A revised version of the PBJ Data Specifications (Version 4.00.0) is available to Users. The new release of the Data Specifications reconciles changes to the file layout, fileSpecVersion 4.00.0. Census tags have been removed from the 4.00.0 version due to CMS no longer collecting Census data from PBJ as of April, 2018. No immediate changes are needed when using the current PBJ Submission File fileSpecVersions (2.00.0 and 2.00.3), however, Users are encouraged to begin using PBJ fileSpecVersion 4.00.0.  XML files submitted with versions other than 4.00.0 on or after June 2, 2020 will be rejected. Please note this does not apply to the PBJ Administration Submission File format. Users who use this file format for linking employees should continue to use fileSpecVersion 1.00.0. 

On April 21, CMS added an errata:

4.00.0 fileSpecVersion: CMS is delaying the previously communicated June 1, 2020 date for rejecting PBJ file Spec Versions 2.00.0 and 2.00.3. The PBJ system will continue to accept PBJ fileSpecVersions 2.00.0, 2.00.3 and 4.00.0 until further notice from CMS. Details can be found in the following document: Errata V4.00.1 for PBJ Data Submission Specifications (V4.00.0) 04-16-2020.

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 twice in October 2019.

January 2020 addition: Technical specifications for claims-based measures

In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.

“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”

While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”

Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”

Telehealth has existed for quite a while, and as its use has expanded in recent years, some healthcare groups have even provided the services to their entire network of facilities. These networks often paid for telehealth access out of their own pockets, as accessibility and financial assistance for Medicare beneficiaries has previously been very limited, with coverage only available to facilities in designated rural areas and only for patients who had a previously-established relationship with their doctor. However, on March 6, the $8.3 billion dollar Coronavirus Preparedness and Response Supplemental Appropriations Act was passed, which allowed the Department of Health and Human Services (HHS) “to temporarily waive certain Medicare restrictions and requirements regarding telehealth services during the coronavirus public health emergency.”

Then, on March 13, President Trump declared the COVID-19 outbreak a national emergency. And thus, we received the 1135 waiver, which expanded telehealth services:

Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

COVID-19: Peer support and crisis communication strategies to promote institutional resilience.

Wu AW, Connors C, Everly Jr GS. Ann Intern Med. 2020

To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic:

·  Encourage leadership to focus on resilience

·  Ensure that crisis communication provides both information and empowerment

·  Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.

Unprecedented solutions for extraordinary times: helping long-term care settings deal with the COVID-19 pandemic.

Gaur S, Dumyati G, Nace DA, et al.  Infect Control Hosp Epidemiol. 2020

This commentary discusses the provision of safe care in long-term care settings during the COVID-19 pandemic. The authors propose the following measures to ensure the safety of long-term care patients:

·  facilities should only accept patients with COVID-19 infections if they can provide effective airborne isolation;

·  patients recovering from COVID-19 need to have 2 negative tests on 2 consecutive days, as well as remain fever-free without mediation for at least 48 hours and not require ventilatory support that generates aerosols;

·  facilities should screen potential admissions for typical and atypical signs and symptoms of COVID-19, and;

·  facilities that are currently COVID-19 naïve should not accept any new admissions for whom there may be a concern for COVID-19.

Emerging Infectious Diseases

Volume 26, Number 5—May 2020

Biphasic Outbreak of Invasive Group A Streptococcus Disease in Eldercare Facility, New Zealand

Abstract

A 3-month outbreak of invasive group A Streptococcus disease at an eldercare facility, in which 5 persons died, was biphasic. Although targeted chemoprophylaxis contained the initial outbreak, a second phase of the outbreak occurred after infection control processes ended. To retrospectively investigate the genomic epidemiology of the biphasic outbreak, we used whole-genome sequencing and multiple bioinformatics approaches. Analysis of isolates from the outbreak and isolates prospectively collected during the outbreak response indicated a single S. pyogenes emm81 clone among residents and staff members. Outbreak isolates differed from nonoutbreak emm81 isolates by harboring an integrative conjugative genomic element that contained the macrolide resistance determinant erm(TR). This study shows how retrospective high-resolution genomic investigations identified rapid spread of a closed-facilty clonal outbreak that was controlled, but not readily cleared, by infection control management procedures.

Ref: QSO-20-28-NH

DATE: April 24, 2020

TO: State Survey Agency Directors

FROM: Director Quality, Safety & Oversight Group

SUBJECT: Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts, and Frequently Asked Questions

Memorandum Summary

• CMS is committed to taking critical steps to ensure America’s nursing homes are prepared to respond to the threat of the COVID-19.

• Nursing Home Compare website & Nursing Home Five Star Quality Rating System: We are announcing that the inspection domain will be held constant temporarily due to the prioritization and suspension of certain surveys, to ensure the rating system reflects fair information for consumers.

• Posting of surveys: CMS will post a list of the surveys conducted after the prioritization of certain surveys, and their findings, through a link on the Nursing Home Compare website.

• Nursing Home Staff: CMS is publishing a list of the average number of nursing and total staff that work onsite in each nursing home, each day. This information can be used to help direct adequate personal protective equipment (PPE) and testing to nursing homes.

• Frequently Asked Questions (FAQ): We are releasing a list of FAQs to clarify certain actions we have taken related to visitation, surveys, waivers, and other guidance.

DATE: April 19, 2020

TO: State Survey Agency Directors

FROM: Director Quality, Safety & Oversight Group

SUBJECT: Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID19 Persons under Investigation) Among Residents and Staff in Nursing Homes

Memorandum Summary

• CMS is committed to taking critical steps to ensure America’s health care facilities are prepared to respond to the 2019 Novel Coronavirus (COVID-19) Public Health Emergency (PHE).

• Communicable Disease Reporting Requirements: To ensure appropriate tracking, response, and mitigation of COVID-19 in nursing homes, CMS is reinforcing an existing requirement that nursing homes must report communicable diseases, healthcare-associated infections, and potential outbreaks to State and Local health departments. In rulemaking that will follow, CMS is requiring facilities to report this data to the Centers for Disease Control and Prevention (CDC) in a standardized format and frequency defined by CMS and CDC. Failure to report cases of residents or staff who have confirmed COVID -19 and Persons under Investigation (PUI) could result in an enforcement action. This memorandum summarizes new requirements which will be put in place very soon.

• Transparency: CMS will also be previewing a new requirement for facilities to notify residents’ and their representatives to keep them up to date on the conditions inside the facility, such as when new cases of COVID-19 occur.

AHRQ systematic review

Purpose of Review

To assess the effectiveness and harms of opioid therapy for chronic noncancer pain, alternative opioid dosing strategies, and risk mitigation strategies. 

Key Messages

• Opioids are associated with small improvements versus placebo in pain and function, and increased risk of harms at short-term (1 to <6 months) followup; evidence on long-term effectiveness is very limited, and there is evidence of increased risk of serious harms that appear to be dose dependent.
• At short-term followup, evidence showed no differences between opioids versus nonopioid medications in improvement in pain, function, mental health status, sleep, or depression.
• Evidence on the effectiveness and harms of alternative opioid dosing strategies and the effects of risk mitigation strategies is lacking, although provision of naloxone to patients might reduce the likelihood of opioid-related emergency department visits, a taper support intervention might improve functional outcomes compared to no taper support, and co-prescription of benzodiazepines and gabapentinoids might increase risk of overdose.
• No instrument has been shown to be associated with high accuracy for predicting opioid overdose, addiction, abuse, or misuse.

1. Nonopioid Pharmacologic Treatments for Chronic Pain

AHRQ systematic review  

Purpose of Review

Evaluate the benefits and harms of nonopioid drugs in randomized controlled trials of patients with specific types of chronic pain, considering the effects on pain, function, quality of life, and adverse events.

Key Messages

• In the short term, improvement in pain and function was small with specific anticonvulsants, moderate with specific antidepressants in diabetic peripheral neuropathy/post-herpetic neuralgia and fibromyalgia, and small with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis and inflammatory arthritis.
• In the intermediate term, evidence was limited, with evidence of benefit for memantine in fibromyalgia and for serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants in low back pain and fibromyalgia.
• In the long term, evidence was too limited to draw conclusions. In general, evidence on quality of life was limited and no treatment achieved a large improvement in pain or function.
• Small to moderate, dose-dependent increases in withdrawal due to adverse events were found with SNRIs duloxetine and milnacipran, anticonvulsants pregabalin and gabapentin, and NSAIDs. Large increases were seen with oxcarbazepine. NSAIDs have increased risk of serious gastrointestinal, liver dysfunction, and cardiovascular adverse events.

2. Noninvasive Nonpharmacological Treatment for Chronic Pain

A Systematic Review Update

Purpose of Review

To assess noninvasive nonpharmacological treatments for common chronic pain conditions.

Key Messages

• Interventions that improved function and/or pain for ≥1 month:
• Some interventions did not improve function or pain.
• Serious harms were not observed with the interventions.

On April 10, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2021 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing (CMS-1737-P) as required by law. In a major break from recent years, CMS offers no proposals for updating the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and only what the agency describes as “minor administrative proposals” related to the SNF Value-Based Purchasing (VBP) program.

However, CMS does propose several other revisions in addition to the required Medicare Part A payment rate update. These include:

• Multiple changes to the ICD-10-CM code mappings used for case-mix classification in the Patient-Driven Payment Model (PDPM);

• Technical changes to the regulatory language in the Code of Federal Regulations, including a proposed change that will clarify the “practical matter” criterion of a Part A skilled level of care by removing an outdated example that referred to the repealed Part B therapy cap provision; and
  

• Changes to how SNFs are identified as rural or urban for wage index classification, as well as a proposal to cap wage index decreases from FY 2020 to FY 2021 as a transition measure.