Infection Prevention and Control Resources

With the latest updates to the State Operations Manual, it is more important than ever to promote resident safety and well-being through infection prevention and control. A robust and successful infection control program requires many thoughtfully designed and well-operating pieces—from antibiotic stewardship and physician engagement to immunization planning and tracking, reduced hospital readmissions, and comprehensive clinical surveillance. Explore the resources below to learn how you can bolster your infection control program.

Learn more about  AADNS's comprehensive Antibiotic Stewardship Program in Long-Term Care Virtual Workshop.

  • Five Star Technical User's Guide UPDATED (4/18)

    By CMS - April 25, 2018

    CMS created the Five-Star (5 Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated April 2018.

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  • Five Star Help Line Open Through April 27

    By QTSO - April 25, 2018

    The Five Star Preview Reports will be available on April 23. To access these reports, select the CASPER Reporting link located on the CMS QIES Systems for Providers page. Once in the CASPER Reporting system, select the 'Folders' button and access the Five Star Report in your 'st LTC facid' folder, where st is the 2-character postal code of the state in which your facility is located and facid is the state-assigned Facility ID of your facility.

    Nursing Home Compare will update with April's Five Star data on April 25, 2018.

    Important Note: The 5 Star Help line (800-839-9290) will be available April 23, 2018 through April 27, 2018. Please direct your inquiries to if the Help Line is not available.

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  • LTCSP Procedure Guide and Training - Updated(4/18)

    By CMS - April 25, 2018

    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. Below is a broad overview of the key onsite parts of the LTCSP (parts 3 – 7).

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  • PBJ Hits Five Star: Take These Steps to Clean Your Staffing Data

    By Caralyn Davis, Staff Writer - April 25, 2018

    This month, the Centers for Medicare & Medicaid Services (CMS) will begin using Payroll-Based Journal (PBJ) electronic staffing data to calculate the nursing and physical therapy (PT) staffing measures, as well as the Five Star Quality Rating System staffing ratings, on Nursing Home Compare, according to CMS survey-and-certification memo QSO-18-17-NH. By May 1 at the latest, CMS will update the Five Star Technical Users’ Guide to include the technical specifications for the updated staffing measures and ratings’ methodology, and effective June 1, providers will no longer have to complete the staffing section of the CMS-671 although the rest of the form will still need to be completed for survey.

    Many directors of nursing services (DNSs) should see some changes in their staffing measures and Five Star staffing ratings, says Suzy Harvey, RN-BC, RAC-CT, managing consultant for BKD in Springfield, MO.

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  • What You Need to Know About the Transition to Value-Based Care

    By Emily Royalty-Bachelor, Staff Writer - April 24, 2018

    Valued-based purchasing is coming to long-term care facilities nationwide—and it’ll be here before you know it.

    This payment model is designed to support the practice of resident-centered care—which many long-term care facilities have already implemented to some degree. Still, in an industry with deep traditional roots, particularly in regard to reimbursements, the shift in payment model may be jarring—and preparing for the change may be overwhelming.

    But it doesn’t need to be.

    With the help of a few tools and a little advance planning, you can help make your facility’s transition to value-based care a simple one.

    “It's important that we stay ahead of the curve, and that's always a challenge,” says Michelle Bulger.

    Bulger, alongside Patty Embree, vice president of innovation at Vincentian Collaborative System, will be co-instructing a conference session at the 2018 AADNS annual conference in National Harbor, MD, on this very subject. The June 29 session, called “Making the Move to Value-Based Care,” will shed light on practical, actionable steps and tools you can implement within your own facility today to prepare for this coming change.


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  • Q&A: Do we need to report to ombudsman if a short-term resident was sent out to the hospital for change of condition?

    By Susan Duong, RN-BC - April 24, 2018
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  • CMS Basic Life Safety Online Training Course Available (4.18)

    By CMS - April 24, 2018

    New CMS eLearning course: The BLSC Training Online Course is intended to cultivate and refine surveyor skills, foster understanding of the survey process, and enhance surveyors’ overall ability to conduct LSC surveys for Medicare and Medicaid certification on behalf of CMS.

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  • SNF QRP May 15, 2018, Deadline Reminder for Q1 - Q4 CY 2017 Data Submission (4/18)

    By CMS - April 23, 2018

    CMS has extended the Skilled Nursing Facility Quality Reporting Program (SNF QRP) deadlines for calendar year (CY) 2017. Minimum Data Set (MDS) assessment data for January-December (Q1-Q4) of CY 2017 are due May 15, 2018. However, providers are encouraged to verify their MDS submissions on at least a quarterly basis.

    It is recommended that the applicable CMS CASPER validation reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CCN and facility name. 

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  • PBJ Public Use Files: 3Q 17 Data Available (4/18)

    By CMS - April 23, 2018
    CMS releases quarterly Payroll-Based Journal (PBJ) public-use files that currently include nursing hours and resident census data for every nursing home in the United States. 
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  • Resident Prioritization Tool

    By CMS and Telligen - April 10, 2018
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  • Step Up Your GDR Game Part 1: Team-Building is Critical

    By Caralyn Davis, Staff Writer - April 10, 2018
    In the second quarter of 2017, 15.5 percent of long-stay nursing home residents received an antipsychotic medication as measured by the publicly reported MDS-based quality measure (QM), Percent of Residents Who Received an Antipsychotic Medication (Long-Stay). That represents a 35 percent decrease in the national prevalence since the fourth quarter of 2011, according to the most recent data from the National Partnership to Improve Dementia Care in Nursing Homes.
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  • The Importance of a Thorough Investigation: What You Need to Know

    By Emily Royalty-Bachelor, Staff Writer - April 10, 2018
    As a director of nursing services or an administrator of a long-term care facility, you naturally hope that the day-to-day care, services, and activities that happen within the facility proceed without incident. However, despite precautions and oversight, reportable incidents do indeed occur. That’s why it is imperative that, when they do, you have policies and procedures in place to conduct a thorough investigation and that you implement processes to prevent similar incidents from occurring again.
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  • Q&A: How are others assessing for grab bars/assist bars now that F700 is stating that they are side rails?

    By DNS Network - April 10, 2018
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  • Perspectives of Clinicians at SNFs on 30-Day Hospital Readmissions: A Qualitative Study (4/18)

    By PubMed - April 09, 2018
    Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. Skilled nursing facilities (SNFs) play an important role in the readmission process, but few studies have examined the factors that contribute to readmissions from SNFs, leaving hospitalists and other hospital-based clinicians with limited evidence on how to reduce SNF readmissions. We interviewed 28 clinicians at 15 SNFs. The interviews covered 24 patient readmissions. SNF clinicians described a range of procedural, technological, and cultural contributors to unplanned readmissions. Commonly cited causes of readmission included a lack of coordination between emergency departments and SNFs, poorly defined goals of care at the time of hospital discharge, acute illness at the time of hospital discharge, limited information sharing between a SNF and hospital, and SNF process and cultural factors.SNF clinicians identified a broad range of factors that contribute to readmissions. Addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.
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  • PBJ Data Used in 5 Star Effective April 2018; CMS-671 Collection Ends June 1 (4/18)

    By CMS - April 09, 2018

    • Transition to Payroll-Based Journal (PBJ) Data – Starting in April, 2018, CMS will use PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System.

    • Staffing data audits - We are providing lessons-learned from audits conducted, and guidance to facilities for improving their accuracy. Nursing homes whose audit identifies significant inaccuracies between the hours reported and the hours verified, or facilities who fail to submit any data by the required deadline will be presumed to have low levels of staff. This will result in a one-star rating in the staffing domain, which will drop their overall (composite) star rating by one star for a quarter.

    • Requirement for registered nurse (RN) staffing – We are reminding nursing homes of the importance of RN staffing and the requirement to have an RN onsite 8 hours a day, 7 days a week. Nursing homes reporting 7 or more days in a quarter with no RN hours will receive a one-star rating in the staffing domain, which will drop their overall (composite) star rating by one star for a quarter. This action will be implemented in July 2018, after the May 15, 2018 submission deadline for data for 2018 Calendar Quarter 1, 2018 (January – March, 2018) data.

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