The Centers for Medicare & Medicaid Services (CMS) recently confirmed the revisions to the State Operations Manual (SOM), Appendix PP, which went into effect April 28, 2025. The revisions are redlined here. While many revisions …
This workbook simulates the survey functions in iQIES and may provide a bare-bones (i.e., basic) walkthrough of how surveyors will approach survey using iQIES. To access, go to https://qtso.cms.gov/software/iqies/reference-manuals Then go to the section titled iQIES …
Note: Unlike the draft, this transmittal includes Only the updated sections of Appendix PP. Please be aware that there are at least some changes from the draft manual. Transmittal # R229SOMA Issue Date 2025-04-25 Subject …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, director of education and certification strategy for AAPACN, discuss the new …
The Centers for Medicare & Medicaid Services (CMS) released a revised memo, QSO-25-07-NH, which detailed a launch plan to transition the long-term care survey process to the Internet Quality Improvement and Evaluation System (iQIES) platform. …
A quick review of the draft revised surveyor guidance in Quality, Safety, and Oversight (QSO) memo QSO-25-14-NH that goes into effect on April 28, 2025, may initially concern the director of nursing services (DNS) and …
On April 28, 2025, new and revised surveyor guidance, as well as revised critical element pathways, will go into effect during survey, according to the March 10, 2025 Quality, Safety, and Oversight memo QSO-25-14-NH, which …
Hearing a staff member say, “State just walked in the door,” shouldn’t ignite survey panic mode in the director of nursing services (DNS) and other department leaders in the nursing home, says Michelle Synakowski, RN, …
Memo # QSO-25-14-NH Memorandum Summary: Revised Surveyor Guidance: CMS is releasing the following revised guidance for nursing home surveyors: Admission, Transfer & Discharge, Chemical Restraints/Unnecessary Psychotropic Medication, Resident Assessment, Nursing Services, Payroll Based Journal, Quality …
Memo # Admin Info 25-07-NH Summary The iQIES Nursing Home launch is currently scheduled for July 14, 2025. The CMS iQIES team is developing a training and support plan to help all State Agency and CMS …
March 2025 Updates Person-Level – Data Collection Forms and Instructions LTCF Resident Optional Person Level Reporting for Long Term Care Residents (Form 57.216) [PDF – 264 KB] – February 2025 LTCF Healthcare Personnel Optional Person Level …
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 …
Memo # Admin Info: 25-06-NH Posting Date 2025-01-17 Fiscal Year 2025 Memo Name Contact or Reference Memo Posting Revised: Guidance for Federal Monitoring Surveys (FMS) Memorandum Summary • Guidance on Conducting Federal Monitoring Surveys (FMS) – FY2025 Guidance on how CMS Location staff will …
To register at QSEP and take the course, you just need to provide an email address. https://qsep.cms.gov Updated: January 16, 2025 This course consists of four presentations by the Division of Nursing Homes outlining the …
Starting Jan. 1, 2025, facilities are required to electronically report new information about COVID-19, influenza, and respiratory syncytial virus (RSV) to the National Healthcare Safety Network (NHSN). According to the Dec. 31, 2024, Quality, Safety …
Fiscal Year (FY) 2025 Mission & Priorities document (MPD) – Action Admin Info 25-05-AllFiscal Year (FY) 2025 Mission & Priorities document (MPD) – Action For questions or concerns relating to this memorandum, please contact your …
The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)17.0 is now available. The MDS 3.0 QM User’s Manual V17.0 contains detailed specifications for the MDS 3.0 QMs and includes a Notable …
Memo #QSO-25-11-NH Posting Date 2024-12-31 Fiscal Year 2025 Memorandum Summary • Acute Respiratory Illness Reporting Requirements: The LTC facility requirements for reporting COVID-19-related data expired on December 31, 2024, except for reporting COVID-19 resident and staff vaccination …
The Department’s Office for Civil Rights seeks to update HIPAA Security Rule for the first time since 2013 On December 27, 2024, the U.S. Department of Health and Human Services (HHS), through its Office for …
FFS & MA NOMNC/DENC What’s New 11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) …
Quick Reference Guide: Re-Submitting COVID-19 Vaccination Data using the Person-Level Vaccination Forms Introduction This Quick Reference Guide (QRG) will provide information on using the Re-submit all changed weeks button for your facility’s person-level COVID-19 vaccination …
Vaccination Updates for the Respiratory Virus Season Reporting Annual Healthcare Personnel Influenza Vaccination Data This is a friendly reminder that reporting annual influenza vaccination data among healthcare personnel (HCP) is required for CMS-certified free-standing acute …
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 …
Use of Additional Doses of 2024–2025 COVID-19 Vaccine for Adults Aged ≥65 Years and Persons Aged ≥6 Months with Moderate or Severe Immunocompromise: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024 …
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 …
Memo #QSO-25-09-ALL Fiscal Year 2025 REVISION TO QSO-19-09-ALL REVISED ORIGINALLY RELEASED ON MARCH 5, 2019 • Core Appendix Q and Subparts – Appendix Q to the State Operations Manual (SOM), which provides guidance for identifying …
De-escalation/Behavioral Expression Toolkit De-Escalation Strategies In-Service Toolkit The de-escalation toolkit aims to equip staff with the knowledge and techniques necessary to prevent escalating behaviors and enhance safety within a nursing facility. The de-escalation toolkit offers …
From https://oig.hhs.gov/compliance/nursing-facility-icpg/ The Nursing Facility ICPG—together with OIG’s General Compliance Program Guidance (GCPG) that applies to all individuals and entities involved in the health care industry—serves as OIG’s updated and centralized source of voluntary compliance program guidance for …
Sepsis—a key driver of hospital readmissions—can have negative clinical impacts for residents and negative financial, quality, survey, and even legal impacts for nursing homes. Here is a review of important basics: What is sepsis? The …
Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process Memo # QSO-25-07-NH Posting Date 2024-11-18 Fiscal Year 2025 Memorandum SummaryRevised Surveyor Guidance: CMS is releasing the …
The newly revised Clinical Practice Guideline for Diabetes Management in the Post-Acute and Long-Term Care (PALTC) Setting provides (1) new information on overall goals in diabetes care, (2) detailed information on how to use and …
Report Materials Why OIG Did This Review What OIG Found The National Background Check Program successfully established a program to help States identify efficient, effective, and economical procedures for conducting background checks on prospective long-term …
Directors, Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG) Memorandum Summary CMS is releasing the Fiscal Year 2025 guidance for the State Performance Standards System (SPSS), the process used to oversee …
Final FEMA Exception Memo for Milton: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension Limited Waiver of HIPAA Sanctions & Penalties During a Declared Emergency: 2024 Public Health Emergency for State of Florida in Response to Hurricane Milton October 8, 2024 What: President Joseph R. …
Final FEMA Exception Memo for Helene: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension Hurricane Helene – South Carolina and Tennessee (2024) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on September 30, 2024, …
REVISED: Updates to Nursing Home Care Compare Staffing and Quality Measures Memo # QSO-25-01-NH REVISIONS TO QSO-23-21-NH, ORIGINALLY RELEASED ON September 20, 2023. • Adjustment to Staffing and Quality Measures: CMS will update the staffing …
Provider Bulletin #22a October 1, 2024 Dear Colleague, We are pleased to announce several important updates for the provider community and others who rely on Livanta’s services as a Medicare Beneficiary and Family Centered Care …
Compliance with Residents’ Rights Requirement related to Nursing Home Residents’ Right to Vote Memo #QSO-24-21-NH Posting Date 2024-09-26 Fiscal Year 2024 Memorandum Summary• The Centers for Medicare & Medicaid Services (CMS) is affirming the regulatory …
The National Healthcare Safety Network (NHSN) Long-Term Care Facility Component Manual Tracking Healthcare-Associated Infections (HAIs) in Long-term Care Facilities The National Healthcare Safety Network (NHSN) Manual 2025 COVID-19 VACCINATION PROTOCOL Weekly COVID-19 Vaccination Module for …
With the help of contractors, CMS revised the SNF ABN, Form CMS-10055, and the form instructions. The SNF ABN form and instructions are located in the download section and are available for immediate use, but …
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 …
Certain For-Profit Nursing Homes May Not Have Complied With Federal Requirements Regarding the Infection Preventionist Position (A-01-22-00001) Not all for-profit nursing homes we reviewed met Federal requirements. Seventy-six of the 100 for-profit nursing homes in …
Hurricane Debby – Georgia and South Carolina (2024) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on August 07, 2024, giving us the flexibility to support our …
Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on July 12, 2024, giving us the flexibility to support our beneficiaries in Texas, effective retrospectively since July 05, 2024. …
Link to rule: https://www.federalregister.gov/public-inspection/2024-16907/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Wage index files: CMS-1802-F Wage Index Tables for FY 2025 – Final (ZIP) Fact Sheet: On July 31, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating Medicare …
Healthcare Workplace Violence Speaker Series Workplace safety affects all healthcare staff, patients, and visitors. ASPR TRACIE recently added two new recordings to our Workplace Violence Speaker Series: An Overview of the Healthcare Facility Armed Assailant Planning …
F-tag 689 (Free of Accident Hazards/Supervision/Devices) was the No. 1 tag cited at the immediate jeopardy (IJ) level in 2023—and remains at the top halfway into 2024, according to QCOR data accessed on June 30, …
Everyone loves a good mystery. Many like to watch their favorite mysteries on television or read a good thriller. However, mystery and suspense should not be a part of the facility assessment review. The final …
The Centers for Medicare & Medicaid Services (CMS) has released the Standing Technical Expert Panel (TEP) for the Development, Evaluation, and Maintenance of Post-Acute Care (PAC) and Hospice Quality Reporting Program (QRP) Measurement Sets Summary …
Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting; Correction SUMMARY: This document corrects typographical and technical errors in the final rule that appeared in …
Recently Added Items Announced Agency Title Component Report Number(s) June 2024 Centers for Medicare and Medicaid Services Assessment of the Special Focus Facility Program for Nursing Homes Office of Evaluation and Inspections OEI-01-23-00050;OEI-01-23-00052 June 2024 …
Engineering controls can be implemented to isolate people from a hazard and provide protection for long-term care residents and staff. Engineering Controls for Long-Term Care
This site includes access to a provider enrollment and certification roadmap: https://www.cms.gov/medicare/provider-enrollment-and-certification/enroll-as-an-institutional-provider
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 …
Improves quality of information on labels, safety data sheets; takes effect July 19, 2024 WASHINGTON – The Department of Labor today announced a final rule from its Occupational Safety and Health Administration that will update the …
Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings https://www.cdc.gov/healthcare-associated-infections/php/toolkit/icar.html AT A GLANCE ON THIS PAGE
https://www.cdc.gov/long-term-care-facilities/hcp/training/index.html AT A GLANCE ON THIS PAGE Course link: https://www.train.org/cdctrain/training_plan/3814 Training resources
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html AT A GLANCE Frequently asked questions about using enhanced barrier precautions in nursing homes to prevent MDROs. ON THIS PAGE
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html KEY POINTS How to implement personal protective equipment (PPE) use in nursing homes to prevent spread of multi-drug resistant organisms (MDROs). Summary of recent changes Enhanced Barrier Precautions in Nursing Homes – Video, Posters, …
AGENCY: Office for Civil Rights, Office of the Secretary, Department of Health and Human Services; Centers for Medicare & Medicaid Services, Department of Health and Human Services. ACTION: Final rule and interpretation. SUMMARY: The Department …
Q1. What is CMS announcing? Q2. What are the finalized minimum nurse staffing standards? Q3. Why did CMS decide to finalize a total nurse staffing threshold? Q4. What if my facility already exceeds this level …
The Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule adopts the Centers for Medicare & Medicaid Services’ (CMS) proposed three-pronged, comprehensive staffing approach for Medicare- and Medicaid-certified …
When an abuse situation occurs, staff must know how to respond and must do so in a timely manner. Opportunities to practice enable staff to sharpen their responses to these events. AAPACN’s Mock Abuse Drill …
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 …
Main Points Deprescribing has emerged as a clinical practice to reduce polypharmacy and use of potentially inappropriate medications (PIMs) and serve as a mechanism for quality improvement and increased patient safety. The purpose of this …
The expedited determination beneficiary notification process covers a lot of ground in skilled nursing facilities (SNFs), affecting residents in the fee-for-service (FFS) Medicare Part A program and Medicare Advantage plans, as well as residents who …
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 …
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 …
Memo (Technical corrections posted: 09/27/2023): 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 …
Memo # QSO-23-23-NHs Posting Date 2023-09-25 Fiscal Year 2023 Title Memorandum Summary CMS is committed to reinvesting civil money penalty (CMP) funds for projects to support the quality of care and life for nursing home …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
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 …
