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  5. » CMS Updates LTC Surveyor Guidance – LeadingAge NY Analysis: Segment 5: Pain, ADL Definitions, CPR Certification, and Physical Environment

CMS Updates LTC Surveyor Guidance – LeadingAge NY Analysis: Segment 5: Pain, ADL Definitions, CPR Certification, and Physical Environment

(Jan. 14, 2025) This week will complete LeadingAge NY's analysis of the Centers for Medicare and Medicaid Services' (CMS) updates to the guidelines for surveyors described in memorandum QSO-25-07-NH. As a reminder, Feb. 24, 2025 is the official start date for implementation of these updates. This article will review the modifications and major updates to directives around pain recognition and management, definitions for activities of daily living (ADLs), cardiopulmonary resuscitation (CPR) training, and physical environment. Providers should also be aware that CMS made additional notes to several F-tags reminding surveyors to assess for psychosocial harm when evaluating the severity of a citation.

Pain Management – F697

Revisions to the guidance for acute, chronic, and subacute pain were made to align with Centers for Disease Control and Prevention (CDC) definitions, as stated below. CMS also clarified that clinicians may consider prescribing immediate-release opioids instead of extended-release or long-acting options and emphasized the need for individualized opioid treatment plans.

“Acute Pain” refers to pain that is usually sudden in onset and time-limited with a duration of less than 1 month and often is caused by injury, trauma, or medical treatments such as surgery. (From the Centers for Disease Control and Prevention (CDC)).

“Chronic Pain” refers to pain that typically lasts greater than 3 months and can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or unknown cause. (From the CDC).

“Subacute Pain” refers to pain that has been present for 1–3 months. (From the CDC).

Additionally, resource links on opioid use were updated and expanded, as described below.

NOTE: Requirements at 483.10(c)(5) describe the resident’s right to be informed of the risks and benefits of the proposed treatment. For concerns related to informing the resident or resident representative of the risks of opioid use for pain, refer to F552.

For additional information, refer to:

CPR – F678

Updates were made to CPR certification to align with current nationally accepted standards. Appendix PP updates include the following statement:

Staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards.

​​​​​​​For concerns related to CPR certification that meets accepted professional standards the survey team should consider §483.21(b)(3)(ii), Services Provided by Qualified Persons, F659 and/or §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. F836.

Physical Environment – F906, F907, F909 through F918, F920, F922, F925

CMS has made updates to Appendix PP clarifying bedroom and bathroom occupancy requirements for new construction, specifying that resident bedrooms should contain no more than two residents and that each bedroom must contain a bathroom consisting of at least a sink and toilet. The guidance further clarifies that these occupancy requirements also apply to adjoining private rooms that share a bathroom such that no more than two residents may share the bathroom.

ADLs – F677

CMS made the following updates to ADL definitions to the guidance in Appendix PP. CMS also reminds surveyors to use the ADL Critical Element (CE) Pathway, along with the interpretive guidelines, when determining if facility practices are in place to identify, evaluate, and intervene to maintain, improve, or prevent an avoidable decline in ADLs.

  • Independent: if the resident completes the activity by themself with no assistance from a helper.
  • Setup or clean-up assistance: if the helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity, but not during the activity. For example, the resident requires assistance cutting up food or opening container or requires setup of hygiene item(s) or assistive device(s).
  • Supervision or touching assistance: if the helper provides verbal cues or touching/steadying/contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.
  • Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
  • Substantial/maximal assistance: if the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
  • Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity.

Training Resources

CMS has posted guidance training for nursing home surveyors and providers publicly in the Quality, Safety, and Education Portal (QSEP). This specific training can be found on the QSEP page by going to Long Term Care Appendix PP Regulatory and Interpretive Guidance Updates – Effective February 2025 (LTCAPP_PP) within the training catalogue page.

Use of the CE Pathways for pain recognition and ADLs is helpful in preparation and implementation of these updates. More information on CMS's updated surveyor guidelines can be found here.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147

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