If you've been working in skilled nursing for any length of time, you know that the State Operations Manual is an evolving rulebook. CMS often releases updates that clarify, revise, or—let's be honest—can complicate how we demonstrate compliance.

The latest round of changes arrived via QSO-26-03-NH on January 30, 2026, with an effective date of March 30, 2026. These updates to Chapters 5 and 7 of the SOM don't revolutionize the survey process, but they do tighten up several critical areas that directly impact how surveyors conduct investigations and how facilities must respond to deficiencies. If you're responsible for survey readiness, regulatory compliance, or quality assurance, here's what you need to understand.

Why These Updates Matter

CMS describes these revisions as efforts to "align instructions and guidance with current policies" and "ensure oversight and investigations are thorough and consistent across the country." Translation: They're codifying practices that many state agencies were already doing and attempting to close gaps that allowed for inconsistent enforcement.

The changes affect complaint investigation procedures, survey team operations, enforcement actions, and—significantly—how facilities must demonstrate correction of deficiencies. Let's break down the key categories.

Chapter 5 Updates: Complaint Investigation Procedures

Immediate Jeopardy Prioritization — Expanded Examples

What Changed: CMS added new examples of complaint allegations that warrant immediate jeopardy (IJ) prioritization, including discharging a resident to an unsafe setting.

Why It Matters: This expansion makes explicit what many surveyors were already doing—treating discharge planning failures as potential IJ situations. If your facility discharges a resident without appropriate assessment of their post-discharge safety, you're now clearly in IJ territory.

What to Do: Review your discharge planning protocols with fresh eyes. Ensure you're documenting not just where residents are going, but why that placement is safe and appropriate. Your social services and discharge planning teams need to understand that inadequate discharge assessment isn't just poor practice—it's an IJ risk.

Off-Site Investigation Requirements

What Changed: CMS clarified that off-site complaint investigations must be approved by CMS in advance to ensure uniform application. Additionally, examples of complaint intakes that can be reviewed off-site were clarified.

Why It Matters: This addresses inconsistency in how state agencies were handling complaints. Some were conducting off-site reviews for allegations that should have triggered onsite surveys.

What to Do: This is mostly a state agency requirement, but it means you're more likely to see surveyors onsite for complaints that previously might have been handled via phone calls or document requests. Don't assume that providing documentation remotely will resolve a complaint—be prepared for an onsite investigation.

Fire-Related Complaint Procedures

What Changed: Complaint procedures for fires resulting in serious injury or death were updated to align with current processes.

Why It Matters: This standardizes how state agencies must respond to fire-related incidents that result in harm, ensuring consistent investigation protocols nationwide.

What to Do: If your facility experiences a fire resulting in serious injury or death, expect an immediate and thorough investigation. Your fire safety systems, evacuation procedures, staff training, and response protocols will all be scrutinized.

Terminology Changes for LTC Providers

What Changed: The terms "substantiated" and "unsubstantiated" were removed from LTC provider complaint processes to align with current practices.

Why It Matters: This is a terminology update that reflects how complaint investigations are actually documented and processed. It doesn't change investigation procedures but does standardize language. Language is now directed at whether or not noncompliance was identified.

What to Do: No action required—this is primarily an internal state agency documentation change.

Chapter 7 Updates: Survey and Enforcement Procedures

Survey Procedures and Team Composition

What Changed: CMS updated guidance for survey team composition, including clarification of the role of surveyors who are not State Minimum Qualifications Team (SMQT) certified. Additionally, references to the outdated Appendix P have been eliminated and replaced with references to the current Long-Term Care Survey Process (LTCSP) Procedure Guide.

Why It Matters: These are primarily organizational and reference updates to ensure surveyors are using current guidance documents. The clarification about non-SMQT surveyors helps define team member roles more clearly. You may see different surveyor configurations than you're used to, with team members who have more limited investigative authority.

What to Do: Treat all surveyors with equal professionalism and responsiveness. Don't make assumptions about who has authority to do what. If you have questions about a surveyor's role, ask the team coordinator.

Nurse Staffing Waivers and Resident Room Variances

What Changed: Regulatory requirements and guidance for nursing staffing waivers and structural variances have been relocated from Appendix PP to Chapter 7 and further detailed.

Why It Matters: This is an organizational change—moving waiver guidance out of the survey-specific appendix and into the main chapter. The waiver process itself isn't changing, but the guidance is now more accessible and detailed.

What to Do: If your facility needs to request a staffing waiver or room variance, you'll now reference Chapter 7 instead of Appendix PP. The process remains largely the same, but review the updated guidance for any additional detail that may help with your waiver application.

Immediate Jeopardy Identification and Removal

What Changed: Revised guidance on identifying immediate jeopardy, determining when it has been removed, and outlining conditions for lowering the severity level once IJ has been removed.

Why It Matters: This aligns Chapter 7 with Appendix Q guidance and provides more consistency in how IJ is called and cleared. Facilities need to understand the distinction between removing the immediate threat and demonstrating sustained compliance.

What to Do: If you're cited for IJ, removing or abating the immediate jeopardy is only the first step. You must demonstrate systemic correction, not just that you fixed the specific problem the surveyors found, to restore substantial compliance with the regulatory intent. Your POC needs to address root causes and show how you'll prevent recurrence across your entire resident population.

Acceptable Plan of Correction Requirements

What Changed: CMS clarified what constitutes an acceptable POC after a facility is found non-compliant with conditions of participation. This addresses an OIG recommendation.

Why It Matters: Vague or inadequate POCs have been a persistent problem. CMS is tightening standards for what they'll accept as evidence that you've corrected deficiencies.

What to Do: Your POC needs to clearly identify what you did to fix the specific problem, how you'll prevent it from happening again, and how you're monitoring to ensure your corrections are sustained. Generic statements like "staff will be re-educated" won't cut it. Be specific about who, what, when, and how you're correcting and monitoring.

Civil Money Penalty (CMP) Enforcement Updates

What Changed: Significant revisions to CMP policies, including references to the CMP Analytic Tool and annual inflation adjustments per the Annual CMP Inflation Adjustment Act of 2015. More importantly, alignment with the FY 2025 SNF PPS final rule that expanded CMS's ability to impose per-instance and per-day CMPs.

Why It Matters: Financial penalties are getting larger and more frequent. CMS can impose CMPs more aggressively to "drive sustained correction of health and safety deficiencies." The FY 2025 final rule specifically expanded the use of both per-instance and per-day penalties.

What to Do: Understand that CMPs are both punishment and leverage to force compliance. If you receive per-day CMPs, the clock is ticking and the costs are accumulating daily. Prioritize correction and get surveyors back onsite to verify compliance as quickly as possible. Budget for the reality that CMPs are increasing and being imposed more frequently.

Civil Money Penalty Reinvestment Program (CMPRP)

What Changed: New guidance clarifying allowable and non-allowable uses of CMP funds, the application review process, and reporting requirements. CMS will now publicly post State CMP Fund Balances.

Why It Matters: If you're considering applying for CMP funds to support quality improvement projects, the rules are now clearer and more transparent. Public posting of fund balances also increases accountability.

What to Do: If you have a legitimate quality improvement project that could benefit residents, review the updated CMPRP guidance to understand what's fundable. The program exists to improve care quality—use it if you qualify.

Informal Dispute Resolution (IDR) Process Alignment

What Changed: IDR procedures were revised to align with the Independent IDR (IIDR) process. Guidance was added for uploading deficiencies pending IDR or IIDR to CMS record-keeping systems to increase transparency.

Why It Matters: The dispute resolution process is more standardized and visible. Deficiencies under dispute will appear in CMS systems, increasing public transparency even before disputes are resolved.

What to Do: If you're planning to dispute deficiencies, understand that the dispute will be visible in CMS data. Filing frivolous disputes hoping to delay public disclosure won't work. Dispute only when you have substantive evidence that the citation was incorrect.

The Bottom Line

These SOM updates are about standardization, clarification, and—let's call it what it is—enforcement consistency. CMS is tightening procedural elements to ensure that surveyors across the country are applying the same standards and that facilities can't exploit ambiguities in the guidance.

For providers, the message is clear: demonstrate compliance through observable outcomes, not just documentation. When you're cited, correct thoroughly and systemically, not superficially. And understand that the financial consequences of non-compliance are increasing.

The effective date is March 30, 2026. That gives you about two months to review these changes with your leadership team, update your survey readiness processes, and ensure your quality assurance program can demonstrate the kind of comprehensive correction CMS now expects.

Survey readiness is about genuinely meeting regulatory requirements in ways that protect residents and improve care. Having a process to review and correct potential risk areas is vital to a positive survey outcome and quality improvement.

How Strategic Healthcare Programs Can Help

Navigating these updates requires more than just reading the guidance—it demands a systematic approach to identifying vulnerabilities, conducting meaningful self-assessments, and implementing corrections that will stand up to surveyor scrutiny.

SHP's QMS Module allows you to conduct comprehensive facility reviews using the same task-based process and critical elements that surveyors employ during standard surveys. Walk through observations, record reviews, resident interviews, and staff interviews in a structured format that mirrors the actual survey experience, then generate a statement of deficiencies (2567) citations complete with scope and severity assignments. It's not just a checklist—it's genuine survey preparation that helps your team understand what surveyors will look for and how deficiencies are identified and corrected.

The MDS Indicator Facility Rate Report takes the guesswork out of resident sample selection. Using the same MDS-based risk indicators that state survey agencies review during off-cycle survey preparation, this report identifies high, medium, and low-risk residents across key clinical areas. When CMS emphasizes observable outcomes and multi-source validation, you need to know which residents are most likely to expose gaps in your care delivery. This report tells you exactly where to focus your mock survey efforts.

The Pin Point Prediction Report provides critical context by analyzing your facility's survey history and comparing your performance against market trends. Understanding your citation patterns, repeat deficiencies, and how you measure up against neighboring facilities helps you prioritize your quality improvement efforts and anticipate surveyor focus areas. With CMS tightening enforcement and expanding CMP authority, knowing your risk profile isn't optional—it's essential.

These tools work together to create a comprehensive survey readiness strategy that aligns with the updated SOM requirements: identify risks through data analysis, validate compliance through structured mock surveys, and correct deficiencies before surveyors arrive.

Need help implementing these updates or want to discuss how SHP's analytics and survey preparation tools can strengthen your compliance program? Reach out to your SHP account representative. We're here to help you translate regulatory guidance into actionable strategies that protect your residents and your facility.

About the Author

Greg Seiple

Vice President - Clinical Informatics

Greg Seiple's journey in Long Term Care began as a nursing assistant in 1993, while pursuing his nursing degree. Over 19 years with HCR ManorCare, he progressed from various facility roles to Assistant Vice President in Clinical Services. Greg's expertise extends to VP and SVP roles in corporate clinical teams. Now, as VP of Clinical Informatics at SHP/IntelliLogix, he brings a wealth of experience. Additionally, Greg shares his knowledge as an adjunct instructor at Penn State University, teaching in the Nursing Home Administrators course.