State Operation Manual Revisions to Chapters 5 and 7
On January 30, 2026 CMS released QSO-26-03-NH which announces the revisions to Chapter 5 and Chapter 7 of the State Operations Manual. CMS indicates that these updates were to “align instructions and guidance with current policies in QSO memos and established practices”. Key revisions to note include the following:
Chapter 5:
The Chapter 5 revisions “ensure that the oversight and investigations of alleged non-compliance are thorough and consistent across the country”. CMS states they also “clarify that off-site investigations must be approved by CMS in advance to ensure uniform application”. These revisions also provide additional examples of “intakes that warrant immediate jeopardy prioritization, such as discharging a resident to an unsafe setting.” In addition, just as we saw on CMS Exhibit 359 (Follow-up Investigation Report) the terms “substantiated” and “unsubstantiated” were removed to align with current practices and instead, the terms “verified” and “not verified” are referenced.
Chapter 7:
CMS indicates that the Chapter 7 revisions “standardize oversight, investigation procedures, enforcement actions, and the Civil Money Penalty Reinvestment Program (CMPRP)”. These revisions address a wide range of survey guidance including:
-
- survey team composition
- resident privacy and confidentiality
- photography during survey
- off-hours survey
- past non-compliance
- severity and scope of deficient practices
- and conducting exit conferences
Key Revisions include the following:
-
- Nurse Staffing Waivers and Resident Room Variances: This section provides a process for nursing homes to obtain a waiver and is not related to the survey process, therefore it has been moved from Appendix PP to Chapter 7.
- Onsite vs. Off-site revisits: This clarifies procedures for conducting revisits after surveyors identify non-compliance.
- Immediate Jeopardy (IJ): There are updates on identifying immediate jeopardy, determining when it has been removed, and outlining conditions for lowering the severity level once IJ has been removed.
- Acceptable Plan of Correction (PoC): This clarifies areas related to the acceptable plans of correction after a facility was found to be non-compliant with the requirements of participation (RoP).
- Enforcement Guidance: Revises policies for Civil Money Penalties (CMP) which includes the use of the CMP Analytic Tool and the annual adjustment of CMP amounts according to the Annual CMP Inflations Adjustment Act of 2015. These also address the expansion of CMS’ ability to impose per instance and per day CMPs to “promote sustained correction of health and safety deficiencies”.
- Civil Money Penalty Reinvestment Program: These revisions clarify the allowable and non-allowable uses of CMP funds, the current application review process, and reporting requirements for the results of the project. Of note is that the updates clarify that State CMP Fund Balances from the State Plan will be publicly posted.
- Informal Dispute Resolution (IDR): Aligns IDR procedures with the IIDR process and adds guidance on uploading deficiencies pending IDR or IIDR to the CMS record-keeping system to improve transparency.
It is important to note that the revisions go into effect March 30, 2026. You can find the QSO, a summary of changes, and Advance copies of Chapter 5 and Chapter 7 at: https://www.cms.gov/files/document/qso-26-03-nh-original-release-date-2026-01-30.pdf
In the QSO memo, CMS also addresses new resources to “Improve Quality of Care”. This Quality in Focus interactive video series includes 10-15 minute videos geared toward provider types with the aim to reduce the deficiencies most commonly cited during CMS surveys, like infection control and accident prevention. See the Quality, Safety, & Education Portal Training Catalog and select Quality in Focus at: https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx
Written By:
Janine Lehman, RN, RAC-CT, CLNC
Director of Clinical Services
Proactive LTC Consulting
Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!