Memo # Admin Info: 24-05-NH Posting Date 2023-11-20 Fiscal Year 2024 Memorandum Summary • Guidance and Focus Concerns – Identifies the FY2024 and FY2025 Focus Concerns and guidance on how CMS Location staff will conduct …
This video will help providers and physicians understand the need and importance of medical record documentation to support the services billed. Watch this video to learn more about what the CERT program has identified as …
Audit of Nursing Homes’ Nurse Staffing Hours Reported in CMS’s Payroll-Based Journal Nursing homes are required to electronically submit complete and accurate direct care staffing information to CMS’s Payroll-Based Journal (PBJ) system on a quarterly …
Centers for Medicare & Medicaid Services Rules Medicare and Medicaid Programs: Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities; Medicare Providers’ and Suppliers’ Disclosure of Private Equity Companies …
In the Jan. 18, 2023, Quality, Safety, and Oversight (QSO) memo QSO-23-05-NH, the Centers for Medicare & Medicaid Services (CMS) announced plans to conduct offsite audits to assess whether nursing homes appropriately assess, document, and …
The GCPG is a reference guide for the health care compliance community and other health care stakeholders. The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other items useful for understanding health …
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. November 2023 Updates Resources …
The October 2023 release of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC). The data are based on quality assessment data submitted by SNFs to …
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 …
Over the past few years, the Centers for Medicare & Medicaid Services (CMS) has placed increasing emphasis on drug regimen review (DRR) aka medication regimen review (MRR). Since 2018, skilled nursing facilities have captured one …
Admissions are vital to a facility. They may occur daily, or even multiple times a day, and should be a part of routine operations. However, the admission process can be cumbersome, and it is easy …
The admission process can be lengthy, and staff can miss important details. Use the Medical Record Audit: New Admission/Readmission checklist to ensure the facility has obtained critical information from newly admitted and readmitted residents and …
Question: We completed a combined 5-Day/Admission assessment on day 15 of the stay. After submission, our system shows we are out of compliance for CAAs/MDS based on the signature/completion date. Do we need to bill …
Preparing for and responding to nursing home residents or healthcare personnel (HCP) who develop signs or symptoms of a respiratory viral infection: Find the toolkit at https://www.cdc.gov/longtermcare/prevention/viral-respiratory-toolkit.html
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 …
Memo # QSO-23-21-NH Posting Date 2023-09-20 Fiscal Year 2023 Title Memorandum Summary • Adjustment to Staffing and Quality Measures: CMS will update the staffing level case-mix adjustment methodology and replace some of the Quality Measures …
The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V16.0 is now available. The MDS 3.0 QM User’s Manual V16.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable …
In the long-awaited Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposes a three-pronged, comprehensive staffing approach for Medicare- …
In February 2022, the Biden-Harris Administration announced a comprehensive set of reforms aimed at improving quality and safety for residents in nursing homes. One aspect of this initiative was conducting a new Nursing Home Staffing …
Resources: Press Release: The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued a proposed rule that seeks to establish comprehensive staffing requirements for nursing homes—including, …
F740 (Behavioral Health Services) is not a frequently cited F-tag so far in calendar year (CY) 2023, according to QCOR data posted on Aug. 13, 2023. However, the consequences can be severe—surveyors often issue 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 …
Question: Are there specific requirements for CNA documentation? Answer from Alexis Roam, MSN, RN-BC, CPHQ, DNS-MT, QCP-MT: Although Appendix PP of the State Operations Manual (SOM) includes numerous references to documentation, it does not specify what …
Memo # QSO-23-02-ALL (EXPIRED) Posting Date 2023-07-25 Fiscal Year 2023 EXPIRATION INFORMATION: CMS PUBLISHED A FINAL RULE WHICH ENDED THE REQUIREMENTS RELATED TO STAFF VACCINATION FOR ALL PROVIDER TYPES, EFFECTIVE ON 8/05/23. ADDITIONALLY, THIS RULE …
The use of psychotropic medications in the skilled nursing facility (SNF) is a controversial issue with implications for resident, regulatory, and financial outcomes. The many requirements can be confusing, especially for a relatively new director …
Nursing homes face significant risk and liability under F-tag 609 (Reporting of Alleged Violations), says Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a partner in the Benesch Healthcare + Practice Group at Benesch, Friedlander, Coplan …
Question: Where can I find the list of Special Focus Facilities and candidates? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT: CMS releases their Special Focus Facility (SFF) Program list monthly. This list includes …
So far in fiscal year 2023 (Oct. 1, 2022 – Sept. 30, 2023), F-tag 607 (Develop/Implement Abuse/Neglect, etc. Policies) is not even in the top 20 most frequently cited F-tags nationwide. However, this citation does …
Occupational Safety and Health Administration 29 CFR Part 1904 [Docket No. OSHA-2021-0006] RIN 1218-AD40 Improve Tracking of Workplace Injuries and Illnesses AGENCY: Occupational Safety and Health Administration (OSHA), Labor. ACTION: Final rule. SUMMARY: OSHA is …
Toolkit: Medical Record Review Methodology07-06-2023 | OEI-06-21-00030 | Complete Toolkit Toolkit: Clinical Guidance for Identifying Harm07-06-2023 | OEI-06-21-00031 | Complete Toolkit What are the Adverse Events (AE) Toolkits? The AE toolkits are technical resources to assist the …
Memo # QSO-23-18-NH Posting Date 2023-06-28 Fiscal Year 2023 Memorandum Summary • Posting Nursing Home Affiliation on Nursing Home Care Compare: CMS will include ownership and operatorship affiliation information on our Nursing Home Care Compare …
The director of nursing services (DNS) position is multi-faceted, and a new DNS must learn a lot quickly. Areas such as providing residents quality care and staffing take top priority, and rightfully so. However, another …
The Centers for Medicare & Medicaid Services (CMS) revised two Critical Element Pathways on June 5, 2023: Medication Storage and Infection Control. The CMS Critical Element Pathways are used by surveyors to determine compliance during …
In This Issue This month’s newsletter focuses on establishing and monitoring a Naloxone program for your nursing facility. Become informed about regulatory guidance and share new COE-NF resources that will assist your facility in implementing …
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 …
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 …
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 …
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 …
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 …
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 …
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 & …
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 …
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 …
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, …
