The Keys to Develop a Past Noncompliance Plan

The director of nursing services (DNS) received a call in the middle of the night that a resident with a diagnosis of dementia had eloped, and it appeared she had been missing for several hours—a conversation no DNS wants to have. She immediately enacted the missing resident protocol. Luckily, staff …

Uncomplicating Drug Classifications

Medications are an essential part of the care and interventions provided to residents in a skilled nursing facility. These medications may be used to manage chronic conditions, slow disease progress, ease symptoms, or even prevent a condition. With each medication, the associated risks and benefits must be considered. High-risk medications …

PDPM Overview for Supporting SNF Staff

The Centers for Medicare & Medicaid Services (CMS) implemented the Patient-Driven Payment Model (PDPM) in October 2019 for residents receiving Medicare Part A coverage in the skilled nursing facility (SNF). PDPM replaced the previous legacy payment model, the Resource Utilization Group (RUG-IV) system, still used by some state Medicaid agencies …

Sepsis Assessment and Reporting: Tips for Nursing Staff

Nurses play a key role in the early identification and treatment of sepsis, assessing the resident and reporting to the physician or nonphysician practitioner (NPP), as well as potentially managing residents with sepsis in-house in some cases. Nurse leaders can take the following steps to help nursing staff effectively assess …

The “Golden Hour” of Admission

For both residents and their loved ones, admission into a post-acute care facility can be an overwhelming experience. In addition to the condition that brought residents to the facility, the transition itself involves changing environment, acclimating to new routines, and entrusting one’s care to a team of unfamiliar people. Amid …

October 2025 MDS Draft Item Sets: The SDOH Should Drive the NAC’s Planning

On Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS version 1.20.1 item sets and item matrix for implementation on Oct. 1, 2025. The change history included with the item sets indicates planned changes to sections A (Identification Information), B (Hearing, Speech, and Vision), …

Residents on Part B Therapy? Provide Beneficiary Notices to Avoid a Financial Hit

Nurse assessment coordinators (NACs) who manage Medicare services typically are at least familiar enough with the beneficiary notice requirements that skilled nursing facilities (SNFs) must meet under fee-for-service (FFS) Medicare Part A to monitor those processes. “However, NACs may not always be as aware that facilities also have a responsibility …

ICD-10-CM: Navigating the Term “With,” Combination Codes, and Complications of Care

Accurate diagnosis coding is critical in nursing facilities (NFs) for care planning, reimbursement, and quality measurement. NF coders must understand ICD-10-CM conventions, general coding guidelines, and chapter-specific coding guidelines that affect how diagnoses are assigned. Coding guidance can be found in the ICD-10-CM Official Guidelines for Coding and Reporting for FY …

Why Getting MDS Right Is Non-Negotiable: The Importance of MDS Accuracy

Written by Kristine Martinez BSN, RN, RAC-CTA, QCP Completing a Minimum Data Set (MDS) correctly is no small task. With approximately 510 answers or choices on a comprehensive MDS (not including CAA investigation), and approximately530 answers or choices on a 5-day MDS, the potential for missed or miscoded information on any …

Direct-Care Staff Are Front-Line Defenders Against Sepsis: What They Need to Know

Since the COVID-19 pandemic began in 2020, the risk of developing sepsis has increased nationwide, according to the September 2024 report An Assessment of Sepsis in the United States and Its Burden on Hospital Care (Sepsis Assessment) from the Agency for Healthcare Research and Quality (AHRQ). Sepsis-related inpatient stays in …