CMS recently shared that they are making a few technical changes to the interpretive guidance before issuing a final version of Appendix PP. We anticipate CMS will release a final version of Appendix PP by or around November 28, 2017. In addition, CMS has made some of the related changes to the critical element pathways and posted the updates with a date of November 8 on their website here:…. Below is a summary of the changes CMS has told us they have made or will be making to the guidance and pathways. Note that several other pathways in the zipped file at the link above appear to also have a new date of 11-8-17, and we are seeking additional information about any further changes to those pathways.

  • Administering Crushed Oral Medications
    • AHCA, along with ASCP and other stakeholders, provided feedback to CMS regarding the guidelines for crushing and combining oral medications into food. In response to those concerns, CMS is revising the interpretive guidance to convey that best practice would be to separately crush and administer each medication with food to address concerns with physical and chemical incompatibility of crushed medications and ensure complete dosaging of each medication. However, they will add new guidance that separating crushed medications may not be appropriate for all residents and should not be counted as a medication error unless there are instructions not to crush the medication(s). Facilities should use a person-centered, individualized approach to administering all medications. If a surveyor identifies concerns related to crushing and combining oral medications, the surveyor should evaluate whether facility staff have worked with the resident/representative and appropriate clinicians (e.g., the consultant pharmacist, attending physician, medical director) to determine the most appropriate method for administering medications which considers each resident’s safety, needs, medication schedule, preferences, and functional ability. Interpretive guidance related to crushed medications administered via feeding tube will remain unchanged.
    • CMS has revised the facility task/pathway for Medication Administration Observation, CMS 20056, to reflect this change.
  • SNF Beneficiary Protection Notification Review:
    • CMS is revising the form and notices that must be provided to residents when their Part A stay is ending or they no longer meet the skilled care requirement when the resident has not used all Medicare benefit days for that episode and eliminating the five alternative denial letters.
    • CMS has updated the SNF Beneficiary Notice task/pathway to reflect this change.
  • F686 – Tissue tolerance tests
    • CMS determined that guidance in F686 for pressure ulcers related to tissue tolerance tests was not a current standard of practice, so they are going to remove the references in the guidance requiring a tissue tolerance test.
  • F838 – Facility assessment (FA)
    • The surveyor guidance (§483.70(e)) states that “the assessment must include or address the facility’s resources which include but are not limited to a facility’s operating budget…” CMS is correcting this guidance to remove the inappropriate wording that a facility must include their operating budget in the FA, as that is not part of the FA regulation. They have stated they will keep the guidance that “It should serves as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources, and may include the operating budget necessary to carry out facility functions.” The key word is may, as they do not require the facility to include the operating budget as part of their assessment.

As we identify additional technical corrections and other broad concerns about the guidance, we will continue to provide that information to CMS and encourage you to do the same by sharing the information with AHCA and/or emailing CMS directly at CMS responds in writing to questions sent to that inbox, and it is very helpful to have the written record of corrections and clarifications CMS provides.

  • We recently reported to CMS another error that must be corrected in Appendix PP. As you may recall, the proposed rule on the reformed RoPs indicated that the bathroom requirement at 483.90(f) would apply to newly certified facilities as well as to construction and reconstruction approved after Nov. 28, 2016, but the word reconstruction was eliminated in the final rule for the bathroom requirement. However, the advance copy of Appendix PP includes the word “reconstruction” and goes on to define the word “reconstruction” in this section (as it does under 483.90(e) for the bedrooms). We have requested this correction in the final version of Appendix PP as well. For more information on this requirement, please see AHCA’s Action Brief on physical environment at:…