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 June 29, 2022, the Centers for Medicare and Medicaid Services (CMS) released updates to the surveyor guidance in Appendix PP of the State Operations Manual. Highlights of the updates can be found in the …
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. September 2022 update (As …
Question: Are there regulatory requirements regarding the use of outdoor patios by independent residents that should be included in a facility policy? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT: There is no regulation …
Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 Summary of Recent Changes Updates as of September 23, 2022 In most circumstances, asymptomatic HCP with higher-risk exposures do not require work restriction. Updated …
Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes has been replaced by Infection Control Guidance and it applies to “all U.S. settings where healthcare is delivered, including nursing homes and …
Nursing Home Visitation – COVID-19 (REVISED) Memo # QSO-20-39-NH REVISED 09.23.2022 Memorandum Summary • CMS is committed to continuing to take critical steps to ensure America’s healthcare facilities are prepared to respond to the Coronavirus …
Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements Memo # QSO-20-38-NH REVISED 09/23/2022 QSO-20-38-NH REVISED (PDF) Memorandum …
Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Summary of Recent Changes Updates as of September 23, 2022 Updated to note that vaccination status is no longer …
QSO-22-25-CLIA DATE: September 26th, 2022 TO: State Survey Agency Directors FROM: Director, Quality, Safety & Oversight Group (QSOG) SUBJECT: CMS Rescinds December 7, 2020, Enforcement Discretion for the Use of SARS CoV-2 Memorandum Summary CMS …
The FDA published the FDA Voices: “FDA Issues New Guidance to Help Facilitate Availability of Naloxone to Prevent Opioid Overdoses and Reduce Death,” by Marta Sokolowska, Ph.D., Deputy Center Director for Substance Use and Behavioral …
Guidance for Federal Monitoring Surveys (FMS) Memo # Admin Info-22-09-All Posting Date 2022-09-21 Fiscal Year 2022 Summary • Provide guidance on how CMS Location staff will conduct Federal Monitoring Surveys (FMS) in FY2022 and FY2023. …
Notice from CMS: In March 2019, CMS released memorandum QSO-19-08-NH, which outlined a plan to update the quality measure (QM) rating thresholds every six months. The plan was to increase the thresholds by 50% of …
The September update of Appendix B to the RAI 3.0 User’s Manual contains changes to the list of State RAI Coordinators, MDS Automation Coordinators, RAI Panel members, and CMS locations and contacts. To ensure accurate formatting, use a …
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 …
Mrs. C is an 85-year-old resident with cognitive impairments. She often wanders from room to room and likes to pick up pretty trinkets and put them in her purse for safekeeping. Mr. M finds her …
The baseline care plan has been a requirement of Medicare/Medicaid participation under F-tag 655 (Baseline Care Plans) since the November 2017 implementation of phase two of the Reform of Requirements for Long-Term Care Facilities. “While …
Question: Do residents in Wyoming need to have a two-step Mantoux test upon admission and readmission to a facility if it is in a low-risk area or will screening suffice? Answer from Alexis Roam, MSN, …
Effective Date Document/File Name Description of Change 09/26/2022 Survey Resources with Staff Vaccine Documents Folder Updated: 1. LTC Survey Pathways (CMS 20054-Infection Prevention Control and Immunization) 2. FIC Folder (CMS 20054-Infection Prevention Control and Immunization, …
In Joint Letter with CFPB, HHS Stresses to Nursing Homes and Debt Collectors Prohibition on Requiring Caregivers to Assume Responsibility for Cost of Resident’s Care The U.S. Department of Health and Human Services (HHS), through …
LANSING, MI – A nurse has been charged with causing serious physical and mental harm to a vulnerable adult, Michigan Attorney General Dana Nessel announced. Beverly Ann Bratcher, 56, of Newaygo was charged in the 61st District …
Five-Star, NHQI, SNF QRP, SNF VBP, PBJ data COVID-19 Vaccination Rates – State and National Averages State and National averages for facility resident and healthcare personnel COVID-19 vaccination rates. Data are presented as one row …
Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers REVISED Memo # QSO-22-15-NH & NLTC & LSC REVISED Posting Date 2022-08-29 Fiscal Year 2022 Summary CMS continues to review the need for existing emergency …
On June 29, 2022, the Centers for Medicare and Medicaid Services (CMS) released updates to the surveyor guidance in Appendix PP of the State Operations Manual. Some are minor technical updates, while others introduce entirely …
CMS has issued a new fact sheet with information about which COVID-19 Public Health Emergency (PHE) waivers and flexibilities have already been terminated, have been made permanent, or will end at the end of the …
You can read the blanket waivers for COVID-19 in the List of Blanket Waivers (PDF) UPDATED (8/18/2022). Unless otherwise noted, these waivers will terminate at the end of the COVID-19 public health emergency (PHE) From https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
While key details are still pending, the Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule makes clear that meeting the reporting requirements of the Skilled Nursing Facility Quality Reporting …
From NETEC Long-term care (LTC) settings are communities where residents congregate closely in shared spaces, and equipment is used between residents, staff, visitors, and vendors who enter and leave frequently. This makes LTC an ideal …
These FAQs were created to address questions about Enhanced Barrier Precautions as defined in the CDC guidance “Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs)” FAQS addressed …
National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report (April 2022) he National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for …
Certain Nursing Homes May Not Have Complied With Federal Requirements for Infection Prevention and Control and Emergency Preparedness (A-01-20-00005) Selected nursing homes may not have complied with Federal requirements for infection prevention and control and emergency …
Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; etc. PDF 348 Pages (962 KB)Permalink Press release: CMS Acts to Improve the …
Audits of Nursing Home Life Safety and Emergency Preparedness in Eight States Identified Noncompliance With Federal Requirements and Opportunities for the Centers for Medicare & Medicaid Services to Improve Resident, Visitor, and Staff Safety We …
Hillcrest Nursing and Rehabilitation, located in Massachusetts, failed to provide an individual’s health care proxy with timely access to her son’s medical records. In addition to a monetary settlement of $55,000, Hillcrest will undertake a …
Summary of Recent Changes: Added additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for …
Renewal of the Determination that a Public Health Emergency Exists Nationwide as the Result of the Continued Consequences of Coronavirus Disease 2019 (COVID-19) Pandemic COVID-19 National July 15, 2022
On June 29, 2022, the Centers for Medicare & Medicaid Services (CMS) released significant revisions to the State Operators Manual (SOM), which surveyors will use to identify noncompliance starting on Oct. 24, 2022. While revisions in several …
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 …
On June 29, the Centers for Medicare & Medicaid Services (CMS) issued a major update to surveyor guidance via Quality, Safety and Oversight (QSO) memo QSO-22-19-NH to strengthen the implementation of the already-in-effect Phases 2 …
CMS Issues Significant Updates to Improve the Safety and Quality Care for Long-Term Care Residents and Calls for Reducing Room Crowding June 29, 2022 As part of the Biden-Harris Administration’s initiative to promote the safety and quality …
Long Term Care Regulatory and Interpretive Guidance and Psychosocial Severity Guide Updates – June 2022 (LTCRIGPSG) Access here: https://qsep.cms.gov/pubs/CourseMenu.aspx?cid=0CMSLTCRegIG_PSG OR https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx Training Description This course consists of a series of presentations by the Division of …
The CMS regulatory agenda for spring 2022 is available. Find the full agenda here, but three key upcoming rules are highlighted below: Reporting of Crimes Occurring in Federally Funded Long Term Care Facilities and Enforcement …
An Estimated 91 Percent of Nursing Home Staff Nationwide Received the Required COVID-19 Vaccine Doses, and an Estimated 56 Percent of Staff Nationwide Received a Booster Dose (A-09-22-02003) As of the week ended March 27, …
Memo # QSO-22-17-ALL Surveys for compliance with Omnibus COVID-19 Health Care StaffVaccination Requirements Posting Date 2022-06-14 Fiscal Year 2022 Summary • Survey oversight of the staff vaccination requirement for Medicare and Medicaid-certified providers and suppliers …
This manual provides general background and information about the submission requirements, such as sample submission screens, submission deadlines, and definitions of job categories. Note: Changes from the previous version of this policy manual are identified …
Guidance related to Emergency Preparedness- Exercise Exemption based on A Facility’s Activation of their Emergency Plan Memo # QSO-20-41-ALL REVISED 05.26.2022 Posting Date 2022-05-26 Fiscal Year 2022 Summary • Emergency Preparedness Training and Testing Program …
Nursing home leaders can reference this resource to ensure that the facility’s emergency preparedness plan is current and captures an all-hazards approach to meeting the health, safety, and security needs of staff and residents during …
Toolkit for States to Mitigate COVID-19 in Nursing Homes (PDF) UPDATED (5/6/22) From https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
The Department of Health and Human Services (HHS) is taking actions to promote competition and transparency in our nation’s health care system that can improve the safety and quality of nursing homes and hospitals. The Centers for …
Last week, the AAPACN 2022 Conference was held in Las Vegas, bringing together nursing professionals for exceptional learning opportunities. One outstanding session occurred on Thursday, April 14, when representatives from the Centers for Medicare & …
An updated version of the Skilled Nursing Facility (SNF) Provider Threshold Report (PTR) is now available. The PTR is a user-requested, on demand report which enables users to obtain the status of their data submission …
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 …
Antipsychotic Medication Prescribing in Long Term Care Facilities Increased in the Early Months of the COVID-19 Pandemic Issue Brief Prescriptions dispensed for antipsychotics in nursing homes and assisted living facilities increased since the beginning of …
Revised Guidance for the Interim Final Rule -Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination — The guidance in this memorandum does not apply to the following states at this time: Alabama, Alaska, …
In this LTC DON Chat podcast, Amy Stewart, vice president of education and certification strategy for AAPACN, and Janet Feldkamp, a partner with Benesch Healthcare, discuss updates on survey and regulatory issues that skilled nursing facilities …
Excerpt of press release describing the attack: NHS Management, LLC Provides Notice of Data Privacy Incident TUSCALOOSA, Ala., April 5, 2022 /PRNewswire/ — NHS Management, LLC (“NHS”) is providing notice of an event that may affect the security …
AHRQ has created a guide for nursing home leaders as they implement COVID-19 vaccination programs among staff members. The resource identifies important factors to consider from planning to implementation, including guidance on updating policies and …
Agency releases 2021 injury, illness data WASHINGTON – The U.S. Department of Labor’s Occupational Safety and Health Administration is initiating an enforcement program that identifies employers who failed to submit Form 300A data through the agency’s …
Three new online resources from AHRQ are available to help nursing homes adopt best practices aimed at controlling and preventing infection and improving the emotional well-being of staff and residents: Best Practices Guide for COVID-19 Infection Control …
WASHINGTON – The U.S. Department of Labor’s Occupational Safety and Health Administration is proposing amendments to its occupational injury and illness recordkeeping regulation, 29 CFR 1904.41. The current regulation requires certain employers to electronically submit injury and …
Residents of long-term care facilities (nursing homes) have been severely impacted by COVID-19 and are disproportionately represented in the number of COVID-19-related deaths in the United States. Data reported by nursing homes to the Centers …
JAMA Network Open Study Key Points excerpt: Findings This quality improvement study of 13 339 nursing homes found that daily variation of staffing was significantly associated with the 5-Star Survey and Quality Measures rankings. There was little …
CMS is providing clarification to recent guidance for visitation (see CMS memorandum QSO-20-39- NH REVISED 11/12/2021). While CMS cannot address every aspect of visitation that may occur, we provide additional details about certain scenarios below. …
Registration and data submission resources. PBJ QTSO Registration and Training 02-24-2022 (PDF) From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
US Department of Labor announces enforcement, effort for focused inspections in hospitals, nursing care facilities treating COVID-19 patients WASHINGTON – For two years, millions of the nation’s healthcare workers have been battling the coronavirus. Many have endangered themselves …
New Report published by APIC outlines actions needed to successfully battle future pandemics while fighting the rise of healthcare-associated infections ARLINGTON, Va., March 8, 2022 /PRNewswire/ — As the world enters the third year of the COVID-19 pandemic, …
Social determinants of health (SDOH) are items most long-term care professionals are familiar with, but they may not immediately recognize how the determinants affect their job. According to the Office of Disease Prevention and Health …
FACT SHEET: Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes FEBRUARY 28, 2022 All people deserve to be treated with dignity and respect and to have …
Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2022 Changes in the 2022 Adult Immunization Schedule Vaccine-specific changes in the 2022 immunization schedule for adults …
Nursing Home Capabilities and Collaboration to Ensure Resident Care During Emergencies Nursing homes face a broad range of challenges from public emergencies, such as emerging infectious disease outbreaks and natural disasters. To protect residents and …
Updates as of Feb. 17: Guidance streamlined Added links to guidance on testing for determining length of work restriction for healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2 and for mitigating staff shortages in healthcare settings Time period …
In calendar 2020, F-tag 726 (Competent Nursing Staff) was the 35th most-cited tag nationwide—up from 41st in pre-pandemic 2019. However, as the staffing crisis continued to worsen, F726 declined to the 46th overall most-cited tag …
Memo # QSO-22-12-ALL Posting Date 2022-02-09 Fiscal Year 2022 State Obligations to Survey to the Entirety of Medicare and Medicaid Health and Safety Requirements under the 1864 Agreement Summary The 1864 Agreement is the agreement …
CMS Omnibus COVID-19 Health Care Staff Vaccination Rule- Implementation Timeline (PDF) (1/19/22) COVID-19 Health Care Staff Vaccination Requirements Infographic (PDF) (1/19/22) COVID-19 Health Care Staff Vaccination Requirements Decision Tree Graphic (PDF) (1/25/22) CMS Omnibus COVID-19 Health Care Staff …
Question: I completed a Medicare PPS assessment one day after the completion due date. What is the penalty for late MDS assessment completion? Answer: There is no financial penalty for late completion. You may possibly …
51 minute course plus training slides with notes Surveying for the New Staff Vaccination Rule – Long Term Care (LTC) – Training Menu https://qsep.cms.gov/pubs/CourseMenu.aspx?cid=0CMSSVAX_LTC or https://qsep.cms.gov/ Training Description This course provides an overview of the …
Title Fiscal Year (FY) 2022 Mission & Priorities document (MPD) – Action Memo # Admin Info 22-03-ALL Posting Date 2022-01-28 Summary The Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG) remain …
These resources enable nursing home staff to track and trend COVID-19 vaccine administration data, including boosters, for both residents and staff. The tools support efficient collection of information on vaccination rates and support the coordination …
Jan 26, 2022 As part of its commitment to improve transparency and help families and caregivers find the best quality of nursing home care for their loved ones, the Centers for Medicare & Medicaid Services …
One-page graphic flyer How to safely visit nursing homes (PDF) (01/25/22) https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Jan 18, 2022 NETEC COVID-19 Webinar Series presentation: Respiratory Protection Program (RPP) for the Non-Acute Healthcare Providers. For more information on this webinar presentation, please visit https://repository.netecweb.org/items/show/1659 Respiratory Protection Program (RPP) for the Non-Acute Healthcare …
Columbia, MD – Workers in Medicare- or Medicaid-funded health-care provider organizations are now required by the Centers for Medicare & Medicaid Services (CMS) to be vaccinated against COVID-19 as a condition of participation in Medicare …
There are several great resources for facility leaders to utilize. The Society for Post-Acute and Long-term Care Medicine (AMDA) has several great resources in their COVID-19 Vaccine Education Toolkit. These resources are free to everyone, …
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 Dr. Karl Steinberg, president of AMDA and a longtime nursing home medical director and …
There are plenty of statistics documenting the hazard falls pose for the elderly. The Centers for Disease Control and Prevention (CDC) has a website sharing important facts about falls. CDC notes that: One out of …
Memo # QSO-22-08-NH Posting Date 2022-01-07 Fiscal Year 2022 Summary CMS will begin posting the following information for each nursing home on the Medicare.gov Care Compare website: Weekend Staffing: The level of total nurse and …
Litigation Update for CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule: Update #3: Following the Supreme Court’s decision in Missouri v. Biden on January 13, 2022, implementation and enforcement of Medicare and Medicaid Programs; Omnibus …
Transitioning Certification Functions for Changes of Ownership, Administrative Changes, and Initial Enrollment Performed by the CMS Survey and Operations Group Memo # Admin Info: 22-02-ALL Posting Date 2021-12-23 Fiscal Year 2022 Summary The Centers for …
Question: Has anyone encountered surveyors requesting consents for assist bars/enabler bars used for functional mobility not posing as a restraint per the interdisciplinary team assessment? Answer by Carol Maher, RN-BC, CPC, RAC-MT : A restraint …
Question: I am trying to find the CMS definition of elopement. What exactly do they call an elopement? Answer by Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: The State Operations Manual, appendix …
Question: Is there a waiting period to continue therapy services when a resident transitions from Medicare Part A to Medicare Part B therapy services? Answer by Kim Steele RN, WCC, RAC-CT, RAC-CTA: There is no …
Case Marks First Charges Brought in District of South Carolina Related to Fraudulent Vaccine Cards Columbia, South Carolina — Acting United States Attorney M. Rhett DeHart announced today that a Federal Grand Jury in Columbia returned …
Survey and Enforcement of the Vaccine Requirement for Health Care Staff in Medicare- and Medicaid-certified Providers and Suppliers Suspended While Court Ordered Injunctions are in Effect: The Centers for Medicare & Medicaid Services (CMS) will …
Long-term care leadership often observes that the nurse assessment coordinator (NAC) role calls for detail-orientation and strong time-management and assessment skills, because these nurses must coordinate the resident assessment that drives the care plan, quality …
This tool, developed by Centers for Disease Control and Prevention in partnership with the U.S. Department of Veteran Affairs, includes five practice case scenarios that involve a range of ages and circumstances and may be …
The magnitude of facility-initiated discharges in nursing homes remains unknown. Many challenges exist to identifying and addressing inappropriate facility-initiated discharges, including that neither Administration for Community Living (ACL) nor Centers for Medicare and Medicaid Services …
While still a small percentage of overall nursing home citations, citations at the level of immediate jeopardy (IJ) have skyrocketed since the start of the COVID-19 public health emergency, largely driven by an explosion of …
The CY 2022 Home Health Final Rule that was released on Nov. 2 finalizes the continuation of the requirement for long-term care facilities to report COVID-19 information to the Centers for Disease Control and Prevention …
Question: Where can I find information on the new CMS COVID-19 vaccination requirements? Answer from Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP: CMS has developed a FAQ document regarding the Interim Final Rule that answers …
