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

    Tuesday, February 23, 2021 | IHI
    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)

    Monday, February 22, 2021 | ASPR TRACIE

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

    Sunday, February 21, 2021 | ASPR TRACIE
    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)

    Sunday, February 7, 2021 | CMS

    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)

    Sunday, February 7, 2021 | CMS

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

    Sunday, January 10, 2021 | CMS

    • 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)

    Sunday, December 13, 2020 | CMS
    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)

    Friday, December 11, 2020 | HHS

    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)

    Tuesday, December 8, 2020 | CMS

    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)

    Tuesday, December 1, 2020 | CMS

    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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