Clinical Surveillance Resources

When it comes to resident care, your role is to see the bigger picture and to put systems in place that not only protect your residents but also promote their best possible function. Preventing and identifying medical errors and adverse events is imperative for facility leaders. Using the latest technologies to synthesize resident care outcome data -- in complement with implementing proper bedside and clinical decision-making protocols -- are part of a strong clinical surveillance system that bolsters quality assurance. Find out what you need to know and how your facility can take evidence-based steps to improve care. 

  • CMS Proposes PASRR Changes (2/20)

    By CMS - February 18, 2020

    DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 431, 433, 435, 441, and 483 [CMS-2418-P] RIN 0938-AT95 Medicaid Program; Preadmission Screening and Resident Review

    AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

    ACTION: Proposed rule.

    SUMMARY: This proposed rule would modernize the requirements for Preadmission Screening and Resident Review (PASRR), currently referred to in regulation as Preadmission Screening and Annual Resident Review, by incorporating statutory changes, reflecting updates to diagnostic criteria for mental illness and intellectual disability, reducing duplicative requirements and other administrative burdens on State PASRR programs, and making the process more streamlined and person-centered.

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  • CMS QSO Memo Explains 2 New Toolkits to Ensure Safety and Quality in Nursing Homes (2/20)

    By CMS - February 18, 2020

    CMS developed optional toolkits to aid nursing home teams with reducing adverse events and improving dementia care. These toolkits were the result of CMS work with nursing home Breakthrough Communities—a learning collaborative design where a subset of nursing homes joined learning sessions and team calls to learn about quality improvement concepts.

    Memorandum Summary

    The Centers for Medicare & Medicaid Services (CMS) is announcing the release of two toolkits that align with the CMS strategic initiative to Ensure Safety and Quality in Nursing Homes.

    • Developing a Restful Environment Action Manual (DREAM) Toolkit – CMS has created a toolkit that offers education and person-centered, practical interventions that nursing home administrators, directors of nursing, and bedside staff can implement to promote high-quality sleep for residents living with dementia.

    • Head-to-Toe Infection Prevention (H2T) Toolkit – CMS has created a toolkit that offers educational materials and practical interventions for bedside staff designed to prevent common infections by improving activities of daily living (ADL) care.

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  • Developing a Restful Environment Action Manual (DREAM) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    As many as 70% of adults with dementia experience sleep disturbances, which are associated with various negative health outcomes. High quality sleep is necessary for optimal cognitive and physical functioning, especially for residents who already experience cognitive decline due to dementia. The DREAM Toolkit provides educational material and practical tools for nursing home staff to help all residents living with dementia improve sleep quality. Nursing homes can choose from a variety of strategies in the DREAM Toolkit to help improve quality of life and quality of care, especially for residents living with dementia.

    The DREAM Toolkit consists of the following components:

    1) Implementation Guide

    2) Handbook

    3) Sleep Matters Video: https://youtu.be/2Ub55iKej84  

    4) Pocket Guide for Clinical Teams

    5) Sleep Environment Improvement Tool

    6) Resident Preferences Tool

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  • Head to Toe Infection Prevention (H2T) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    Infections comprise a large share of adverse events in nursing homes. The Head to Toe Infection Prevention Toolkit contains educational materials and practical tools to support the clinical team in providing person-centered care that helps prevent and control common infections like pneumonia, skin infections, and urinary tract infections. The Toolkit aims to educate licensed nurses and nurse aides on infection prevention practices and provide tools that can be integrated into their daily work.

    The H2T Toolkit consists of the following components:

    1) Implementation Guide

    2) Infection Prevention Handbook

    3) Staff Presentation

    4) Resource for Residents and Loved Ones

    5) Observation Guide

    6) Customizing Care Tool

    7) Suspected Infection Investigation Tool

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  • Q&A: How do you assess for the risk of dehydration at your facility?

    By Juzell (Joey) Pettis, DNS-CT, DWC, WCC - February 11, 2020
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  • Q&A: What are your post-fall assessment protocols?

    By Ruth Minnema, RN, NHA, RAC-CT - February 11, 2020
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  • ACIP Immunization Recommendation Change for Pneumococcal conjugate (PCV13) for > 65 (2/20)

    By ACIP - February 10, 2020

    Changes in the 2020 Adult Immunization Schedule

    Changes in the 2020 adult immunization schedule for persons aged ≥19 years include new or revised recommendations for hepatitis A vaccine (HepA) (2); human papillomavirus vaccine (HPV) (3); influenza vaccine (4); serogroup B meningococcal vaccine (MenB); pneumococcal vaccine (5); and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) (6). Following are the changes to the cover page, Table 1, Table 2, and Notes.

    Cover page

    • Trademark symbols (®) were added to all vaccine trade names.
    • PedvaxHIB was added to the table of trade names for Haemophilus influenzae type b vaccine.
    • The footnote on the cover page has been edited and now reads “Do not restart or add doses to vaccine series if there are extended intervals between doses.”

    Table 1

    • Age ranges: The columns for age groups 19–21 years and 22–26 years have been combined, thereby reducing the number of columns for age ranges from five to four. This change was made because of the change in recommendation for catch-up HPV vaccination for all adults aged ≤26 years.
    • Tetanus, diphtheria, pertussis row: This row has been edited to state that tetanus and diphtheria toxoids (Td) or Tdap may be used for the decennial tetanus booster.
    • Human papillomavirus (HPV) row: The rows for males and females have been combined, reflecting that catch-up vaccination is now recommended for all adults aged ≤26 years. In addition, a blue box has been added for persons aged 27–45 years to indicate that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Pneumococcal conjugate (PCV13) row: The box for persons aged ≥65 years who do not have an additional risk factor or another indication has been changed to blue to indicate that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Meningococcal B (MenB) row: A blue box has been added for persons aged 19–23 years who are not at increased risk for meningococcal disease, indicating that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Legend: A blue box has been added to indicate that shared clinical decision-making is recommended regarding vaccination. The text defining the gray box has been edited and now reads “No recommendation/not applicable.”

    Table 2

    • Tdap or Td row: This row has been revised to read that Td or Tdap may be used for the decennial tetanus booster.
    • Human Papillomavirus (HPV) row: This row has been combined into a single row including both males and females, reflecting that HPV vaccine is now recommended for all adults aged ≤26 years.
    • Hepatitis A (HepA) row: The box for persons living with human immunodeficiency virus (HIV) infection (regardless of CD4 count) is now yellow, reflecting the new recommendation that previously unvaccinated persons in this group should be vaccinated.
    • Legend and bar text: The gray box in the Legend has been edited and now reads “No recommendation/not applicable.” The red box has been edited and now reads “Not recommended/contraindicated — vaccine should not be administered.” The text appearing in the red bars has been changed from “Contraindicated” to “Not Recommended.”
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  • CMS QSO Memo re: Coronavirus and Healthcare Facility Expectations (2/20)

    By CMS - February 10, 2020

    Memo #20-09-ALL

    Posting Date 2020-02-06

    Fiscal Year 2020

    Summary

    • Information Regarding Patients with Possible Coronavirus Illness: the U.S. Centers for Disease Control and Prevention (CDC) has issued information on the respiratory illness caused by the 2019 Novel Coronavirus (2019-nCoV). Links to these documents are provided.
    • Healthcare Facility Expectations: CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.
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  • Do You Know Who Your New QIN-QIO Is? (2/20)

    By Staff - February 05, 2020

    In November 2019, the Centers for Medicare & Medicaid Services quietly implemented the 12th Statement of Work for the Quality Improvement Network Quality Improvement Organizations (QIN-QIOs).

    This five-year contract includes a shift in how/where the QIN-QIOs operate. There are now 14 Medicare-funded QIN-QIOs nationwide. For example, IPRO is a lead contractor partnering with two other QIOs to cover 11 states and the District of Columbia. IPRO will direct activities in New York, New Jersey, and Ohio; Healthcentric Advisors will cover all six New England states (Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island); and Qlarant will handle Maryland, Delaware, and the District of Columbia.

    "QIN-QIOs serving under the 12th Statement of Work will provide customized quality improvement to nursing homes and providers, serving rural communities and the most vulnerable populations. Through this body of work, CMS is focusing on results, protecting taxpayer dollars, and most importantly, ensuring the safety and quality of care delivered to every Medicare beneficiary," says HealthCentric Advisors.

     The QIN-QIOs will address nursing home and community coalition quality improvement in the following areas:

    • Improving Behavioral Health Outcomes – Including Opioid Misuse
    • Increasing Patient Safety
    • Increasing Chronic Disease Self-Management
    • Increasing the Quality of Care Transitions
    • Improving Nursing Home Quality
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  • Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) (2/20)

    By CDC - February 03, 2020

    The Centers for Disease Control and Prevention (CDC) continues to closely monitor an outbreak of respiratory illness caused by a novel coronavirus (2019-nCoV) that was initially detected in Wuhan City, Hubei Province, China in December 2019.

    This CDC Health Alert Network (HAN) Update provides a situational update and interim guidance to state and local health departments that supersedes guidance in CDC’s HAN 426 distributed on January 17, 2020.

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  • Sexual Expression/Intimacy Requires a Person-Centered Approach

    By Caralyn Davis, Staff Writer - January 28, 2020

    The Centers for Medicare & Medicaid Services (CMS) makes clear that nursing homes should have a sexual expression/intimacy program that supports sexually intimate relationships when possible. Specifically, F607 (Develop/Implement Abuse/Neglect, etc. Policies) in Appendix PP of the State Operations Manual states:

     

    The facility must have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves (but is not limited to):

    • Establishing a safe environment that supports, to the extent possible, a resident’s consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the [sic] identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident’s right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship;

     

    Here are critical steps for establishing a viable sexual expression/intimacy program for residents:

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  • Antipsychotic Medication Use Data Report and Late Adopter Data Report Updated (1/20)

    By CMS - January 27, 2020

    National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report (October 2019)

     

    The National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for individuals with dementia living in nursing homes. The National Partnership has a mission to deliver health care that is person-centered, comprehensive and interdisciplinary with a specific focus on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need. The Centers for Medicare & Medicaid Services (CMS) promotes a multidimensional approach that includes; research, partnerships and state -based coalitions, revised surveyor guidance, training for providers and surveyors and public reporting. 


    CMS is tracking the progress of the National Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In 2011Q4, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 40.1 percent to a national prevalence of 14.3 percent in 2019Q2. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 45 percent. CMS acknowledges that circumstances exist where clinical indications for the use of antipsychotic medications are present and does not expect that the national prevalence of antipsychotic medication use will decrease to zero. 

     

    National Partnership to Improve Dementia Care in Nursing Homes: Late Adopter Data Report (October 2019) 

    CMS announced that the National Partnership met its goal of reducing the national prevalence of antipsychotic medication use in long-stay nursing home residents by 30 percent by the end of 2016. It also announced a new goal of a 15 percent reduction in those homes with currently limited reduction rates. Nursing homes with low rates of antipsychotic medication use are encouraged to continue their efforts and maintain their success, while those with high rates of use are to work to decrease antipsychotic medication use by 15 percent for long-stay residents by the end of 2019, using the prior baseline rate (2011Q4). These homes have been identified as late adopters.

    Nursing homes were identified as late adopters, based upon 2017Q1 data. These nursing homes continued to have a high rate of antipsychotic medication use, their percentage of change from 2011Q4 to 2017Q1 increased or decreased very little, and they remained above the national average in 2017Q1. This quarterly data report is specific to the progress of the late adopters. In 2011Q4, 21.4 percent of long-stay nursing home residents, living in a nursing home identified as a late adopter, were receiving an antipsychotic medication; since then there has been a decrease of 13.7 percent to a national prevalence, among late adopters, of 18.5 percent in 2019Q2. For more information on the National Partnership, please send correspondence to dnh_behavioralhealth@cms.hhs.gov. 

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  • March 3 CMS Quarterly Dementia Care Call to Target Infection Prevention, Staffing, Restful Environment: Register Now

    By CMS - January 05, 2020
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  • Q&A: Is there a regulation on how early we can begin getting people up for the day?

    By Cheryl Johnson, MSN, RN, Director of Healthcare Services, Buckner Retirement Services, Inc. - December 04, 2019
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  • Nursing Home Infection Control Self-Assesssment Worksheet From CMS and CDC (12/19)

    By CMS - December 02, 2019

    This 2019 Nursing Home Infection Control Worksheet (ICWS) is a collaborative effort by CMS and CDC and meant to be used by facilities as a self-assessment tool. It comprises both regulatory requirements and best practices in infection prevention and control. A facility that uses this ICWS will identify gaps in practice and have a “roadmap” that can lead to an improved infection prevention and control program. The assessment reviews the following domains:

    • Infection Control program infrastructure and Infection Preventionist
    • Infection Preventionist relationship to Quality Assurance Committee
    • Infection surveillance and outbreak response.
    • Influenza and pneumococcal Immunization
    • Linen management
    • Infection prevention during transitions of care
    • Water Management Program
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