Key Takeaways from the 2025 Appendix PP Updates
Written by: Sheena Mattingly, M.S., CCC-SLP, RAC-CT, EVP of Quality & Compliance
Every year, CMS updates Appendix PP of the State Operations Manual, which means new rules, revised guidelines, and changes that impact how skilled nursing facilities operate. Staying on top of these updates is essential—but let’s be honest, it’s a lot to sift through. That’s why we’ve done the heavy lifting for you. Here’s a breakdown of the most important changes you need to know, along with practical steps to help you stay compliant.
Top 10 Appendix PP Updates You Should Know:
- Critical Element Pathways (CEPs) – What You Need to Focus On
CEPs guide surveyors in assessing skilled nursing facilities, acting as a roadmap for identifying deficiencies.
Action Step: Review all CEPs with your team, paying extra attention to the Discharge CEP. There’s a lot of updated language, so make sure everyone understands the changes.
- The Reasonable Person Concept – A New Way to Evaluate Impact
The “reasonable person concept” refers to a tool surveyors use to assess the severity level of negative, or potentially negative, psychosocial outcomes the deficiency may have had on a reasonable person in the resident’s position.
Action Step: Go over this shift with your team. It changes how facilities evaluate psychosocial outcomes, which means your staff needs to anticipate how residents might experience care on an emotional level.
- Residents’ Right to Be Informed – No More Surprises
Residents have the right to be involved in their treatment decisions.
Action Step: Before increasing psychotropic medications, ensure the resident (or their family/representative) understands the benefits, risks, alternatives, and any major warnings. Written consent isn’t required, but documentation of the discussion is.
- Psychotropic Drug Use – Stricter Oversight
The regulations haven’t changed, but enforcement is tougher.
Action Step: Make monthly medication reviews a priority. Diagnosis alone isn’t enough to justify psychotropic drug use. Consider forming a Psychotropic Medication Review Committee to strengthen oversight.
- Schizophrenia Diagnoses – Tightened Requirements
CMS is cracking down on misdiagnosed schizophrenia cases.
Action Step: Ensure every schizophrenia diagnosis is backed by proper documentation that aligns with DSM criteria. Conduct routine audits to catch inconsistencies before surveyors do.
- Chemical Restraints – The Definition Just Got Stricter
Any medication used to make care more convenient for staff—rather than treating a medical condition—now counts as a chemical restraint.
Action Step: Review this definition with your team. Be mindful of documentation—avoid phrases like “to manage behavior.”
- Antibiotic Use – More Scrutiny, More Accountability
Overprescribing antibiotics can now lead to multiple citations, including F757 and F881.
Action Step: Double-check that your facility follows the Antibiotic Stewardship Program and that staff are properly trained to comply.
- Gradual Dose Reductions (GDR) – Tracking Matters
Tapering medication should be considered if the resident is stable, symptoms have improved, or non-drug approaches have worked.
Action Step: Make sure there’s a clear process in place to track and document GDRs.
- Medical Director Responsibilities – Defined Expectations
Medical directors must actively participate in resident care policies, facility quality assessment and assurance initiatives, and address issues the coordination of medical care.
Action Step: Confirm that your medical director (or their designee) is engaged in these responsibilities and that your facility has structured processes to support compliance.
- QAPI and Health Equity – New Considerations
Surveyors will now look at how facilities address health equity when collecting feedback, monitoring outcomes, and reviewing adverse events.
Action Step: Integrate health equity discussions into your QAPI meetings. Consider including a statement in meeting minutes to further document your commitment to health equity.
Key Policies You Should Review and Update:
- Psychoactive Medications & Non-Pharmacological Interventions – Update consent forms and staff training materials.
- Abuse & Chemical Restraint – Align policies with the revised definitions.
- Antipsychotic Use & QAPI – Make sure QAPI discussions address this.
- Transfer & Discharge – Incorporate the latest Appendix PP language.
- CPR & Bedrail Inspections – Ensure compliance with updated FDA guidance.
- Resident & Representative Notification – Strengthen documentation for medication changes.
- COVID-19 Vaccination Policies – Revise outdated exemption policies.
Please Note: The effective date of Appendix PP Updates is delayed to 4/28/25.
