Post-Acute Care Tools from AAPACN
Check out this continually growing list of free downloadable tools created by AAPACN nurse experts. These tools will help you and your team get on the same page with changing regulations, interrupted stay issues, and survey readiness. Want access to all AAPACN articles? Learn more about AAPACN and AAPACN membership.
- At-a-Glance QM, QRP, and VBP ToolWith so many Quality Measures originating from three different payment initiative programs, it’s a lot to keep track of. AAPACN’s At-a-Glance QM, QRP, and VBP tool organizes all of the measures for you. This tool has been …
- SNF QRP Quick Facts ToolsThe Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) has developed a variety of measures that use data from the MDS 3.0, Medicare Fee-for-Service Claims, and Centers for Disease Control and Prevention (CDC) National Healthcare …
- 2024 Five-Star and Care Compare MDS 3.0 Quality Measure Data PeriodsCare Compare refreshes MDS 3.0 Quality Measure (QM) data quarterly in January, April, July, and October with the most recent four full quarters of data. AAPACN’s 2024 Five-Star and Care Compare MDS 3.0 Quality Measure …
- Beneficiary Notice Guidelines ToolAre you confused about which beneficiary notices are needed and when? The Beneficiary Notice Guidelines tool lists scenarios that you might run into, clarifying exactly what notices are needed to reduce the risk of claim denials and …
- Respiratory Virus Vaccination ToolkitRespiratory viruses carry the potential for serious illness and can lead to hospitalization. Vaccination is an integral part of a proactive infection control program that combats these viruses. Nurse leaders can use this toolkit to …
- Sepsis: Nurse Documentation Training AideStarting Oct. 1, 2024, additional supporting documentation is required to capture a diagnosis of sepsis at I2100, Septicemia on the MDS. Nurse assessment coordinators can use the AAPACN Sepsis: Nurse Documentation Training Aide to provide …
- Influenza and Pneumonia Vaccination ToolkitThe flu season is here, and yearly vaccination is a key component of an infection control program. The Influenza and Pneumonia Vaccination Toolkit will assist the director of nursing services (DNS) with auditing influenza and …
- Substance Use Disorder (SUD) ResourcesSubstance use disorder (SUD) is becoming more common in nursing home residents. While SUD can be challenging, there are several resources that can help nurse leaders to develop, implement, and sustain a SUD program. AAPACN …
- Template for Care Area Assessment Summary NoteAAPACN’s Template for Care Area Assessment (CAA) Summary Note can help guide the interdisciplinary team members through how to determine and document rationale for the care plan determination by summarizing the underlying causes, contributing factors, …
- Facility Assessment Considerations: A DNS Guide at a GlanceThe Centers for Medicare & Medicaid Services requires the facility assessment be reviewed and updated to determine what resources are needed to care for its residents. AAPACN’s Facility Assessment Considerations: A DNS Guide at a …
- NAC Preparation Guide for the Triple Check Meeting ToolGathering all of the necessary reports for the triple check meeting is a lot for nurse assessment coordinators (NACs) to keep track of. AAPACN’s NAC Preparation Guide for the Triple Check Meeting tool can help …
- Quick Guide to the SNF QRP iQIES Report: Resident-Level QM ReportThe Quick Guide to the SNF QRP iQIES Report: Resident-Level QM Report tool offers detailed information on how to interpret the SNF QRP Resident-Level Report for each MDS-based measure, depending on if the resident has …
- Guide to Successful Restorative ProgramsThere are many reasons to beef up your facility’s restorative program, from reducing risk of functional decline, improving Five-Star and Quality Measure ratings, minimizing risk of falls and immobility, to improving reimbursement under PDPM. But …
- Prepare for a Collaboration with Therapy Using SBARAppendix PP of the State Operations Manual states that every resident must receive treatment and care to promote the highest practicable physical, mental, and psychosocial well-being. This optimal treatment and care requires collaboration. When the …
- MDS Coding Criteria for Restorative Nursing ProgramsRestorative nursing programs must meet specific criteria to code on the MDS. Failure to meet these criteria will result in inability to capture restorative nursing on the MDS. Nurse assessment coordinators can use the MDS …
- Mock Abuse Drill ToolkitWhen 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 …
- Documentation Template: Isolation for Active Infectious DiseaseThe strict coding criteria for O0110M1, Isolation or quarantine for active infectious disease, requires precise documentation to support the MDS. AAPACN’s new Documentation Template: Isolation for Active Infectious Disease tool can help nurse assessment coordinators …
- MDS 3.0 Final Validation Reports Quick Facts and ResourcesNurse assessment coordinators (NACs) are responsible for the coordination and completion of the MDS assessments; however, to ensure these assessments are accepted without error into the National Submissions Database, the Final Validation Report must also …
- AAPACN’s Nursing Department Culture Assessment and Improvement WorksheetTo improve staff retention, the director of nursing services (DNS) and administrator should regularly assess the nursing department’s culture. AAPACN’s Nursing Department Culture Assessment and Improvement Worksheet can help the DNS and administrator review multiple …
- Dialysis Communication SheetIt’s important to communicate regularly with the dialysis partner regarding a resident’s status for continuity of care. The facility should communicate certain details to the dialysis partner and vice versa on days the resident has …
- PDPM At-a-Glance ToolThe PDPM At-a-Glance tool breaks down the complex methodology of each component used in the Patient-Driven Payment Model—physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), non-therapy ancillaries (NTA), and nursing. This tool provides key …
- MDS Daily Startup for the NAC Backup ToolWhen the nurse assessment coordinator (NAC) goes on vacation, there’s a lot to keep track of while they are out of office. The MDS Daily Startup for the NAC Backup tool is intended to help …
- MDS Items Impacting Reimbursement for PDPM and SNF QRP – Updated ToolDo you know what MDS items impact reimbursement under the Patient-Driven Payment Model (PDPM) or the Skilled Nursing Facility Quality Reporting Program (SNF QRP)? Use this quick guide, MDS Items Impacting Reimbursement for PDPM and …
- Sections K and O Assessment PeriodsEffective Oct. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) added columns for MDS items K0520 and O0110 to assess services provided “on admission” and “at discharge.” This change results in different assessment …
- OBRA Scheduling Tools for Calendar Year 2024AAPACN offers two great tools to assist nurse assessment coordinators (NACs) in scheduling OBRA assessments. Be prepared for 2024 with these two tools that are free to members: This AAPACN resource is copyright protected. AAPACN …
- The Dietitian’s Role in Nursing and ReimbursementTo meet residents’ individualized needs, the director of nursing services (DNS) requires the expertise of many healthcare professionals working collaboratively, including the dietitian. This tool provides guidance on how to enhance collaboration between the nursing …
- Patient Health Questionnaire Completion DeterminationEffective Oct. 1, 2023, the full Patient Health Questionnaire (PHQ)-9 will only be completed if the resident responds to the gateway PHQ-2 questions in a certain way. The Patient Health Questionnaire Completion Determination chart clarifies …
- MDS Data Collection for the NAC ToolDo you have an organized approach to collect MDS data during the 7- and 14-day look-back periods? AAPACN’s MDS Data Collection for the NAC tool provides an organized approach to gathering supporting data from the …
- Medical Record Audit: New Admission/ReadmissionThe 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 …
- Section M Pressure Ulcer/Injury: Algorithms for Present on AdmissionProperly coding pressure ulcers or injuries can be tricky. AAPACN’s Section M Pressure Ulcer/Injury: Algorithms for Present on Admission helps guide the assessor on whether to code present on admission in variety of situations. …
- Provider ICD-10-CM Documentation Tip Sheet for Long-Term CareICD-10-CM coding requires consistent and complete documentation from the provider (physician/nonphysician practitioner) to support all aspects and specific details of the diagnosis. This AAPACN Provider ICD-10-CM Documentation Tip Sheet for Long-Term Care tool serves as …
- Nurse Assessment Coordinator FTE Calculator Tool FY 2024AAPACN has re-released the Nurse Assessment Coordinator (NAC) FTE Calculator for SNF leaders to estimate the time needed to complete assessments as well as project how many hours the NAC needs for meetings and other …
- Section GG 3-Day Assessment Periods and AlgorithmEffective Oct. 1, 2023, section GG will be required on all OBRA and PPS assessments for all long-term care residents. This results in many different section GG assessment periods depending on the assessment type(s). The …
- Section GG Data Collection ToolAAPACN has updated the Section GG 3-Day Data Collection Tool to include all of the new self-care and mobility items effective Oct. 1, 2023. This AAPACN resource is copyright protected. AAPACN individual members may download …
- Learning Timeline for AAPACN Education and ResourcesAre you considering advancing your career and looking to gain knowledge to be successful in your next role? Or are you already in the position you love but looking to improve your knowledge for additional …
- Business Case TemplateThere are times when the nursing department needs new solutions or process changes to enhance resident care or improve staff workload. Often, these are high-cost solutions that require approval from the governing body, executive staff, …
- When MDS 3.0 Quality Measure Triggers Start and StopNurse assessment coordinators can use AAPACN’s When MDS 3.0 Quality Measure Triggers Start and Stop quick guide to determine when a resident will start and stop triggering an MDS 3.0 Quality Measure (QM) based on …
- Guide to Primary iQIES Reports for the Director of Nursing ServicesA 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 …
- Infection Preventionist Job DescriptionThe infection preventionist (IP), under the direction of the director of nursing services (DNS), is responsible for the development, implementation, direction, and operation of the facility’s infection prevention and control program (IPCP). The IP’s responsibilities …
- Substantive Changes to the Final MDS Nursing Home Item SetsOn April 3, 2023, the Centers for Medicare & Medicaid Services (CMS) released the final MDS Nursing Home Item Sets version 1.18.11. Nursing homes will be required to implement the new item sets—with their many …
- Submission to iQIES ChecklistAre your MDS assessments and tracking forms ready for submission to the national database? This checklist will prepare users to submit MDS item sets in the electronic health record (EHR) to the Centers for Medicare …
- Skilled Nursing Facility COVID-19 Related Waivers At-a-GlanceThe Centers for Medicare & Medicaid Services (CMS) issued several blanket waivers and updates during the COVID-19 public health emergency (PHE). While many of these waivers have already been terminated, several will remain in place …
- Emergency Crash Cart Checklist and Crash Cart Daily Signature LogEmergency crash carts need to be ready at all times to use in case of an emergency. Use AAPACN’s Emergency Crash Cart Checklist and Crash Cart Daily Signature Log to ensure that readiness. For permission …
- NAC Quick Reference Guide to the End of the COVID-19 PHE WaiversThe Centers for Medicare & Medicaid Services (CMS) has announced the COVID-19 public health emergency (PHE) will end on May 11, 2023. The end of the PHE declaration also marks the end of temporary waivers …
- Personal Protective Equipment (PPE) Donning and Doffing Competency ToolUnderstanding how to put on (don) and remove (doff) personal protective equipment (PPE) will be critical in mitigating risk for COVID-19. Download AAPACN’s Personal Protective Equipment (PPE) Donning and Doffing Competency Tool. This AAPACN resource …
- Hand Hygiene Competency ToolProperly washing hands and performing hand hygiene is an essential skill every healthcare worker (HCW) must possess. The AAPACN Hand Hygiene Competency Tool can assist nurse leaders documenting achievement of competence with this skill.
- Prepare for a Conversation with Leadership Using SBARNurse assessment coordinators (NACs) work in a unique role. They have the responsibility of managing the MDS but are often not in supervisory position over the interdisciplinary team members that complete portions of the MDS. …
- Schizophrenia Care Planning Checklist by Federal SourceThe 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 …
- Retaining Talent: Check-In with New Employee TemplateWhen new employees see their leader is invested in their success, including proficiency in their job performance as well as becoming a part of team, the odds of retaining the employee increase dramatically. AAPACN’s Retaining …
- Medicare Medical Review Contractors OverviewSince the Medicare program is heavily monitored for improper payments to protect the Medicare Trust Fund, it is likely your facility will experience a medical review by a Medicare contractor. The AAPACN Medicare Medical Review …
- Medical Record Alert SheetWhile 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 …
- Bed Safety GuideIt is important that a resident’s bed is in good working condition to maintain safety and provide the highest quality of care for the resident. Utilize AAPACN’S Bed Safety Guide to ensure each bed in …
- Preparing for Section G Retirement: Care Plan UpdatesCMS has announced the retirement of section G, activities of daily living with the MDS item set version 1.18.11, which goes into effect Oct. 1, 2023. To prepare for this change, nurse assessment coordinators can …
- SAMPLE Task List for the Nurse Assessment Coordinator (NAC)The new nurse assessment coordinator (NAC) may be overwhelmed with the numerous tasks required of the position. To ease some of this burden, AAPACN developed the Sample Task List for the Nurse Assessment Coordinator tool …
- OBRA Scheduling Tools for Calendar Year 2023AAPACN offers two great tools to assist nurse assessment coordinators (NACs) in scheduling OBRA assessments. Be prepared for 2023 with these two tools that are free to members: For permission to use or reproduce this …
- Laboratory Test ToolAAPACN’s Laboratory Test Tool provides useful knowledge to nurses regarding the most widely ordered laboratory tests. Areas of knowledge include components of each test, reasons the physician may order the laboratory test, if the resident …
- MDS Trickle-Down EffectMDS data has a substantial impact on many different facility outcomes; however, communicating just how important this data is can be a daunting task. Using a water pipeline analogy, the AAPACN MDS Trickle-Down Effect tool …
- Skilled or Not? Tool – REVISEDUnderstanding the technical and skilled level care requirements for Medicare A is always a challenge. We’ve broken down the process with our Skilled or Not? tool. For permission to use or reproduce this article in full or …
- NAC Job DescriptionThe nurse assessment coordinator’s role in ensuring compliance with complex federal requirements is paramount to the success of the financial operations of a facility and the care of residents. Use this NAC Job Description, to …
- Guide to Key MDS-Related CASPER Reports for the Nurse Assessment Coordinator (NAC) ToolA systematic approach to utilizing the CASPER reports is necessary for monitoring Quality Measures, managing MDS assessments, and reimbursement. While there are numerous reports available via CASPER, AAPACN’s Guide to Key MDS-Related CASPER Reports for …
- IPA Algorithm ToolDo you and the interdisciplinary team know when an Interim Payment Assessment (IPA) is warranted? In AAPACN’s IPA Algorithm tool, find out the steps you’ll need to take in the event that there is a …
- Drug Regimen Review Quick GuideHelp your clinical team to understand the MDS Drug Regimen Review (DRR) process and to identify clinically significant medication issues that need immediate physician follow-up. Use the Drug Regimen Review Quick Guide tool to shore …
- COVID-19 Diagnosis Flow Chart for FY 2023The complexities of assigning codes for COVID-19 and associated manifestations can be a confusing process. The AAPACN COVID-19 Diagnosis Flow Chart tool uses chapter-specific coding guidance for FY 2023 and will assist the user to …
- Payroll-Based Journal (PBJ) Audit ToolThe Centers for Medicare & Medicare Services (CMS) requires PBJ data to be submitted at least quarterly. It is imperative that this data is accurate as it is publicly reported and impacts the Five Star …
- PDPM FY2023: MDS Nurse FTE Calculator ToolAAPACN has re-released the MDS Nurse FTE Calculator for SNF leaders to estimate the time needed to complete assessments as well as project how many hours the NAC needs for meetings and other duties for fiscal …
- 10 Fast Facts About Trauma-Informed Care ToolDo you know what trauma-informed care is and who is at risk? In AAPACN’s 10 Fast Facts About Trauma-Informed Care tool, you’ll get the quick and important details you need to know about trauma-informed care in …
- Discharge Process ChecklistDischarge planning is the process of transitioning a resident from the facility to a lower level of care. The goal of each discharge is to establish a person-centered discharge plan that prevents avoidable readmissions to …
- Five-Star Staffing Measures Scoring and Methodology ToolThe July 2022 Care Compare refresh reflected a major overhaul of how the Five-Star Staffing stars are calculated. The staffing domain is now based on six staffing measures, three based on hours per resident day …
- Interrupted Stay Tracker ToolFor Medicare residents, nurse assessment coordinators (NACs) need to determine whether an interrupted stay has occurred and ensure that the correct MDS assessments, both OBRA and PPS, are in place. AAPACN’s Interrupted Stay Tracker tool …
- Interrupted Stay Policy Quick GuideThe interrupted stay policy designates that a Medicare stay is considered a continuous stay when it is interrupted by less than three non-covered days. AAPACN’s Interrupted Stay Policy Quick Guide provides the key facts for …
- Interrupted Stay Flow ChartDetermining whether an interrupted stay has occurred can be a challenge, especially when so many different factors must be considered. AAPACN’s enhanced Interrupted Stay Flow Chart will help nurse assessment coordinators (NACs) navigate different scenarios to …
- Medicare A2400C Algorithm with the NPE and Interrupted StayAAPACN has adapted the A2400C flow chart from section A of the RAI User’s Manual to show how A2400C impacts how the nurse assessment coordinator (NAC) schedules the PPS Part A Discharge assessment and how …
- Quality Assurance and Performance Improvement (QAPI) Meeting ToolsQAPI is a data-driven, proactive approach to improving the quality of care, life, and services for residents. A QAPI meeting is an opportunity for the QAA/QAPI Steering Committee to discuss performance of the full scope …
- Quick Facts – SNF QRP Proposed Measure: Influenza Vaccination Coverage among Healthcare PersonnelThe Centers for Medicare & Medicaid Services (CMS) proposed a new Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) measure that will potentially be included in FY 2025 program year. The Influenza Vaccination Coverage Among …
- Mandatory Training ChecklistGovernment entities require mandatory staff trainings to be completed at least annually. AAPACN’s Mandatory Training Checklist is intended to assist the facility leader in ensuring staff have completed mandated trainings per facility policy. For permission …
- Resident Cognitive Level Determination: For the SLP and Nursing Components Under PDPMIf the BIMS interview is not completed, the PDPM Cognitive Level will be used to determine cognitive impairment under the SLP and Nursing components of PDPM. AAPACN has updated its Resident Cognitive Level Determination Tool to help nurse …
- Stay Interview Template and Action PlanA stay interview is a conversation between the manager and employee to learn why the employee continues to choose the company as their place of employment—what keeps them coming back every day. Moreover, it’s an …
- Social Determinants of Health and the Impact on Discharge PlanningUsing social determinants of health (SDOH) when developing a resident’s discharge plan can help identify and address potential risks that could adversely affect the resident’s ability to safely discharge back to the community. AAPACN’s Social …
- Hospice Collaboration ToolkitThe Hospice Collaboration Toolkit assists facility leaders to understand hospice services and provides guidance on how to enhance collaboration, thus improving the quality of care and the quality of life for residents nearing end-of-life experience. …
- Section GG Process Flow Chart ToolThe functional assessment coded in section GG often brings with it many questions— Should therapy complete this section? What type of documentation is needed? Can I use nurse aide documentation? How do we determine usual …
- Stretch and SMART Goal Setting Worksheet ToolGoal setting for personal, professional, and organizational growth is a proven tactic to help individuals and teams achieve higher performance. Nurse leaders can use this worksheet to help their team or themselves develop a stretch …
- Admission Sample Questionnaire ToolThis conversation starter will help your team learn more about a new residents’ interests, routines, and goals and engage the resident in their care planning right from admission. AAPACN’s Admission Sample Questionnaire tool (print) can …
- Morning Stand-Up Meeting Minutes ToolMorning stand-up is meant to be a brief meeting (15 minutes or less) to exchange information that affects the operations of multiple departments on that given day. The information exchanged should be shared with the …
- Emergency Drills: Code and Elopement ToolkitWhen emergency events happen, such as cardiac and respiratory arrest or an elopement, it is imperative that staff know how to respond. Nurse leadership should provide opportunities for staff to practice and perfect their response …
- Nurse Aide (CNA) In-Service Training and Competency Tracker ToolF947, Required in-service training for nurse aides, requires that each certified nursing assistant (CNA) complete a minimum of 12 hours of in-service training per year starting on the CNA’s hire date. Nurse leaders can customize …
- Interview Template ToolNurse leaders want to hire candidates with the right characteristics and talents necessary to be successful in their jobs. AAPACN’s new Interview Template Tool allows the nurse leader to customize the desired characteristics and talents, …
- COVID-19 Diagnosis Coding Guidance Timeline for Auditing Claims Diagnosis Coding ToolRecently, CMS resumed medical reviews for Medicare claims for dates of service after March 2020; however, it may be difficult for facility staff to audit COVID-19-related diagnoses due to how frequently guidance was updated from …
- Maximizing Your Pharmacy’s Benefits ToolAAPACN’s latest set of tools provides nurse leaders with guidance on how to best utilize the pharmacy’s services and expertise and assists nurse leaders to collaborate with the pharmacist and maximize his or her expertise …
- Interim Payment Assessment Considerations ToolA question that comes up often lately for nurse assessment coordinators (NACs) is, “Should I do an IPA?” The assessment is optional, which can also make deciding when to complete one a challenge. Depending on …
- Guide to Resident-at-Riskby AAPACN To meet the needs of medically complex residents, a holistic, individualized approach to care is required, including when a resident is at risk for a decline or change in condition. This guide provides …
- AAPACN Onboarding Essentials: Welcoming Staff to Promote Retention ToolRetaining a talented workforce is a top priority; to achieve this goal, leaders must create a welcoming onboarding experience. This toolkit presents education for department managers and administration as well as tools leaders can use …
- 10-Week Nurse Assessment Coordinator Orientation Guide ToolOrientation for a new nurse assessment coordinator (NAC) is a very complex and long process. It is important to establish a realistic schedule that will allow for effective learning but will not be overwhelming. AAPACN’s …
- Certified Nurse Aide (CNA) Retention Tip Sheet ToolLeadership significantly affects CNA retention. To improve your facility’s CNA retention, as a leader, use the Certified Nurse Aide (CNA) Retention Tip Sheet that outlines the five leadership principles and 10 actions to help leaders …
- Survey Readiness: Critical Element Pathways, Observations, Reviews, and Policy Calendar ToolSurveyors use critical element pathways (CEPs) to work through the steps of their investigation and to determine compliance with several federal regulations. In addition to CEPs, other tools including observational guides are also used to …
- Employee File Audit SheetAll long-term care facilities must compile and maintain a personnel file and a medical file for each employee. AAPACN’s Employee File Audit Sheet is intended to assist facility leaders in their review of the employee …
- COVID-19 Tools from AAPACNIn response to the COVID-19 pandemic, AAPACN is developing several tools and resources to help LTPAC providers. The tools and resources available to date include: Updated Personal Protective Equipment (PPE) Donning and Doffing Competency Tool COVID-19: …
- COVID-19 Tools From AAPACNIn response to the COVID-19 pandemic, AAPACN is developing several tools and resources to help LTPAC providers. The tools and resources available to date include: Updated Personal Protective Equipment (PPE) Donning and Doffing Competency Tool COVID-19: …
- Weekly Medication Storage Inspection ToolCorrect medication storage is a component of the nurse leader’s responsibility and should be part of their rounds. The AAPACN Weekly Medication Storage Inspection tool assists the reviewer to conduct inspections for compliance, and also …
- Comprehensive Diagnosis Collection Flow Chart ToolICD-10-CM coding plays a substantial role in the accuracy of Medicare reimbursement under PDPM. However, collecting this information often requires a lot of research and queries or clarifications with the resident’s physician. AAPACN’s Comprehensive Diagnosis …
- Daily Clinical Rounds ToolDaily clinical rounds allow the nurse leader opportunities to connect with staff and residents, gain valuable information, reinforce consistency of standards, and model clinical leadership behaviors. The AAPACN Daily Clinical Rounds tool assists the nurse …