This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP). It is a one-stop shop containing a multitude of reference materials that are provided to the surveyors going …
On May 11, 2023, the Centers for Medicare & Medicaid Services (CMS) ended certain emergency waivers; put in place during the public health emergency, these waived some F-tag elements that would otherwise have applied during …
Question: Is there a requirement regarding how abuse training is completed? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT:CMS requires education on certain topics for new and existing staff, specifically, training on abuse, neglect, …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Alexis Roam, MSN, RN-BC, CPHQ, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss how to …
Five-Star, NHQI, SNF QRP, SNF VBP, PBJ data Data sets: Provider Information General information on currently active nursing homes, including number of certified beds, quality measure scores, staffing and other information used in the Five-Star …
From MLN Connects: CMS finalized staff education requirements while ending the COVID-19 staff vaccination requirements for Long-Term Care Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities. These provisions were included in the “COVID-19 …
A systematic approach to utilizing the Internet Quality Improvement and Evaluation System (iQIES), (formerly CASPER), reports is necessary for QAPI, survey readiness, and reimbursement. While there are numerous reports available via iQIES, this tool highlights …
Direct links: SNF Training Program Overview SNF Understanding Changes to the MDS 3.0 RAI Manual v1.18.11 Training Webinar SNF Social Determinants of Health and New Data Elements in Section A Training Webinar SNF Section C: …
Antipsychotic drug use among long-stay residents decreased steadily from 31 percent in 2011 to 22 percent in 2019, according to the November 2022 report Long-Term Trends of Psychotropic Drug Use in Nursing Homes from the …
Prior to the COVID-19 public health emergency (PHE), skilled nursing facilities (SNFs) were gearing up to take more medically complex fee-for-service Medicare Part A residents, including residents with infusion therapy needs, as a result of …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss the new …
Weekly health care personnel (HCP) & Resident COVID-19 Vaccination Weekly COVID-19 Vaccination Data Reporting Long-term care facilities can track weekly COVID-19 vaccination data for residents and healthcare personnel (HCP) through NHSN. May 2023 Updates Person-Level …
UPDATED Certification and Survey Provider Enhanced Reports (CASPER) Daily Minimum Data Set (MDS) Census Reports for Nursing Homes The 1704D Daily MDS Census Detail and 1704S Daily MDS Census Summary reports in the Payroll-Based Journal …
A facility-initiated transfer or discharge of a resident from a nursing home can be an unsafe and traumatic experience for the resident and the resident’s family. To address these concerns, Congress passed the Nursing Home …
Nursing Home Visitation – COVID-19 (REVISED to align with the end of the COVID-19 PHE) Memo # QSO-20-39-NH REVISED 05.08.2023 Fiscal Year 2023 Summary • CMS is committed to continuing to take critical steps to …
Infection Control Guidance Updated May 8, 2023 For healthcare personnel, see Isolation and work restriction guidance. For strategies to mitigate healthcare personnel staffing shortages, see Contingency and crisis management. For healthcare professionals advising people in non-healthcare settings …
F557 (Respect, Dignity/Right to Have Personal Property) is one of the shorter F-tags in terms of the amount of guidance provided by the Centers for Medicare & Medicaid Services (CMS), coming in at well under …
Key excerpt: Nursing Homes We know that compliance helps an organization remain focused on providing high-quality care. OIG work has pinpointed breakdowns in quality of care across many health care sectors. Perhaps the most pronounced …
Includes a three-page section, Long Term Care Facilities (Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs)), plus guidance for all providers on staff vaccinations and emergency preparedness. Memo # QSO-23-13-ALL Posting Date 2023-05-01 Fiscal Year …
According to the Centers for Medicare & Medicaid Services (CMS), “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 …
In calendar year (CY) 2022, F-tag 695 (Respiratory/Tracheostomy Care and Suctioning) was the 13th most-cited at the immediate jeopardy (IJ) level. In comparison, F695 was the 17th most frequent citation at the IJ level in …
Through this Notice, OIG is notifying the public of the following: • OIG will no longer publish updated or new CPGs in the Federal Register. All current, updated, and new CPGs will be available on …
SNOW IDs Status Categories Provider Types Description Date Reported Date Resolved Open Reports SNF Please be advised that the Submission Status for the HCP Influenza Vaccine measure is displaying incorrectly on the SNF Provider Threshold …
Question: Should a complaint of rough handling during care involve a complete abuse investigation, even if they have cognitive impairment? Answer from Denise Winzeler BSN, RN, LNHA, DNS-MT, QCP-MT: The short answer is yes, this …
Infection Control Assessment Tools Acronyms & Definitions ICAR: Infection Control Assessment and Response Program IP: Infection Prevention Healthcare Personnel IP Competency: The proven ability to apply essential knowledge, skills, and abilities to prevent the transmission of pathogens during …
Following FDA regulatory action, CDC has taken steps to simplify COVID-19 vaccine recommendations and allow more flexibility for people at higher risk who want the option of added protection from additional COVID-19 vaccine doses. CDC’s …
With the migration of Minimum Data Set (MDS) assessment submissions and reporting into iQIES, the Provider and Quality Measure reports that are currently available in the Certification and Survey Provider Enhanced Reporting (CASPER) system will …
CMS will be transitioning to a new data source for a provider’s demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities / Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation …
For 67 of the 100 sampled nursing homes, the Centers for Medicare & Medicaid Services (CMS) did not accurately report on Care Compare 1 or more deficiencies that surveyors identified during yearly and complaint inspections. …
In calendar year (CY) 2022, F-tag 695 (Respiratory/Tracheostomy Care and Suctioning) was the 11th most commonly cited F-tag nationwide. In comparison, F695 was the 16th most common citation overall in CY 2021 and only the …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss the latest …
The Centers for Medicare & Medicaid Services (CMS) released QSO-23-10-NH on March 30, 2023, listing new enhanced enforcements for facilities receiving deficiencies in F880 and F887. These new enforcements include remedies such as directed plans …
The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 01/31/2026 will be mandatory on 6/30/23. …
Memo # QSO-23-11-LSC Posting Date 2023-03-31 Fiscal Year 2023 Summary Various CMS regulations governing certain providers and certified suppliers require compliance with the 2012 edition of the National Fire Protection Association (NFPA) Health Care Facilities …
Measure specifications and calculations are detailed in this manual. March 2023 updates APPENDIX – Claims-based Measures Technical Specifications Updates 03-20-23.pdf and Nursing Home Compare Claims-based Measures Tech Specs 2023 From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures
Tuberculosis — United States, 2022 Weekly / March 24, 2023 / 72(12);297–303 Kimberly R. Schildknecht, MPH1,2; Robert H. Pratt2; Pei-Jean I. Feng, MPH2; Sandy F. Price2; Julie L. Self, PhD2 (VIEW AUTHOR AFFILIATIONS) Summary What is already …
Quality of life is a “fundamental principle” that feeds into—and flows from—all resident care and services, according to 42 Code of Federal Regulations (CFR) §483.24. The F-tag 675 surveyor guidance in Appendix PP of the …
The National Emerging Special Pathogen Training and Education Center (NETEC) has released a workbook for “assessing operational elements for special pathogen preparedness, response, and recovery unique to the long-term care setting.” The workbook is designed …
Find resources and technical assistance at https://nursinghomebehavioralhealth.org/ Current resources include: Center of Excellence for Behavioral Health in Nursing Facilities – Frequently Asked Questions DOWNLOAD SAMHSA informational pamphlet about bipolar disorder’s definition, signs/symptoms, types and treatment …
In this first episode of a two-part series on Special Focus Facilities, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, …
“As explained by Petitioner, and not disputed by CMS, Petitioner’s former executive director became the executive director at another facility and reported data on behalf of that facility to the NHSN. Petitioner determined, with the …
Memo # Admin Info -23-06-NH Posting Date 2023-02-10 Fiscal Year 2023 Summary Implementation Dates for the Revised Chapter 5 – CMS expects the state survey agencies (SAs) to implement the revised timeframes for investigating nursing …
You do have to register, but it’s free: Enhancing Quality Improvement Adoption in US Nursing Homes Johnson M, Renton M. Enhancing Quality Improvement Adoption in US Nursing Homes. Boston: Institute for Healthcare Improvement; 2023. (Available …
The Centers for Medicare & Medicaid Services (CMS) recently announced they would be conducting audits on MDS coding of residents with a diagnosis of schizophrenia. With the increased scrutiny of this diagnosis, nurse assessment coordinators …
Proposed rule would require disclosure of additional ownership and management information to shine a light on private equity ownership Administration seeking to implement Section 6101(a) of the Affordable Care Act As President Biden made clear …
The Centers for Disease Control and Prevention (CDC) recently updated the instructions for reporting person-level vaccination data via the Person-Level Vaccination Forms. Providers who are required to submit their data to the Weekly COVID-19 Vaccination …
SUBJECT: Revisions to State Operations Manual (SOM), Chapter 7 I. SUMMARY OF CHANGES: Technical Changes – Changed “regional office” to “CMS Location” and “Central Office” to “CMS Headquarters”. NEW/REVISED MATERIAL – EFFECTIVE DATE: February 10, …
The NHSN Long-term Care Facility Component supports the nation’s COVID-19 response through the LTCF COVID-19 Module. Facilities eligible to report data to NHSN’s COVID-19 Module include nursing homes/skilled nursing, long-term care for the developmentally disabled, and assisted …
Weekly / February 10, 2023 / 72(6);145–152 Summary What is already known about this topic? COVID-19 vaccine effectiveness decreased with waning of vaccine-derived immunity and emerging Omicron sublineages. An updated (bivalent) booster dose enhances protection against …
Effective Date Document/File Name Description of Change 06/05/2023 1. Initial Survey 2. Survey Resources Updated: 1. Instructions for the Interim LTC Initial Survey and Certification Process 2. LTCSP Initial Certification Tag Review Tool 3. …
The LTCSP Procedure Guide provides instruction on the procedural and software steps necessary for completing the LTCSP. Use the Procedure Guide for all standard surveys of SNFs and NFs, whether freestanding, distinct parts, or dually …
Inadequate hand hygiene before and after care processes (e.g., when donning or doffing gloves) is a perennial problem for nurses and other staff members in nursing homes. However, even staff who perform hand hygiene correctly …
Listen to this podcast for a discussion on survey citation F695, Respiratory/Tracheostomy Care and Suctioning – what it is, why it is important, and how skilled nursing facilities can avoid it. Amy Stewart, MSN, RN, …
Question: Do we need to obtain an order from a physician to be able to place a new admission or move a current resident to the secured (locked) unit in our care facility? Answer from …
SUBJECT: Revisions to State Operations Manual (SOM), Appendix PP I. SUMMARY OF CHANGES: Technical Corrections – corrected endnote numbering and references, updated broken web links, deleted duplicated regulatory text. NEW/REVISED MATERIAL – EFFECTIVE DATE: October …
CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Nursing Home Compare Web site features a quality rating system that gives each nursing home …
The CY 2023 PFS Final Rule contains provisions concerning Medicareprovider enrollment. These principally involve the following: (1) Moving skilled nursingfacilities (SNFs), various provider enrollment ownership changes, and certain other providersand suppliers into the “high” level …
Question: Where can I find information about iQIES? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT: The Centers for Medicare & Medicaid Services (CMS) recently released the new iQIES Reports User Manual. This manual …
The Centers for Medicare & Medicaid Services (CMS) released a memo last week containing updates to Care Compare and Quality Measure ratings. These changes include: CMS will consider a lesser action to the star ratings …
2015—the year that the Centers for Medicare & Medicaid Services (CMS) added antipsychotic medication use quality measures (QMs) to the Five-Star Quality Rating System—marked the beginning of some difficult trends in the potentially inappropriate diagnosis …
Starting on January 17, 2023, post-acute facilities and Medicare health plans will no longer receive phone calls for appeal notifications (when a new appeal has been filed). Post-acute facilities and Medicare health plans will receive …
Participants will learn to identify requirements of a person-centered care plan, identify ways to develop a relationship with a resident that facilitates care planning, and define person-centered care according to the Centers for Medicare & …
Jan. 11, 2023: As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Xavier Becerra, Secretary of Health …
Long-term care is one of the most regulated settings in this country. The interpretive guidance in Appendix PP of the State Operations Manual, which surveyors apply during an onsite survey, is 856 pages long—and that …
While completing MDS assessments, nurse assessment coordinators can monitor for regulatory compliance during the chart review. If compliance issues arise, leadership should be notified to correct them. NACs can utilize AAPACN’s Medical Record Alert Sheet …
F-tag 880 (Infection Prevention and Control) is the second most frequent citation nationwide in calendar year (CY) 2022—and the third most frequently cited at the immediate jeopardy (IJ) severity level, according to QCOR (Quality, Certification, …
Question: If the DNS is on the schedule Monday through Friday for 8-hour shifts each day and 40 hours per week, and serves primarily as RN coverage, are they allowed to leave the building for …
CDC’s NHSN provides healthcare facilities, such as long-term care facilities (LTCFs), with a secure reporting platform for reporting outcomes and process measures in a systematic way. Reported data are immediately available for use in strengthening local …
Emergency preparedness planners in nursing homes can adapt this new On-Campus Hospital Armed Assailant Planning Considerations document to help prepare their facilities to mitigate, respond to, and recover from an armed assailant or active shooter situation on …
Full list here: https://www.reginfo.gov/public/do/eAgendaMain Some highlights are excerpted below: HHS/SAMHSA Proposed Rule Stage Medications for the Treatment of Opioid Use Disorder 0930-AA39 HHS/CMS Proposed Rule Stage Administrative Simplification: Adoption of Standards for Health Care Attachment …
Prevention Process Measures: Hand Hygiene, Gown and Glove Use Adherence Most Recent Updates Protocols Supporting Chapters Data Collection Forms & Instructions All Data Collection Forms are Print-only PPM Monthly Reporting Plan Annual Facility Survey FAQs …
The National Forum of ESRD Networks has shared a communication tool, updated on Dec. 2, 2022, that covers nursing home communication to dialysis facilities, as well as dialysis facility communication to nursing homes: LTCF-Dialysis Infection …
AG Healey Secures $1.75 Million Resolution With Nursing Home Chain Over Failure To Meet the Needs of Residents With Substance Use Disorder BOSTON — A Connecticut-based long-term care management company operating nursing homes across southern New England …
The National Center for State Courts (NCSC) has released an updated online course that explains options for assisting individuals who need decision-making support. Finding the Right Fit: Decision-Making Supports and Guardianship is a free, …
Effective Oct. 24, 2022, nursing homes are required to implement revised pain management guidance under F-tag 697 (Pain Management) in Appendix PP of the State Operations Manual for residents with active opioid use disorder or …
From 2015 – 2019, the number of long-stay residents who were coded in MDS item I6000 (Schizophrenia (e.g., Schizoaffective and Schizophreniform Disorders)) jumped by 35 percent, according to the November 2022 report Long-Term Trends of …
As of October 24, 2022, nursing facilities must comply with updates the Centers for Medicare & Medicaid Services (CMS) made to the surveyor guidance in Appendix PP of the State Operations Manual. Although changes to …
by Michele Mummert, RN, RAC-CT, RAC-CTA, DNS-CT, Director of Research and Development, The Compliance Store Care planning is the foundation of resident care in the long-term care setting. Everything done to care for the resident …
Note that this memo is for all healthcare providers, but there are several “nursing homes in particular” statements, including but not limited to: “Nursing homes, in particular, should review and reinforce their infection control protocols …
There is a new Quality in Focus tab at the CMS QSEP Training site: https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx Available LTC-focused resources now available include: Quality in Focus Resources for Addressing LTC Free of Accident Citations Training for Providers …
Long-Term Trends of Psychotropic Drug Use in Nursing Homes(OEI-07-20-00500) OIG found that from 2011 through 2019, about 80 percent of Medicare’s long-stay nursing home residents were prescribed a psychotropic drug. While the Centers for Medicare …
On Oct. 3. 2022, the U.S. Department of Health and Human Services (HHS) renewed the nationwide opioid public health emergency (PHE), marking the launch of the PHE’s sixth year. Some nursing homes have been slow …
Question: What does a facility have to do to maintain compliance if they use bedrails or grab bars? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT: F700 in Appendix PP of the State Operations …
Title Memo # Posting DateSort ascending Fiscal Year Transitioning Certification Functions for Changes of Ownership, Administrative Changes, and Initial Enrollment Performed by the SOG Locations ***Revised to Transition Several Providers and Suppliers and Provide Additional …
It just got a little more difficult for skilled nursing facilities (SNFs) to avoid a 2 percent reduction to their annual payment update (APU) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP). For …
The Centers for Medicare & Medicaid Services (CMS) revised guidance regarding COVID-19 staff vaccination requirements. This revision combines previous memos QSO-22-07-ALL, QSO-22-09-ALL, and QSO-22-11-ALL.CMS defines noncompliance of this requirement as a “rate of less than …
Revised Guidance for Staff Vaccination Requirements Memo # QSO-23-02-ALL Posting Date 2022-10-26 Fiscal Year 2023 Memorandum Summary • CMS is committed to taking critical steps to protect vulnerable individuals to ensure America’s health care facilities …
The Centers for Medicare & Medicaid Services (CMS) finalized the Influenza Vaccination Coverage among Healthcare Personnel (HCP) measure to start collecting data during the 2022-2023 influenza season (October 1, 2022 through March 31, 2023). CMS …
Among the many decisions directors of nursing services (DNSs) make during their day, some of the most challenging involve regulatory requirements the Centers for Medicare & Medicaid Services (CMS) has issued. DNSs may find themselves …
White House Announces More Aggressive Enforcement Actions for SFF On Oct. 22, 2022, the White House announced an enaction of “more aggressive enforcement” actions to strengthen the accountability for the Special Focus Facilities (SFF). These …
Question: Is a concave mattress considered a restraint? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-CTA, RAC-CT, CPC: According to Appendix PP of the State Operations Manual, a restraint is defined as, “Any manual method or …
Memo: QSO-23-01-NH (PDF) Press release: Changes to CMS’ Special Focus Facilities program will increase scrutiny, hold facilities accountable for substandard safety and quality, and improve care for residents As part of the Biden-Harris Administration’s continued commitment …
The LTCSP Initial Pool Care Areas folder, inside the Survey Resources folder, includes four documents, one each for: record review, resident interview, resident observations, and resident representative interview. They walk through what the surveyors investigate/ask …
On Oct. 24, 2022, surveyors will begin using new survey guidance to identify noncompliance with QAPI, trauma-informed care, and resident safety, including abuse, neglect, and exploitation. Skilled nursing facility (SNF) leaders should be in the …
Transmittal # R207SOMA Issue Date 2022-09-30 Subject Revisions to State Operation Manual (SOM), Appendix PP Guidance to Surveyors for Long Term Care Facilities Implementation Date 2022-10-01 CR # N/A Publication # 100-07 I. SUMMARY OF CHANGES: …
