Corporate Compliance

Is your facility doing everything that it can to be compliant? With all of the updates in one place below, you can stay up to date on OIG guidance and the requirements of the Affordable Care Act standards. Also, learn about the most effective prevention tactics to protect your facility from non-compliance so that you can focus on what’s most important - caring for your residents.

  • Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders (2/21)

    By IHI - February 23, 2021
    A resource guide, written by and for directors of nursing, administrators, and other nursing home leaders, outlines steps to reduce or eliminate urgent staff shortages, particularly shortages of direct care workers. This guide is from the Institute for Healthcare Improvement (IHI) and Project ECHO, a project of the Agency for Healthcare Research and Quality (AHRQ).
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  • Emergency Preparedness Report: Identifying and Overcoming Healthcare Communications Vulnerabilities (2/21)

    By ASPR TRACIE - February 22, 2021

    ASPR TRACIE Emergency Preparedness Report: Identifying and Overcoming Healthcare Communications Vulnerabilities: Nashville, TN

    While the Christmas morning recreational vehicle blast outside the AT&T transmission facility in Nashville did not cause a mass fatality incident, it significantly impacted healthcare communications throughout the region. This article describes the impacts, lessons learned, strengths, and challenges faced by two professionals with different perspectives of the Nashville healthcare system.

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  • Center for Medicare Advocacy Offers Nursing Home COVID-19 Lessons Learned and Policy Recommendations (2/21)

    By CMA - February 22, 2021

    The Center for Medicare Advocacy released a new report – Geography Is Not Destiny: Protecting Nursing Home Residents from the Next Pandemic – which explores facilities’ responses to the coronavirus crisis and examines how residents’ deaths were not “inevitable”, as some have claimed. The report contends that COVID-19 exploited and exacerbated long-standing issues, such as staffing, infection control, and management problems, that existed for decades in the long-term care industry.

    As our nation’s nursing homes continue to reel from the unprecedented toll that COVID-19 has taken, questions remain about how many deaths could have been avoided, and – crucially – what can be done to save lives moving forward to prevent a similar catastrophe in the future. Nationwide, 36% of COVID-related deaths have occurred in long-term care facilities (and in some states that figure jumps to over 60%). These statistics are even more shocking considering that less than 1% of the nation’s population live in these facilities.

     “The wrath of COVID-19 in our nursing homes was felt, in large part, because we as a nation have not prioritized fixing these issues,” states Cinnamon St. John, the report’s author – who is also the Center’s Health and Aging Policy Fellow and Associate Director of NYU Rory Meyers’ Hartford Institute of Geriatric Nursing. “COVID-19 will very likely not be the last pandemic we experience in our lifetimes. If we don’t address these issues now, will see these mass casualties again. The good news is that we know more now. The lessons are clear. But we must act. The currency is lives – lives lost, or lives saved,” she added

    The report:

    ·         Analyzes and challenges the assertion that “Geography is Destiny” as the prevailing theory of nursing home transmission (concluding “a facility’s location does not equate to a facility’s fate”)

    ·         Identifies lessons learned for nursing homes

    ·         Provides specific policy recommendations for change

    The report also examines both the challenges and successes of nursing home administrators who have been combatting COVID-19 on a daily basis. “You can either panic during the pandemic or you can be prepared during the pandemic. It’s better to be prepared,” says Reverend Derrick DeWitt, Director and CFO of the Maryland Baptist Aged Home. His nursing home, with about a 90% Medicaid resident population, has remarkably remained COVID-free to this day.

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  • Emergency Preparedness: Healthcare Cybersecurity Readiness and Response (2/21)

    By ASPR TRACIE - February 21, 2021
    As part of our nation’s critical infrastructure, healthcare facilities large and small must be proactive and move quickly to protect themselves from cyberattacks that could directly impact the health and safety of patients and the community at large. According to medical health experts experienced in cybersecurity preparedness, cyberattacks are identified as the top threat in many healthcare systems’ annual Hazard Vulnerable Analyses (HVA).  Healthcare System Cybersecurity: Readiness and Response Considerations addresses this threat.
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  • LTCSP Survey Resources: Surveyor Tools Updated (2/21)

    By CMS - February 07, 2021

    This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP).

     

     

    02/05/2021 Survey Resource folder update: 

     

    LTCSP Procedure Guide

    • Expansion of complaints/FRIs in LTCSP during recertification survey

    LTCSP 11.9.5 User Guide

    • Expansion of complaints/FRIs in LTCSP during recertification survey

     

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  • LTCSP Procedure Guide - Updated (2/21)

    By CMS - February 07, 2021

    The LTCSP Procedure Guide provides instruction on the procedural and software steps necessary for completing the Long-term Care Survey Process. Surveyors use the Procedure Guide for all standard surveys of SNFs and NFs, whether freestanding, distinct parts, or dually participating. The LTCSP steps are organized into seven parts: 1) offsite preparation; 2) facility entrance; 3) initial pool process; 4) sample selection; 5) investigation; 6) ongoing and other survey activities; and 7) potential citations.

    2/5 update

    1. LTCSP Procedure Guide: Expansion of complaints/FRIs in LTCSP during recertification survey

     

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  • Check Your Data: Updated Data Process Will Impact CASPER/SNF QRP Provider Demographic Data (2/21)

    By QTSO - February 06, 2021

    CMS will be transitioning to a new data source for a provider’s demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities / Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Hospices).  These demographic data include such items as the provider name, provider-mailing address, provider physical address, State, ZIP Code, etc.  These provider demographic data are displayed on the Provider and Quality Measure reports generated from the Quality Improvement and Evaluation System (QIES) Certification and Survey Provider Enhanced Reports (CASPER) Reporting application for SNF/NF and Hospice providers and reports generated from Internet Quality Improvement and Evaluation System (iQIES) for HHA, IRF, and LTCH providers.  Additionally these same demographic data are displayed on the public reporting websites such as the Provider Data Catalog (PDC).

    Historically provider demographic data have been maintained in the Automated Survey Processing Environment or ASPEN software; however, CMS will be transitioning to use the demographic information from Provider Enrollment, Chain and Ownership System (PECOS).  While this transition is underway, a final date when all demographic data will be obtained from PECOS has not been identified.  During this transition, all PAC providers will be responsible to ensure their latest demographic data are updated and available in both the ASPEN and PECOS systems. 

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  • CMS Online Platform for Submissions of 1135 Waiver Requests and Inquiries (1/21)

    By CMS - January 10, 2021

    • New Web Platform for 1135 Waivers and Inquiries – The Centers for Medicare & Medicaid Services (CMS) is announcing a new web-based tool to assist Medicare/Medicaid-participating providers and suppliers in submission of 1135 Waiver requests and inquiries. With very limited exception, the new web system should be used for all 1135 waiver requests and/or PHE-related inquiries submitted on or after January 11, 2021.

    • Waiver requests related to Physician Self-Referral (Stark Law) should not be submitted via the new web portal. For these requests, please visit:https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Spotlightfor additional information.

    • This policy memorandum outlines the new changes to submission of 1135 Waiver requests/inquiries as well as resources available to providers and suppliers during the current COVID-19 Public Health Emergency (PHE) and future emergency events.

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  • LTCSP Survey Pathways Updated (12/20)

    By CMS - December 13, 2020
    Available survey pathways include the following:

    • SNF Beneficiary Protection Notification Review
    • Dining Observation
    • Infection Prevention, Control & Immunizations.  Note: 12/10/2020 update for this pathway.
    • Kitchen Observation
    • Medication Administration Observation
    • Resident Council Interview
    • Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review
    • Abuse Critical Element Pathway
    • Environmental Observations
    • Sufficient and Competent Nurse Staffing Review
    • Personal Funds Review
    • Activities Critical Element Pathway
    • Activities of Daily Living (ADL) Critical Element Pathway
    • Behavioral and Emotional Status Critical Element Pathway
    • Urinary Catheter or Urinary Tract Infection Critical Element Pathway
    • Communication and Sensory Problems (Includes Hearing and Vision) Critical Element Pathway
    • Dental Status and Services Critical Element Pathway
    • Dialysis Critical Element Pathway
    • General Critical Element Pathway
    • Hospice and End of Life Care and Services Critical Element Pathway
    • Death Critical Element Pathway
    • Nutrition Critical Element Pathway
    • Pain Recognition and Management Critical Element Pathway
    • Physical Restraints Critical Element Pathway
    • Pressure Ulcer/Injury Critical Element Pathway
    • Specialized Rehabilitative or Restorative Services Critical Element Pathway
    • Respiratory Care Critical Element Pathway
    • Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway
    • Medication Storage and Labeling
    • Preadmission Screening and Resident Review Critical Element Pathway
    • Extended Survey
    • Hydration Critical Element Pathway
    • Tube Feeding Status Critical Element Pathway
    • Positioning, Mobility & Range of Motion (ROMADL) Critical Element Pathway
    • Hospitalization Critical Element Pathway
    • Bladder or Bowel Incontinence Critical Element Pathway
    • Accidents Critical Element Pathway
    • Neglect Critical Element Pathway
    • Resident Assessment Critical Element Pathway
    • Discharge Critical Element Pathway
    • Dementia Care Critical Element Pathway

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  • HIPAA Privacy Rule: Proposed Modifications (12/20)

    By HHS - December 11, 2020

    HHS Proposes Modifications to the HIPAA Privacy Rule to Empower Patients, Improve Coordinated Care, and Reduce Regulatory Burdens

    The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) announces proposed changes to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to support individuals’ engagement in their care, remove barriers to coordinated care, and reduce regulatory burdens on the health care industry.

    The Notice of Proposed Rulemaking (NPRM) is part of HHS’s Regulatory Sprint to Coordinated Care, initiated under HHS Secretary Alex Azar’s value-based transformation agenda and led by HHS Deputy Secretary Eric Hargan, which seeks to promote value-based health care by examining federal regulations that impede efforts among health care providers and health plans to better coordinate care for patients.

    The proposed changes to the HIPAA Privacy Rule include strengthening individuals’ rights to access their own health information, including electronic information; improving information sharing for care coordination and case management for individuals; facilitating greater family and caregiver involvement in the care of individuals experiencing emergencies or health crises; enhancing flexibilities for disclosures in emergency or threatening circumstances, such as the Opioid and COVID-19 public health emergencies; and reducing administrative burdens on HIPAA covered health care providers and health plans, while continuing to protect individuals’ health information privacy interests.

    “Our proposed changes to the HIPAA Privacy Rule will break down barriers that have stood in the way of commonsense care coordination and value-based arrangements for far too long,” said HHS Secretary Alex Azar. “As part of our broader efforts to reform regulations that impede care coordination, these proposed reforms will reduce burdens on providers and empower patients and their families to secure better health.”

    “This announcement is a continuation of our ongoing work under my Regulatory Sprint to Coordinated Care to eliminate unnecessary regulatory barriers blocking patients from getting better care,” said HHS Deputy Secretary Eric Hargan. “These proposed changes reduce burden on providers and support new ways for them to innovate and coordinate care on behalf of patients, while ensuring that we uphold HIPAA’s promise of privacy and security.”

    “The Trump Administration is empowering patients with greater access to their health information and is lifting unnecessary regulations weighing down the health care industry,” said OCR Director Roger Severino.  “The proposed changes to the HIPAA Privacy Rule will promote truly coordinated, value-based health care for all.”

    OCR encourages comments from all stakeholders, including patients and their families, HIPAA covered entities (health plans, health care clearinghouses, and most health care providers) and their business associates, consumer advocates, health care professional associations, health information management professionals, health information technology vendors, and government entities.

    Public comments on the NPRM will be due 60 days after publication of the NPRM in the Federal Register.  The NPRM may be viewed or downloaded from HHS’s website at https://www.hhs.gov/sites/default/files/hhs-ocr-hipaa-nprm.pdf - PDF.*

    * People using assistive technology may not be able to fully access information in this file. For assistance, contact the HHS Office for Civil Rights at (800) 368-1019, TDD toll-free: (800) 537-7697, or by emailing OCRMail@hhs.gov.


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  • Nursing Home COVID-19 Testing FAQs From CMS (12/20)

    By CMS - December 08, 2020

    These Frequently Asked Questions cover the following topics:

    1.      Q: CMS posts county positivity rates for staff testing. What if my state or county also posts rates of COVID-19 positivity for each county?

    2.      Q: Should nursing homes use the percent positivity rate or the color-coded positivity classification to determine their frequency for routine testing (i.e., twice a week, weekly, or monthly)?

    3.      Q: Given CMS’ modifications to the methodology for test positivity to include two weeks of data, do I still have to wait two weeks to reduce testing frequency?

    4.      Q: Should facilities always perform outbreak testing for all residents and staff when a new COVID-19 infection is identified

    5.      Q: Can staff be tested by a different entity than the nursing home?

    6.      Q: Some staff or care providers do not come into the facility each week; do I have to test them at the same frequency as all staff? For example, do they need to come into the facility just to be tested?

    7.      Q: What is a false positive Point of Care antigen test result and what should we do if we potentially have one?

    8.      Q: What steps can be taken to reduce the potential for false-positive antigen tests?

    9.      Q: What if a facility is trying to comply with the testing requirements, but is unable due to factors outside of its control?

    10.  Q: Do individuals providing emergency medical services (EMS) need to be tested?

    11.  Q: What does the 48-hour turn-around time mean?

    12.  Q: When a facility admits a new resident with COVID-19, does that trigger outbreak testing?

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  • LTCSP Initial Pool Care Areas UPDATED (12/20)

    By CMS - December 01, 2020

    This includes four documents, one each for: record review, resident interview, resident observations, and resident representative interview. They walk through what the surveyors investigate/ask related to each care area during the initial pool to help determine which residents they will choose for in-depth investigations in the final sample. In other words, these screening tools trigger surveyors to either investigate further or not investigate further.

     

    Effective Date: 11/21/2020

    In the RI, RO, RR and RRI care areas and probes:

    • Under infections care area, update the probes for the respiratory infection and infections (not UTI, PU, or respiratory) areas 
    • Add a new Transmission-Based Precautions care area
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  • CMS Urgent Call to Action: Staff, Managers Should Complete QSEP Nursing Home COVID-19 Training (11/20)

    By CMS - November 17, 2020

    Agency thanks nursing homes whose staff have completed free CMS training, but urges remaining homes to take advantage of this resource

    The Centers for Medicare & Medicaid Services (CMS) is publicly recognizing the 1,092 nursing homes at which 50% or more of their staff have completed CMS training designed to help staff combat the spread of coronavirus disease 2019 (COVID-19) in nursing homes. CMS applauds these facilities for taking this critical step to equip their staff with the latest information regarding infection control, vaccine distribution, and other topics.

    There are 125,506 individuals from 7,313 nursing homes who have completed the training. This represents approximately 12.5% of the approximately one million nursing home staff in the country. With today’s announcement, CMS is calling on nursing homes to take action, urging them to require their staff to take this free training, as part of the Trump Administration’s continued efforts to keep nursing home residents safe.

    “We’ve provided nursing homes with $20 billion in federal funding, millions of pieces of PPE, free testing machines and supplies, and significant technical assistance and on-the-ground support,” said CMS Administrator Seema Verma. “Ultimately, the ownership and management of every nursing must take it on themselves to ensure their staff is fully equipped to keep residents safe. With coronavirus cases increasing across the country and infection control identified as a major issue, we encourage all nursing homes to take advantage of this no-cost opportunity to train their staff.”

    The training includes multiple modules, with emphases on topics such as infection control, screening and surveillance, personal protective equipment (PPE) usage, disinfection of the nursing home, cohorting and caring for individuals with dementia during a pandemic. CMS developed this training in consultation with the Centers for Disease Control and Prevention (CDC) and expert stakeholders, and announced the training on August 25, 2020. For anyone interested, the training is free to access on a public CMS website; instructions on how to create an account and take the training are available at qsep.cms.gov/welcome.aspx.

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  • HHS Stark Law and Anti-Kickback Reforms to Support Coordinated, Value-Based Care Could Bring Opportunities for SNFs (11/20)

    By HHS - November 16, 2020
    The Department of Health and Human Services (HHS) published two final rules that aim to reduce regulatory barriers to care coordination and accelerate the transformation of the healthcare system into one that pays for value and promotes the delivery of coordinated care.

    The rules provide greater flexibility for healthcare providers to participate in value-based arrangements and to provide coordinated care for patients. The final rules also ease unnecessary compliance burden for healthcare providers and other stakeholders across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.

    The HHS Office of Inspector General (OIG) issued the final rule “Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements,” and the Centers for Medicare and Medicaid Services (CMS) issued the final rule “Modernizing and Clarifying the Physician Self-Referral Regulations.” These rules are part of HHS’s Regulatory Sprint to Coordinated Care, which has examined federal regulations that potentially impede healthcare providers’ efforts that otherwise would advance the transition to value-based care and improve the coordination of patient care across care settings in Federal healthcare programs and the commercial sector. In addition to advancing value-based care, the CMS final rule clarifies and modifies existing policies to ease unnecessary regulatory burden on physicians and other healthcare providers while reinforcing the physician self-referral law’s (often called the “Stark Law”) goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest.

    The new and amended regulations related to the federal Anti-Kickback statute and the civil monetary penalties law issued by OIG address stakeholder concerns that these laws unnecessarily limit the ways in which healthcare providers can coordinate care with and for federal healthcare program beneficiaries. OIG’s final rule modifies and clarifies the agency’s proposed rule in response to comments, as explained in the preamble to the final rule. 

    For example, OIG’s final rule clarifies how medical device manufacturers and durable medical equipment companies may participate in protected care coordination arrangements that involve digital health technology, and the final rule lowers the level of “downside” financial risk parties must assume to qualify under the new safe harbor for value-based arrangements that involve substantial downside financial risk. In recognition of the urgent problem of cyber threats to the healthcare industry, the rule also broadens the new safe harbor for cybersecurity technology and services to protect cybersecurity-related hardware. 

    OIG’s final rule, and the CMS final rule to the extent the Stark Law is applicable, would facilitate a range of arrangements to improve the coordination and management of patient care and the engagement of patients in their treatment if all applicable regulatory conditions are met, including the following examples:

    • To improve patient transitions from one care delivery point to the next, a hospital may wish to provide physician offices with care coordinators that furnish individually tailored case management services for patients requiring post-acute care.
    • A hospital may wish to provide support and to reward institutional post-acute providers for achieving outcome measures that effectively and efficiently coordinate care across care settings and reduce hospital readmissions.  Such measures would be aligned with a patient’s successful recovery and return to living in the community. 
    • A primary care physician or other provider may wish to furnish a smart tablet that is capable of two-way, real-time interactive communication between the patient and his or her physician.  The patient’s access to a smart tablet could facilitate communication through telehealth and the provision of in-home services.
    • A health system furnishes cybersecurity technology to physician practices to reduce harm from cyber threats to all their systems.
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  • OSHA COVID-19 Citations: Lessons Learned (11/20)

    By OSHA - November 13, 2020

    The Occupational Safety and Health Administration cites lessons learned from its COVID-19 inspections and citations, as well as noting nursing homes and other companies that have been fined since the COVID-19 pandemic began.

     Lessons Learned: Frequently Cited Standards Related to COVID-19 Inspections.(November 6, 2020).

    Common COVID-19 Citations: Helping Employers Better Protect Workers and Comply with OSHA Regulations. (November 6, 2020).

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