CMS-20054) to investigate activity compliance. This pathway relies on a triangulation of direct resident and staff observations, detailed resident and family interviews, and comprehensive record reviews.

The State Operations Manual (SOM) and Appendix PP

The State Operations Manual (SOM) is the official publication issued by CMS that guides state survey agencies on how to inspect nursing homes. Appendix PP of the SOM contains the actual federal regulations (Requirements for Participation) along with detailed "Interpretive Guidance" and "Survey Procedures" for each F-Tag.

For the activity department, Appendix PP serves as the ultimate study guide and compliance manual. It defines the standards for F679 (Activities) and F680 (Activity Director Qualifications) and outlines the specific steps surveyors must take to investigate complaints or conduct standard annual surveys.

The Long-Term Care Survey Process (LTCSP)

In November 2017, CMS launched the Long-Term Care Survey Process (LTCSP), which merged the traditional standard survey process with the computer-assisted Quality Indicator Survey (QIS). The LTCSP is highly resident-centered and relies on real-time data entry by surveyors using specialized software.

The survey process follows a structured timeline:

1. Off-site Preparation: Surveyors review the facility's historical data, complaint logs, and MDS submissions to identify potential areas of concern (e.g., high rates of depression, decline in activities of daily living).
2. Initial Pool Process: During the first 24-48 hours on-site, surveyors conduct widespread observations, brief resident screenings, and initial staff interviews. They select a sample of residents (the "active pool") for deep-dive investigation.
3. Sample Selection: Surveyors select residents who represent specific focus areas, including those with cognitive impairment, those who are room-bound, and those who have triggered Quality Measure (QM) alerts.
4. Investigation: Surveyors use specific Investigation Pathways to collect evidence. For activities, they use the Activities Investigation Pathway (Form CMS-20054).
5. Exit Conference: Surveyors meet with facility leadership to share findings and list any cited deficiencies (noted on Form CMS-2567).

The Activities Investigation Pathway (Form CMS-20054)

The Activities Investigation Pathway (Form CMS-20054) is the standardized tool surveyors use to determine if the facility meets F679 requirements. It directs the surveyor to gather evidence through three main techniques (frequently called "triangulation"):

• Observations: Surveyors conduct observations across multiple days, shifts, and locations. They check if residents are engaged in activities listed on the calendar, if independent leisure materials are within reach in rooms, and if staff assist with transport to activities.
• Interviews: Surveyors conduct structured interviews with the resident, family members, activity staff, and CNAs.
• Record Review: Surveyors review the comprehensive assessment (MDS Section F), CAAs, the interdisciplinary care plan, activity attendance logs, and progress notes.

Surveyor Observation Techniques

Surveyors are trained to observe resident engagement in a highly systematic way. They look for specific indicators of compliance and non-compliance:

• Hallway "Parking": A common citation trigger is finding multiple residents parked in wheelchairs in the hallways or lounges with no interaction, stimulation, or activities for long stretches of time.
• Dignity and Age-Appropriateness: Surveyors observe whether activities respect the adult status of the residents. For example, using infant toys, playing babyish music, or using children's coloring books can be cited as a dignity violation under F550.
• Staff Interaction: Surveyors watch how activity staff and CNAs interact with residents during groups. Do they explain the activity? Do they facilitate participation, or are they talking among themselves or looking at their phones?
• Adapted Equipment: They look to see if residents who need adaptive devices (e.g., large-print cards, reading stands, sound amplifiers) actually have them during the program.

Surveyor Interview Protocols

Surveyors use open-ended questions to gather subjective data from residents and families. This feedback holds significant weight during a survey.

Resident and Family Interviews

Surveyors interview sampled residents (or their family representatives if the resident is cognitively impaired) to assess:

• Choice: "Do you choose which activities you attend? Have you ever been forced to attend an activity?"
• Preferences: "Did the staff ask you about your background, hobbies, and interests when you admitted? Do they offer activities that match those interests?"
• Isolation/Boredom: "Are you ever bored? What do you do on weekends or in the evenings?"
• 1:1 Programming: For room-bound residents: "Does anyone from activities visit you in your room? What do they do during those visits? How often do they come?"

Staff Interviews

Surveyors interview activity staff and CNAs to evaluate their knowledge of the residents' care plans:

• Activity Staff: "What are this resident's assessed preferences? What specific interventions are on their care plan? How do you adapt this activity to meet their cognitive needs?"
• Nursing Assistants (CNAs): "What are this resident's favorite activities? How do you help them get to activities? Do you know what independent leisure materials they prefer?"

Evaluating Scope and Severity (The S/S Grid)

When surveyors identify non-compliance under F679 or F680, they assign a citation on the Form CMS-2567. Each deficiency is rated using the CMS Scope and Severity Grid (letters A through L):

• Severity Levels:
  • Level 1 (No actual harm with potential for minimal harm): Administrative oversight (e.g., a minor delay in updating an activity log).
  • Level 2 (No actual harm with potential for more than minimal harm): A systemic issue that causes distress or boredom but no clinical decline (e.g., lack of weekend activities leading to resident boredom). Most activity citations are Level 2 (D, E, F).
  • Level 3 (Actual harm): The facility's failure directly leads to physical or psychosocial decline (e.g., a resident becomes clinically depressed and withdrawn because their individual activity needs were completely ignored).
  • Level 4 (Immediate Jeopardy): The facility's non-compliance has caused, or is likely to cause, serious injury, harm, impairment, or death (rare for activities, but possible if unsafe activity practices cause injury, e.g., choking on activity supplies due to lack of supervision).
• Scope Levels:
  • Isolated (I): Affects a very small number of residents (e.g., one resident in the sample).
  • Pattern (P): Affects multiple residents on a specific unit or shift.
  • Widespread (W): Affects the entire facility population.

Exam Traps and Guidance

• Trap: Assuming record reviews are the most important part of the survey. Under the LTCSP, direct observation and interviews take precedence. A perfectly written care plan will not save a facility from a citation if the resident is observed staring at a wall for three days and tells the surveyor they are bored.
• Trap: Thinking that CNAs are not involved in activities. Surveyors will interview CNAs to see if the interdisciplinary team is communicating. Activity directors must train CNAs on resident activity preferences and their role in transporting residents.