On April 3, 2026, the Centers for Medicare & Medicaid Services (CMS) issued a revised version of memorandum QSO-26-03-NH, originally released January 30, 2026, further updating Chapters 5 and 7 of the State Operations Manual (SOM). While the overall structure and intent of the original guidance remain unchanged, the revised memorandum includes additional clarifications, expanded definitions, and more detailed expectations for survey and enforcement activities.
CMS clarified that these revisions will be reflected in the CMP Analytic Tool for enforcement cycles beginning on or after March 31, 2026. The agency also announced that per-instance civil money penalties (CMPs) will be displayed on Nursing Home Care Compare beginning June 24, 2026, increasing public visibility into enforcement actions.
The revised guidance introduces more specific expectations for surveyor presence onsite. CMS clarified minimum timeframes for survey activity, including expectations for the first day of surveys and the duration of abbreviated surveys. Abbreviated surveys must be conducted over at least two consecutive calendar days, except in limited circumstances such as emergencies or competing Immediate Jeopardy (IJ) situations. Surveyors are also expected to remain onsite for a minimum of five hours on the first day, unless the investigation is completed sooner.
CMS expanded examples of intake allegations that warrant prioritization, including those involving abuse with serious injury, harm, impairment, or death, or the likelihood of such outcomes where resident safety is uncertain. Additional examples include situations where a resident is discharged to an unsafe setting or in a manner that places the resident at risk due to unmet medical needs.
The revised memorandum reinforces that offsite investigations remain rare and must be approved in advance by CMS. Additional examples were included to illustrate when offsite reviews may be appropriate, such as document-based compliance reviews. CMS also clarified documentation expectations for these reviews, including how findings may be recorded in iQIES depending on CMS location practices.
Throughout Chapters 5 and 7, CMS added references to “CMS location” alongside State Agencies (SAs), reflecting CMS’s more explicit role in survey and enforcement processes. This includes responsibilities related to communicating findings, coordinating with CMS Central Office divisions, and reporting survey outcomes. New language also outlines coordination with the CMS Central Office Division of Emergency Preparedness and Life Safety Code (DEPL).
Additional clarifications were made regarding complaint investigations and enforcement. CMS revised language to emphasize that when deficiencies existed at the time of a complaint but have since been corrected, facilities must still be notified that there was noncompliance related to the complaint. The guidance also now explicitly requires that confirmed findings of abuse-related noncompliance be reported to local law enforcement and, when applicable, the Medicaid Fraud Control Unit. CMS also provided more detailed criteria for identifying and citing past noncompliance, including when a plan of correction is not required because the deficiency has already been corrected.
Chapter 7 includes expanded and new definitions to support consistent application of requirements, including updated definitions of abuse (now explicitly including technology-facilitated abuse), Plan of Correction (PoC), resident representative, and instances of noncompliance.
The revised memo expands guidance on nurse staffing waivers, including additional detail on documentation, approval, and oversight. CMS clarified that waivers will be rescinded if required evidence is not provided and are subject to annual renewal. The CMS location must review and approve waivers and notify the appropriate state entities, while facilities must notify residents and their representatives. Additional updates address Life Safety Code waivers and room size and occupancy variances, including approval criteria, surveyor responsibilities, and documentation requirements.
CMS also added detail to survey process expectations, including survey team composition, training, and coordination. The guidance emphasizes ongoing communication between survey teams and facilities throughout the survey process, while clarifying that surveyors are not required to share all observations in real time. Additional updates address exit conference procedures, including the requirement to present preliminary findings, limitations on sharing scope and severity determinations, and expectations for facility participation.
Further revisions address survey methodology and documentation practices, including resident privacy protections and the use of photography as supplemental evidence. CMS also clarified expectations for identifying IJ, including required documentation and processes for determining when IJ has been removed and whether severity levels may be reduced.
Compliance Perspective
Issue
CMS has issued a revised memorandum updating Chapters 5 and 7 of the SOM, adding further clarification to survey processes, enforcement expectations, and compliance requirements. The revisions include more defined survey timeframes, expanded intake prioritization, additional guidance on past noncompliance and IJ, enhanced oversight responsibilities for CMS locations, and expanded criteria for waivers and survey procedures. Facilities should evaluate their current policies, training programs, and audit processes to ensure alignment with these updated expectations and survey practices.
Discussion Points
- Review and update policies and procedures to reflect the revised SOM guidance, including survey timelines, complaint investigation processes, identification and documentation of past noncompliance, and waiver requirements. Policies should also address expectations for ongoing surveyor communication and exit conference protocols. Facilities may benefit from an objective review of their policies and prior survey responses to determine whether they align with current CMS expectations and enforcement trends.
- Provide staff education on key updates, including survey process expectations, identification of IJ and past noncompliance, documentation standards, and staff roles during surveys and exit conferences. Med-Net Academy offers the course Long-Term Care Survey Process, which reviews survey phases, sample selection, survey pathways, and required facility tasks, helping staff understand how surveys are conducted and how to respond effectively throughout the survey process.
- Conduct audits to assess compliance with updated survey and enforcement expectations, including documentation practices, response to complaints, and implementation of corrective actions. Facilities should consider targeted reviews of high-risk areas such as IJ, abuse reporting, and prior deficiencies to ensure sustained compliance. Utilizing mock surveys or focused reviews can help identify gaps, validate corrective actions, and prepare staff for surveyor interactions under the revised guidance. Contact Med-Net Healthcare Consulting or info@mednetconcepts.com for more information.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*