Process Surveillance Plus QAPI Equals Better Infection Prevention Training

Nursing homes are required to establish a surveillance system (i.e., “the routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data”) as part of their infection prevention and control program (IPCP) under F-tag 880 (Infection Prevention and Control) in Appendix PP of the State Operations Manual. This surveillance …

Common Missteps in Addressing Plan of Correction Criteria and Best Practices for Compliance Sustainability

According to the Nursing Homes webpage of the Centers for Medicare & Medicaid Services (CMS) site, “Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs. To …

Learn How to Take Staff Survey Preparation From Reactive to Proactive

“Why in the world did my staff member say this?” and “Why did my staff do that?” are two questions that no director of nursing services (DNS) wants to have when reading the Statement of Deficiencies and Plan of Correction (form CMS-2567) handed out by the state survey team at …

Interrupted Stays: Five Takeaways To Remember

The interrupted-stay policy in the Patient-Driven Payment Model (PDPM) of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) governs when multiple SNF stays are combined into a single interrupted stay (i.e., one continued stay that includes one or more interruption windows) vs. when they are treated …

iQIES Essentials for the Nurse Assessment Coordinator

In the ever-evolving realm of healthcare data management, the transition of the Minimum Data Set (MDS) submission process to the Internet Quality Improvement and Evaluation System (iQIES) in April 2023 marked a significant milestone for skilled nursing facilities (SNFs). Replacing the outdated Quality Improvement and Evaluation System Assessment and Submission …

New Measures, No Data: When Can Facilities Expect to See New Quality Measure Data?

One of the frustrations nursing home providers have experienced since the transition to the Minimum Data Set (MDS) 3.0 version 1.18.11 that went into effect on Oct. 1, 2023, is being able to effectively monitor the new Quality Measures (QMs) introduced at the same time. Although the Centers for Medicare …

Deep Tissue Injury: Section M Assessment and Coding Tips

Pressure-related deep tissue injury (DTI) coded in M0300G (Unstageable Pressure Injuries Related to Deep Tissue Injury) does not play a role in Medicare payment under the Patient-Driven Payment Model (PDPM). While DTI is an unstageable pressure ulcer/injury, only ulcers that are unstageable due to slough and/or eschar (MDS item M0300F1) …

Keys to Competencies in Infection Prevention and Control

Under F-tag 726 (Competent Nursing Staff) in Appendix PP of the State Operations Manual, nursing staff, including registered nurses (RNs), licensed practical or vocational nurses (LPNs/LVNs), and certified nursing assistants (CNAs), must have “the competencies and skill sets necessary to provide nursing and related services to meet the residents’ needs …

Improve Staffing and Quality Care Through Individualized Culture Change of the Nursing Department

Staff turnover is a nationwide problem for nursing homes and it may be worse than previous reports have suggested, according to a study of newly available Payroll-Based Journal data published in the National Library of Medicine. The study also noted a possible negative relationship between a facility’s overall Five-Star rating …

Infection Prevention and Control: How to Finetune Whole-House Staff Education

In calendar year (CY) 2023, F880 (Infection Prevention and Control) was the third most frequently cited F-tag in nursing homes nationwide, as well as the fifth most common at the immediate jeopardy (IJ) level, according to QCOR data accessed on Jan. 16, 2024. That is an improvement over CY 2022, …