Using the CMS State Operations Manual: Facility Guide

The Centers for Medicare and Medicaid Services (CMS) is a federal agency that provides health insurance to the elderly, disabled, and other vulnerable populations. Healthcare institutions serving CMS beneficiaries must comply with federal health and safety standards to maintain their status as CMS program participants. These regulations are detailed in the CMS State Operations Manual (SOM).

If you operate a healthcare institution, it’s important to be familiar with the SOM to quickly access the guidelines for your type of healthcare facility. In this guide, we provide valuable tips for navigating the SOM so you can get the answers you need, when you need them.

What Is the CMS SOM?

The CMS SOM is a federal document containing rules and guidelines for state surveys. The SOM is a type of Internet-Only Manual that replicates CMS’s official documents. The purpose of the manual is to:

• Guide representatives from a state survey agency (SA) through compliance audits, including which procedures to follow if conditions aren’t met.
• Be a reference for healthcare institutions to find policies, procedures, and regulations in preparation for surveys.

CMS compliance audits are a key part of the CMS certification process that determines eligibility to participate in CMS reimbursement programs. During the survey process, SAs evaluate whether or not a healthcare facility meets the minimum health and safety standards required to participate in Medicare or Medicaid programs. These conditions, known as conditions of participation (CoPs), create quality standards to protect the health and safety of beneficiaries.

What’s Inside the Manual?

Within the SOM, you’ll find policy guides for all Medicare/Medicaid-certified providers and suppliers. The guidelines in the SOM help SAs determine whether or not a healthcare institution meets CMS certification requirements. A healthcare facility must meet every condition to participate in CMS programs.

In instances of noncompliance, a surveyor follows the procedure for sending a healthcare facility a Statement of Definciencies according to the guidelines outlined in the CMS State Operations Manual. Skilled nursing facility (SNF) and nursing facility (NF) regulations require evidence of substantial compliance with the requirements to pass inspection. This set of conditions, called Requirements for SNFs and NFs, includes quality standards that define acceptable conditions at these types of facilities.

Other important information in the manual includes, but isn’t limited to:

• Medicare and Medicaid provisions
• The basis for state agencies
• Details about the certification process, including the purpose and goals
• Regulations based on facility type (for example, home health agencies vs. dialysis centers)
• Complaint procedures
• Fiscal management
• State ombudsman programs

How Do You Use the State Operations Manual?

To navigate the CMS SOM, visit CMS.gov and locate Publication #100-07 “State Operations Manual” using the search bar. You’ll find a chapter guide outlining each section. The Appendices page includes separate PDF files for each appendix letter. Click on the corresponding appendix letter to view regulations by the type of Medicare provider or supplier.

For example, long-term care facility leaders who want to learn what to expect during a survey should visit Appendix P, CMS State Operations Manual for Long-term Care Facilities. Alternately, surveyor resources are in Appendix PP, Guidance to Surveyors for Long-term Care Facilities.

The SOM is divided into 10 chapters:

1. Program Background and Responsibilities
2. The Certification Process
3. Additional Program Activities
4. Program Administration and Fiscal Management
5. Complaint Procedures
6. Special Procedures for Laboratories
7. Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities
8. Standards and Certification
9. Exhibits Table of Contents
10. Survey and Enforcement Process for Home Health Agencies and Hospice Programs

To learn details of each chapter topic, click on the relevant chapter and view the subsections. Select “outline view” to see a drop-down menu for each subsection. From here, you can click on each procedure description and view the laws and regulations for each subsection.

Tips for Using the SOM

It’s easy to get lost in the minutia of the regulations and policy guides within SOM. Here are some general tips for understanding how to use it efficiently:

1. Get familiar with the chapters. The SOM covers regulations for various types of CMS providers and suppliers. An administrator of a skilled nursing facility (SNF) may spend more time reviewing Chapter Seven, whereas CMS regulations for hospitals may be located in Chapter Two.
2. Use the search bar. Some chapters of the manual are over 200 pages long — save yourself time by searching for the topic relevant to your question.
3. Utilize bookmarks. As you come across laws and regulations relevant to your healthcare facility, bookmark the page for easy reference.
4. Stay updated on changes. CMS regulations are updated frequently to align with the latest healthcare quality standards. It’s important to stay updated on the latest changes to maintain compliance with CMS standards.

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Getting comfortable with the CMS State Operations Manual is just one step toward ensuring your healthcare facility is compliant with federal health and safety regulations. Stay updated on the latest healthcare compliance and management insights with IntelyCare’s free facility newsletter.