Quality Assurance and Performance Improvement (QAPI)

Quality care is the heart of what we do, and QAPI is the road to get there! You may be thinking that is easier said than done. The resources below have been gathered to assist you in achieving your facility goals for quality care outcomes. Need another reason to better understand QAPI? As value-based payment becomes a reality, facilities are required to demonstrate the quality of care to consumers and payers, continuously improving efficiency and resident outcomes. Learn how you can get ahead of the game with helpful resources.

  • MDS Items D0200 and D0300 Coding: Resident Mood Interview (PHQ-9) Video Tutorial (4/21)

    By CMS - April 02, 2021

    NEW TRAINING AVAILABLE – Resident Mood Interview (PHQ-9) for the Skilled Nursing Facility (SNF) Setting Video Tutorial

    CMS Resident Mood Interview (PHQ-9) for the SNF Setting Video Tutorial

    The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial that depicts a scenario that demonstrates the interview of a resident and subsequent coding of D0200. Resident Mood Interview (PHQ-9©) and D0300. Total Severity Score. Various interviewing tips and techniques are highlighted in the video to promote accurate coding. The video tutorial is approximately 30 minutes in length and is designed to be used on demand anywhere you can access a browser.

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  • QTSO Notice: MDS Long-Stay Residents in CASPER (4/21)

    By QIES Technical Support Office - April 01, 2021
    Attention QIES Users: CMS is in compliance with disposition authority N1-440-09-03 and only retains assessment and supporting data that is less than 10 years old in the QIES National database. Therefore, assessment-based quality measures generated in CASPER for reporting periods of 9 years* or older may be calculated with less than a full set of original assessment records. These reporting periods may not reflect the actual quality of care performed for episodes and stays within that time frame.

    *Note: Some assessment-based quality measures require a 2-year lookback period based on the target date of the stay or episode.

    CASPER reports currently impacted by the data retention policy:

    • MDS 3.0 Facility Level Quality Measure Report
    • MDS 3.0 Resident Level Quality Measure Report
    • MDS 3.0 Facility Characteristic Report
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  • CMS COVID-19 Nursing Homes Best Practices Toolkit and New QIN-QIO Virtual Assistance UPDATED (2/21)

    By CMS - March 23, 2021

    New tool provides innovative solutions for states and facilities to protect our nation’s vulnerable nursing home residents during emergency

    CMS has released a new toolkit UPDATED (3/25/21) developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

    “The coronavirus presents a unique challenge for nursing homes. CMS is using every tool at our disposal to protect our nation’s most vulnerable citizens and aid the facilities that care for them. This toolkit will support state, local leaders and nursing homes in identifying best practices to protect our vulnerable elderly in nursing homes” said CMS Administrator Seema Verma.  

    The toolkit provides detailed resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing homes. The toolkit outlines best practices for a variety of subjects ranging from infection control to workforce and staffing. It also provides contact information for organizations who stand ready to assist with the unique challenges posed by caring for individuals in long-term care settings. Each state was involved in the creation of this toolkit, resulting in a robust resource that may be leveraged by a variety of entities serving this vulnerable population.

    Additionally, CMS has contracted with 12 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to work with providers, community partners, beneficiaries and caregivers on data-driven quality improvement initiatives designed to improve the quality of care for beneficiaries across the United States. The QIN-QIOs are reaching out to nursing homes across the country to provide virtual technical assistance for homes that have an opportunity for improvement based on an analysis of previous citations for infection control deficiencies using publicly available data found on Nursing Home Compare.

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  • CDC Infection Prevention and Control Assessment (ICAR) Tool for Nursing Homes Preparing for COVID-19 UPDATED (3/21)

    By CDC - March 19, 2021

    Guidance released March 10, 2021 regarding Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination | CDC affects only select elements of the current Nursing Home ICAR tool until an updated version of the tool is available. Please reference this guidance when using the ICAR tool to ensure alignment with updated considerations for COVID-19 vaccination status (e.g., visitation, HCP work restriction, resident quarantine).


    Infection Control Assessment and Response (ICAR) tools are used to systematically assess a healthcare facility’s infection prevention and control (IPC) practices and guide quality improvement activities (e.g., by addressing identified gaps).

    This tool is an update to the previous ICAR tool for nursing homes preparing for COVID-19. Notable changes as of November 20, 2020 include:

    • Additions to reflect updated guidance such as SARS-CoV-2 testing in nursing homes
    • Increased emphasis on the review of Personal Protective Equipment (PPE) use and handling
    • Addition of sections to help guide a video tour as part of a remote TeleICAR assessment or in-person tour of a nursing home
    • Addition of an accompanying facilitator guide to aide with the conduction of the ICAR and create subsequent recommendations for the facility

    This updated ICAR tool is a longer but more comprehensive assessment of infection control practices within nursing homes. Due to the addition of example recommendations to aid the facilitator during the process of conducting an ICAR, the facilitator guide version of the tool appears even longer. Facilitators may decide whether to use the tool in its entirety or select among the pool of questions that best fit their jurisdictional needs and priorities as part of quality improvement efforts.

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  • Potential Trend Alert: SNFs Sued re: Alleged False Five-Star Data for Nurse Staffing (3/21)

    By OIG - March 19, 2021

    Note from staff: This lawsuit, brought by the now director of the U.S. Department of Health and Human Services, not only alleges problems with the discharge process, it alleges that SNFs submitted false data to Five-Star, specifically nurse staffing data.


    Attorney General Becerra Sues Nursing Home Chain for Misrepresenting its Quality of Care and Putting Seniors, People with Disabilities at Risk

    Today's lawsuit pertains to Brookdale's current and former California skilled nursing facilities located in the cities of Bakersfield, Camarillo, Carlsbad, Northridge, Rancho Mirage, San Diego, San Dimas, San Juan Capistrano, Santa Rosa, and Yorba Linda 

    March 15, 2021

    SACRAMENTO – California Attorney General Xavier Becerra today joined a coalition of District and City Attorneys, led by Kern County District Attorney Cynthia Zimmer, in filing a lawsuit against Tennessee-based Brookdale Senior Living, Inc. (Brookdale), the nation’s largest senior living operator. Today’s lawsuit, which concerns Brookdale’s ten California skilled nursing facilities, alleges that Brookdale ignored laws that protect patients' safety when they are discharged from a facility. The lawsuit also alleges that Brookdale gave false information to the Centers for Medicare & Medicaid (CMS), information which CMS uses to award “star ratings” to skilled nursing facilities so that consumers can choose a quality facility. By lying to CMS, Brookdale fraudulently increased its star rating in several categories to attract prospective patients and their families.

    The lawsuit alleges that Brookdale failed to properly notify its patients and families of transfers and discharges. Skilled nursing facilities are required to give notice of transfer or discharge at least 30 days in advance, or as soon as practicable. Brookdale failed to timely provide this required notice to its patients, with a copy to the local ombudsmen. Brookdale also failed to properly prepare its patients for transfer or discharge. As a result of these actions, Brookdale endangered the health of its patients and also left families scrambling to find other places to care for their loved ones.

    The lawsuit also alleges that Brookdale misrepresented the quality of its care to the public by reporting false information to CMS. As a means of helping the public to choose a skilled nursing facility, CMS rates facilities on several quality measures on a scale of one to five stars, which are then posted to the CMS website. The lawsuit alleges that Brookdale over-reported its nursing staffing hours to CMS, and by doing so, Brookdale was awarded undeserved four-and five-star ratings. In the lawsuit, the coalition argues that by engaging in these unfair business practices, Brookdale violated both the Unfair Competition Law and False Advertising Law.

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  • CMS Will Use Resident Acuity to Target Weekend Surveys for Nursing Homes With Potential Staffing Problems, and Other Staffing News From the OIG (3/21)

    By OIG - March 16, 2021

    CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More (OEI-04-18-00451)

    The OIG has made four key recommendations related to staffing that CMS concurred with. These recommendations state that CMS should:

    Provide data to consumers on nurse staff turnover and tenure, as required by Federal law

    To comply with Federal statute, CMS must publicly report data on both nurse turnover and tenure on Care Compare. CMS is not currently reporting either of these measures to the public. CMS has made progress toward being able to report turnover data—it has developed a definition for nurse turnover, a critical first step. To ensure safety and quality of care for nursing home residents, CMS should take similar steps to define nurse tenure, and to report on both turnover and tenure as soon as practicable given the many urgent needs that CMS is facing.

    CMS response: CMS stated that it will continue working to publicly report on nurse staff turnover and tenure. CMS described the actions that it has performed to enable it to report on nurse turnover, which CMS has prioritized over reporting on nurse tenure. CMS also reported that the COVID-19 pandemic delayed its plans to introduce data on nurse turnover.

    Ensure the accuracy of non-nurse staffing data used on Care Compare

    CMS should take steps to ensure the accuracy of PBJ data for non-nurse staff that it chooses to include in Care Compare. These steps may be comparable to those that CMS performs to ensure the accuracy of nurse staffing data. For example, CMS may wish to add physical therapists—the only type of non-nurse staff with data currently found on Care Compare—to its audits of PBJ data. CMS may also wish to explore other ways to improve the accuracy of non-nurse staffing data included on Care Compare.

    CMS response: CMS stated that it will explore ways to improve the accuracy of these data by expanding its audits of Payroll-Based Journal data to include data submitted for non-nurse staff.

    Consider residents’ level of need when identifying nursing homes for weekend inspections

    CMS should analyze and use information about the relative acuity (or level of need) of residents as it continues to compile lists of nursing homes with lower staffing to help SSAs target nursing homes for weekend inspections. CMS calculates acuity-adjusted staffing levels for the Staffing Star Ratings found in Care Compare. Acuity-adjusting the weekend staffing levels for nursing homes before identifying those with lower staffing will improve the quality of the nursing-home lists that CMS shares with SSAs for weekend inspections.

    CMS response: CMS stated that it will begin to use information about residents’ level of need when targeting weekend inspections to nursing homes that may have staffing problems.

    Take additional steps to strengthen oversight of nursing home staffing

    CMS should take additional steps to oversee staffing in nursing homes by more fully leveraging the staffing information that it collects and providing it to SSAs. Doing so could help SSAs more efficiently deploy their resources to target staffing reviews on those nursing homes at higher risk for staffing problems during those dates when nurse staffing appeared most problematic. CMS currently does this in a limited manner by providing SSAs with a list of nursing homes that have potentially insufficient staffing on weekends. CMS can build on this effort in several ways. For example, CMS could inform SSAs which nursing homes reported frequently staffing below 8 RN hours or 24 licensed-nurse hours during a quarter and provide those dates to SSAs. CMS could also identify nursing homes at risk of insufficient nurse staffing, which SSAs reported was relatively difficult to determine. CMS may wish to use the underlying data from Staffing Star Ratings to strengthen oversight of nurse staffing. If CMS uses these existing data, it may need to share information with SSAs and guide them on how to use the data.

    Additionally, CMS is currently updating its inspection system. OIG encourages CMS to ensure that staffing information is integrated into the future system so that SSA inspectors can easily access data about specific nursing homes.

    CMS Response: CMS stated that it will work to more efficiently provide useful staffing information directly to State survey agencies. CMS reiterated that staffing is a vital component of the quality of care in nursing homes. CMS also emphasized its commitment to continually improve oversight of nursing homes.

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  • AHRQ: High Nursing Staff Turnover in Nursing Homes Offers Important Quality Information (3/21)

    By AHRQ - March 13, 2021

    Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). 2021

    Prior research has found that high nursing staff turnover is associated with lower patient safety culture. Starting in July 2016, the Centers for Medicare &  Medicaid Services (CMS) began collecting daily staffing data for US nursing homes and found that nurse turnover rates were correlated with facility location, for-profit status, Medicaid patient census, and star ratings. This information can be leveraged by policymakers, payers, and healthcare consumers and may incentive efforts to reduce nursing staff turnover.

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  • SNF QRP FAQs (3/21)

    By CMS - March 01, 2021


    March 1, 2021


    An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in Fiscal Year (FY) 2021 and other useful resources available to providers.


    Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Overview

    1. What is a Quality Reporting Program?

    2. What are the current measures in the SNF QRP?

    3. What are the FY 2021 updates to the SNF QRP?

    Staying Informed About the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

    4. What is the process for adding and removing measures from the SNF QRP?

    5. Are there other resources on the SNF QRP website I can use to stay up-to-date?

    6. Where can I find SNF QRP training materials?

    Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Technical Requirements

    7. How are data collected and submitted for the SNF QRP?

    8. Which items on the SNF MDS are considered for compliance determination?

    9. What are the requirements for the SNF to be considered compliant?

    10. What are the data submission deadlines for the SNF QRP?

    11. Does the definition of “quarter” for the quarterly MDS data submission deadlines include patients admitted during that quarter, discharged during that quarter, or both?

    12. What is QIES? How can I request access to QIES?

    The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and the Minimum Data Set (MDS)

    13. What is the current version of the MDS?

    14. Where can I find the MDS 3.0 Resident Assessment Instrument (RAI) Manual for the SNF QRP?

    15. Who can complete a SNF MDS?

    Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Reconsiderations, Exceptions, and Extensions

    16. Does the Centers for Medicare & Medicaid Services (CMS) tell SNFs if they are noncompliant with the QRP requirements?

    17. I received a letter of notification that my SNF is non-compliant with the SNF QRP requirements. Can I ask CMS to reconsider the decision?

    18. The county where our SNF is located was affected by a natural disaster. Are we excepted from the QRP reporting requirements?

    Other Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions

    19. Does my SNF need to report health care–acquired infection data under the SNF QRP?

    20. My facility’s demographic data are incorrect on Care Compare. How do I correct them?

    21. Where are SNF quality measure data publicly reported?

    22. Which SNF quality measures are reported on the Care Compare website?

    23. Who can I contact with a specific question about the SNF QRP?

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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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  • 2021 Patient Safety Chartbook From AHRQ (2/21)

    By AHRQ - February 18, 2021
    AHRQ has released the National Healthcare Quality and Disparities Report: Chartbook on Patient Safety 2021, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information that has been voluntarily reported by AHRQ-listed Patient Safety Organizations. The Chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. The iteration of the Chartbook contains reports not included in the prior NPSD Chartbook. Nursing home-specific data is included.
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  • Five-Star Helpline Open Feb. 22 - 26

    By QTSO - February 17, 2021

    The Five Star Preview Reports were available on February 15, 2021. 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 the February Five Star data on February 24, 2021.

    Important Note: The 5 Star Help Line (800-839-9290) will be available February 22 through February 26, 2021.

    Please direct your inquiries to BetterCare@cms.hhs.gov  if the Help Line is not available.

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  • When Used Weekly, AHRQ Toolkit Reduces Rehospitalizations at SNFs (2/21)

    By AHRQ - February 17, 2021
    From AHRQ News Now:

    Skilled nursing facilities that tested AHRQ’s Re-Engineered Discharge (RED) toolkit found that training during weekly staff meetings was more effective than a single full-day course, according to a study published in Clinical Nursing Research. The RED toolkit, designed for hospitals, was tested by four skilled nursing facilities from 2013 to 2015. They used either standard implementation, which trained staff via weekly meetings, or enhanced implementation, in which staff training was completed during a single full-day course. Standard implementation facilities also had stronger leadership support for revised discharge procedures. While facilities using the enhanced implementation saw no change in rehospitalization rates, standard implementation reduced rehospitalizations by 45 percent at 30 days, 50 percent at 60 days, and 39 percent at 180 days.

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  • AHRQ 2021 Network of Patient Safety Databases Chartbook (2/21)

    By AHRQ - February 13, 2021

    Agency for Healthcare Research and Quality. 2021

    AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2021, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information that has been voluntarily reported by AHRQ-listed Patient Safety Organizations, including a section on nursing homes. The Chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. The iteration of the Chartbook contains reports not included in the prior NPSD Chartbook.

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  • CMS QSO Memo: Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results (2/21)

    By CMS - February 08, 2021

    DATE: June 1, 2020

    REVISED 01/04/2021

    TO: State Survey Agency Directors FROM: Director Quality, Safety & Oversight Group

    SUBJECT: Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes

    CMS is committed to taking critical steps to protect vulnerable Americans to ensure America’s health care facilities are prepared to respond to the CoronavirusDisease2019(COVID-19) Public Health Emergency (PHE).

    • CMS has implemented a new COVID-19 reporting requirement for nursing homes, and is partnering with CDC’s robust federal disease surveillance system to quickly identify problem areas and inform future infection control actions.

    • Following the March 6, 2020 survey prioritization, CMS has relied on State Survey Agencies to perform Focused Infection Control surveys of nursing homes across the country. We are now initiating a performance-based funding requirement tied to the Coronavirus Aid, Relief and Economic Security (CARES) Act supplemental grants for State Survey Agencies. Further, we are providing guidance for the limited resumption of routine survey activities. CMS has revised the criteria requiring states to conduct focused infection control surveys due to the increased availability of resources for the testing of residents and staff and factors related to the quality of care.

    • CMS is providing Frequently Asked Questions related to health, emergency preparedness and lifesafety code surveys

    • CMS is also enhancing the penalties for noncompliance with infection control to provide greater accountability and consequence for failures to meet these basic requirements. This action follows the agency’s prior focus on equipping facilities with the tools they needed to ensure compliance, including 12 nursing home guidance documents, technical assistance webinars, weekly calls with nursing homes, and many other outreach efforts. The enhanced enforcement actions are more significant for nursing homes with a history of past infection control deficiencies, or that cause actual harm to residents or Immediate Jeopardy.

    • Quality Improvement Organizations have been strategically refocused to assist nursing homes in combating COVID-19 through such efforts as education and training, creating action plans based on infection control problem areas and recommending steps to establish a strong infection control and surveillance program.

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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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