Survey Readiness and Management

Survey readiness is what happens every day that the surveyor does not step onto the floor, all in preparation for the day that he or she does. Be ready.Learn about all of the trends in the new Survey process, how to get ready for survey, manage it while the surveyors are in your facility, to responding to deficiencies. Check back here frequently for survey news!

  • State Operations Manual: Revisions to Appendix Q, Guidance on Immediate Jeopardy (8/19)

    By CMS - August 05, 2019
    Appendix Q to the State Operations Manual (SOM), which provides guidance for identifying immediate jeopardy, has been revised. The revision creates a Core Appendix Q that will be used by surveyors of all provider and supplier types in determining when to cite immediate jeopardy. CMS has drafted subparts to Appendix Q that focus on immediate jeopardy concerns occurring in nursing homes and clinical laboratories since those provider types have specific policies related to immediate jeopardy.Appendix Q has been revised to reinsert language referring criminal acts to local law enforcement.
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  • Sept. 10 Dementia Care: Supporting Comfort and Resident Preferences Call: Register Now (7/19)

    By CMS - July 27, 2019
    During this call, gain insight on approaches to care for residents living with dementia that focus on resident preferences, maintaining comfort, and assisting with unmet needs. Additionally, CMS provides updates on the progress of the National Partnership to Improve Dementia Care in Nursing Homes. A question and answer session follows the presentations.
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  • CMS Final Rule Revises Medicare/Medicaid Arbitration Requirements (7/19)

    By CMS - July 16, 2019

    Medicare and Medicaid Programs: Revision of Requirements for Long Term Care Facilities: Arbitration Agreements

    ACTION: Final rule.

    SUMMARY: This final rule amends the requirements that Long-Term Care (LTC) facilities must meet to participate in the Medicare and Medicaid programs. Specifically, we are repealing the prohibition on the use of pre-dispute, binding arbitration agreements. We are also strengthening the transparency of arbitration agreements and arbitration in LTC facilities. This final rule supports residents’ rights to make informed choices about important aspects of their health care. 

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  • CMS Proposed Rule Would Revise Medicare/Medicaid Requirements for Participation, Including Some Phase 3 Delays (7/19)

    By CMS - July 16, 2019

    Medicare and Medicaid Programs: Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency, and Transparency

    AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule.

    Areas of Major Provisions:

    a. Requirements for Participation

    Resident Rights (§483.10)

    Admission, Transfer, and Discharge Rights (§483.15)

    Nursing Services (§483.35)

    Behavioral Health (§483.40)

    Pharmacy Services (§483.45)

    Food and Nutrition Services (§483.60)

    Administration (§483.70)

    Quality Assurance and Performance Improvement (§483.75)

    Infection Control (§483.80)

    Compliance and Ethics Program (§483.85)

    Physical Environment (§483.90)

    Technical Corrections

    b. Survey, Certification, and Enforcement Procedures

    Informal Dispute Resolution and Independent Informal Dispute Resolution (§488.331 and §488.431)

    Civil Money Penalties: Waiver of Hearing, Reduction of Penalty Amount (§488.436)

    Phase 3 Implementation of Overlapping Regulatory Provisions

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  • QIO-Developed Trauma-Informed Care Resources (7/19)

    By MQIO Program - July 15, 2019

    Purpose of these resources This is a comprehensive, but not all inclusive, list of resources that may be helpful for nursing homes as they work to ensure that residents who are trauma survivors receive culturally competent, traumainformed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident (per §483.25(m) requirement that will be implemented beginning November 28, 2019).

    Who should use these resources? Nursing home leadership teams may assign responsibility to a person, such as a social worker, to review the resources below, identifying those that might be helpful for a) leadership, staff, and/or resident/family education, or b) behavioral/emotional care policy or program development or revision. 

    Why this is important? The included resources provide information that will help nursing homes to build capacity among interdisciplinary team members to deliver holistic resident care, being sensitive to how a range of experiences over the resident’s life may relate to their current physical, emotional, and behavioral health status. Trauma is common throughout human experience, and we need to respond with empathy and understanding. Providing trauma informed care can help staff to avoid re-victimization of those who have survived trauma and create an environment where the individual feels safe and secure. 

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  • New CDC Infection Control Training Targets HAIs (7/19)

    By CDC - July 15, 2019

    The CDC has launched the new Strategies for Preventing HAIs training, the latest of 11 new infection control training courses.  These training courses were developed by national infection prevention experts led by the Health Research & Educational Trust (HRET) for the Centers for Disease Control and Prevention (CDC).


    All courses are free and offer continuing education (CE).

    Access the new courses at the STRIVE training page

    The STRIVE curriculum will include over forty individual training modules grouped into 11 courses that focus on Foundational and Targeted infection prevention strategies. 

    Foundational Infection Prevention Strategies

    · Competency-Based Training (available now)

    · Hand Hygiene (available now)

    · Strategies for Preventing HAIs (available now)

    · Environmental Cleaning

    · Personal Protective Equipment

    · Patient and Family Engagement

    · Business Case


    Targeted Infection Prevention Strategies

    · Catheter-Associated Urinary Tract Infection (CAUTI)

    · Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia

    · Clostridioides difficile Infection (CDI)

    ·  Central Line-Associated Bloodstream Infection (CLABSI)

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  • PBJ Electronic Data Staffing Submissions Data Specs V3.01 - UPDATED (7/19)

    By CMS - July 05, 2019
    The PBJ Data Submission Specifications Version 3.01.0 package is now available. 
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  • PBJ Provider User Guide V3.0.1, Incl. Error Messages / Descriptions - UPDATED (6/19)

    By QTSO - July 01, 2019
    This manual explains how to connect to the Payroll-Based Journal (PBJ) system and submit data. It also defines error messages and descriptions, identifying errors by number, severity, error message, and error description. The description section includes potential corrective actions for providers to take to resolve the errors.
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  • CASPER Reporting User’s Guide for PBJ Providers UPDATED (6/19)

    By QTSO - June 21, 2019
    This user’s guide provides information and instructions pertaining to the CASPER Reporting application. Section 12, Payroll Based Journal (PBJ) Reports, addresses the staffing and census reports available to providers, including the Employee Report, the Census Report, the Staffing Summary Report, and the PBJ Submitter Final File Validation Report.
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  • OIG Audit Finds Staff Didn't Always Comply With Care Plan for Residents With UTI at One NF (6/19)

    By OIG - June 19, 2019

    Princeton Place Did Not Always Comply With Care Plans for Residents Who Were Diagnosed With Urinary Tract Infections (A-06-17-02002)

    Princeton Place did not always provide services to Medicaid-eligible residents diagnosed with UTIs in accordance with their care plans, as required by Federal regulations. Specifically, Princeton Place staff did not always document that they monitored the residents' urine appearance at the frequencies specified in their care plans. Princeton Place did not have policies and procedures to ensure that its staff provided services in accordance with its residents' care plans. As a result of Princeton Place not following residents' care plans, the residents were at increased risk for contracting UTIs and for incurring complications from UTIs, including requiring hospitalization.

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  • CDC Infection Control Interactive Graphic Novel for Environmental Services (EVS) Personnel (6/19)

    By CDC - June 19, 2019

    EVS personnel play a critical role in preventing the spread of germs and healthcare-associated infections

    EVS and the Battle Against Infection” is an interactive graphic novel illustrating the important role of EVS personnel in the prevention of healthcare-associated infections. The online version of the training tool features real-world infection prevention and control scenarios and allows participants to choose options that affect the outcome of the story. 

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  • Early Identification of Sepsis in Nursing Facilities: Opportunities and Hurdles Recorded Webinar/Slides (6/19)

    By NNHQIC - June 19, 2019

    Please join Christine LaRocca, MD and the National Nursing Home Quality Improvement Campaign to learn more about sepsis, who is at risk and the signs and symptoms for early detection. In addition, we will:

    ·        Review examples of sepsis screening tools commonly used in hospital settings;

    ·        Learn what tools to use while recognizing the limitations of sepsis screening tools in the nursing home population; and

    ·        Understand the elements of evidence-based treatment for optimal outcomes.

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  • Abuse and Neglect of Medicare Beneficiaries: OIG Targets SNFs (6/19)

    By OIG - June 12, 2019

    The Department of Health and Human Services Office of Inspector General issued two new reports that address the identification, reporting and investigation of incidents of potential abuse and neglect of our nation's most vulnerable populations, including seniors and individuals with developmental disabilities. OIG issued an early alert in 2017 based on the preliminary findings of this work. Our resulting work, released in June 2019, identify thousands of Medicare claims that indicate abuse and neglect of beneficiaries, including beneficiaries in skilled nursing facilities. If you suspect someone is the victim of abuse or neglect, contact law enforcement immediately.

    Reports:

    CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect 

    Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated

     

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  • CDC Training: Legionella Water Management Programs (5/19)

    By CDC - May 02, 2019
    Preventing Legionnaires’ Disease: A Training on Legionella Water Management Programs (PreventLD Training)
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  • OIG Assessment of Nursing Home Deficiency Trends Finds Need for Improvement (5/19)

    By OIG - May 02, 2019

    Trends in Deficiencies at Nursing Homes Show That Improvements Are Needed To Ensure the Health and Safety of Residents (A-09-18-02010)

    In this data brief, we analyze nursing home deficiencies that were identified by State survey agencies (State agencies) across the Nation for calendar years 2013 through 2017 (review period). This data brief offers the Centers for Medicare & Medicaid Services (CMS) and other stakeholders (e.g., State agencies and nursing home management) insight into deficiency trends at nursing homes nation-wide. It also complements our previous report on State agencies' verification of correction of nursing home deficiencies.

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