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!

  • CMS Proposes PASRR Changes (2/20)

    By CMS - February 18, 2020

    DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 431, 433, 435, 441, and 483 [CMS-2418-P] RIN 0938-AT95 Medicaid Program; Preadmission Screening and Resident Review

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

    ACTION: Proposed rule.

    SUMMARY: This proposed rule would modernize the requirements for Preadmission Screening and Resident Review (PASRR), currently referred to in regulation as Preadmission Screening and Annual Resident Review, by incorporating statutory changes, reflecting updates to diagnostic criteria for mental illness and intellectual disability, reducing duplicative requirements and other administrative burdens on State PASRR programs, and making the process more streamlined and person-centered.

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  • CMS QSO Memo Explains 2 New Toolkits to Ensure Safety and Quality in Nursing Homes (2/20)

    By CMS - February 18, 2020

    CMS developed optional toolkits to aid nursing home teams with reducing adverse events and improving dementia care. These toolkits were the result of CMS work with nursing home Breakthrough Communities—a learning collaborative design where a subset of nursing homes joined learning sessions and team calls to learn about quality improvement concepts.

    Memorandum Summary

    The Centers for Medicare & Medicaid Services (CMS) is announcing the release of two toolkits that align with the CMS strategic initiative to Ensure Safety and Quality in Nursing Homes.

    • Developing a Restful Environment Action Manual (DREAM) Toolkit – CMS has created a toolkit that offers education and person-centered, practical interventions that nursing home administrators, directors of nursing, and bedside staff can implement to promote high-quality sleep for residents living with dementia.

    • Head-to-Toe Infection Prevention (H2T) Toolkit – CMS has created a toolkit that offers educational materials and practical interventions for bedside staff designed to prevent common infections by improving activities of daily living (ADL) care.

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  • Developing a Restful Environment Action Manual (DREAM) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    As many as 70% of adults with dementia experience sleep disturbances, which are associated with various negative health outcomes. High quality sleep is necessary for optimal cognitive and physical functioning, especially for residents who already experience cognitive decline due to dementia. The DREAM Toolkit provides educational material and practical tools for nursing home staff to help all residents living with dementia improve sleep quality. Nursing homes can choose from a variety of strategies in the DREAM Toolkit to help improve quality of life and quality of care, especially for residents living with dementia.

    The DREAM Toolkit consists of the following components:

    1) Implementation Guide

    2) Handbook

    3) Sleep Matters Video: https://youtu.be/2Ub55iKej84  

    4) Pocket Guide for Clinical Teams

    5) Sleep Environment Improvement Tool

    6) Resident Preferences Tool

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  • Head to Toe Infection Prevention (H2T) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    Infections comprise a large share of adverse events in nursing homes. The Head to Toe Infection Prevention Toolkit contains educational materials and practical tools to support the clinical team in providing person-centered care that helps prevent and control common infections like pneumonia, skin infections, and urinary tract infections. The Toolkit aims to educate licensed nurses and nurse aides on infection prevention practices and provide tools that can be integrated into their daily work.

    The H2T Toolkit consists of the following components:

    1) Implementation Guide

    2) Infection Prevention Handbook

    3) Staff Presentation

    4) Resource for Residents and Loved Ones

    5) Observation Guide

    6) Customizing Care Tool

    7) Suspected Infection Investigation Tool

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  • ACIP Immunization Recommendation Change for Pneumococcal conjugate (PCV13) for > 65 (2/20)

    By ACIP - February 10, 2020

    Changes in the 2020 Adult Immunization Schedule

    Changes in the 2020 adult immunization schedule for persons aged ≥19 years include new or revised recommendations for hepatitis A vaccine (HepA) (2); human papillomavirus vaccine (HPV) (3); influenza vaccine (4); serogroup B meningococcal vaccine (MenB); pneumococcal vaccine (5); and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) (6). Following are the changes to the cover page, Table 1, Table 2, and Notes.

    Cover page

    • Trademark symbols (®) were added to all vaccine trade names.
    • PedvaxHIB was added to the table of trade names for Haemophilus influenzae type b vaccine.
    • The footnote on the cover page has been edited and now reads “Do not restart or add doses to vaccine series if there are extended intervals between doses.”

    Table 1

    • Age ranges: The columns for age groups 19–21 years and 22–26 years have been combined, thereby reducing the number of columns for age ranges from five to four. This change was made because of the change in recommendation for catch-up HPV vaccination for all adults aged ≤26 years.
    • Tetanus, diphtheria, pertussis row: This row has been edited to state that tetanus and diphtheria toxoids (Td) or Tdap may be used for the decennial tetanus booster.
    • Human papillomavirus (HPV) row: The rows for males and females have been combined, reflecting that catch-up vaccination is now recommended for all adults aged ≤26 years. In addition, a blue box has been added for persons aged 27–45 years to indicate that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Pneumococcal conjugate (PCV13) row: The box for persons aged ≥65 years who do not have an additional risk factor or another indication has been changed to blue to indicate that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Meningococcal B (MenB) row: A blue box has been added for persons aged 19–23 years who are not at increased risk for meningococcal disease, indicating that shared clinical decision-making regarding vaccination is now recommended for this group.
    • Legend: A blue box has been added to indicate that shared clinical decision-making is recommended regarding vaccination. The text defining the gray box has been edited and now reads “No recommendation/not applicable.”

    Table 2

    • Tdap or Td row: This row has been revised to read that Td or Tdap may be used for the decennial tetanus booster.
    • Human Papillomavirus (HPV) row: This row has been combined into a single row including both males and females, reflecting that HPV vaccine is now recommended for all adults aged ≤26 years.
    • Hepatitis A (HepA) row: The box for persons living with human immunodeficiency virus (HIV) infection (regardless of CD4 count) is now yellow, reflecting the new recommendation that previously unvaccinated persons in this group should be vaccinated.
    • Legend and bar text: The gray box in the Legend has been edited and now reads “No recommendation/not applicable.” The red box has been edited and now reads “Not recommended/contraindicated — vaccine should not be administered.” The text appearing in the red bars has been changed from “Contraindicated” to “Not Recommended.”
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  • CMS QSO Memo re: Coronavirus and Healthcare Facility Expectations (2/20)

    By CMS - February 10, 2020

    Memo #20-09-ALL

    Posting Date 2020-02-06

    Fiscal Year 2020

    Summary

    • Information Regarding Patients with Possible Coronavirus Illness: the U.S. Centers for Disease Control and Prevention (CDC) has issued information on the respiratory illness caused by the 2019 Novel Coronavirus (2019-nCoV). Links to these documents are provided.
    • Healthcare Facility Expectations: CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.
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  • MDS 3.0 Quality Measures (QM) User's Manual V13.0 (2/20)

    By CMS - February 05, 2020

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage.

    The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage. The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.
    Read more
  • Five-Star Technical User's Guide Plus Claims-Based Measures Appendix (2/20)

    By CMS - February 04, 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.


    October 2019 Revisions

    In October 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected the health inspection and quality measure domains. This section provides details on these changes.

    Ratings changes for facilities that receive the abuse icon: To make it easier for consumers to identify facilities with instances of non-compliance related to abuse, starting in October 2019, CMS added an icon to highlight facilities that meet either of the following criteria: 

    1. Harm-level abuse citation in the most recent survey cycle: Facilities cited for abuse where residents were found to be harmed (Scope/Severity of G or higher) on the most recent standard survey or on a complaint survey within the past 12 months. 
    2. Repeat abuse citations: Facilities cited for abuse where residents were found to be potentially harmed (Scope/Severity of D or higher) on the most recent standard survey or on a complaint survey within the past 12 months and on the previous (i.e., second most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13 to 24 months ago). 

    Nursing homes that receive the abuse icon have their health inspection rating capped at a maximum of two stars. Due to the methodology used to calculate the overall rating, the best overall quality rating a facility that receives the abuse icon can have is four stars. 

    Removal of quality measures related to pain: CMS removed two quality measures (QMs) from the Nursing Home Compare website and the Five-Star Quality Rating System in October 2019. These measures are: 

    • Percentage of short-stay residents who report moderate to severe pain. 
    • Percentage of long-stay residents who report moderate to severe pain. 

    As a result of dropping these two measures, the cut-points for the long-stay, short-stay, and overall QM ratings changed. These changes were made to maintain, as close as possible, the same distribution of short-stay and long-stay QM ratings as were posted on Nursing Home Compare in July 2019. 

    January 2020 addition: Technical specifications for claims-based measures

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  • Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) (2/20)

    By CDC - February 03, 2020

    The Centers for Disease Control and Prevention (CDC) continues to closely monitor an outbreak of respiratory illness caused by a novel coronavirus (2019-nCoV) that was initially detected in Wuhan City, Hubei Province, China in December 2019.

    This CDC Health Alert Network (HAN) Update provides a situational update and interim guidance to state and local health departments that supersedes guidance in CDC’s HAN 426 distributed on January 17, 2020.

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  • PBJ Electronic Data Staffing Submissions Data Specs V4.00 Required Effective June 2, 2020 (1/20)

    By CMS - January 27, 2020
    The PBJ Data Submission Specifications Version 4.00 package is now available. 
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  • CMS Training Explains 2019 Updated LTC Emergency Preparedness Requirements (1/20)

    By CMS - January 27, 2020

    Note that only the emergency preparedness changes directly related to LTC.

     NLTC Regulatory Updates 2019 - Training Menu

    In 2019, CMS published the final rules Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction, Part III; and Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. The Non-Long-Term Care Regulatory Updates training provides an overview of changes to these provisions that are designed to reduce regulatory burdens for all provider and supplier types (including long-term-care providers).

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  • Antipsychotic Medication Use Data Report and Late Adopter Data Report Updated (1/20)

    By CMS - January 27, 2020

    National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report (October 2019)

     

    The National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for individuals with dementia living in nursing homes. The National Partnership has a mission to deliver health care that is person-centered, comprehensive and interdisciplinary with a specific focus on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need. The Centers for Medicare & Medicaid Services (CMS) promotes a multidimensional approach that includes; research, partnerships and state -based coalitions, revised surveyor guidance, training for providers and surveyors and public reporting. 


    CMS is tracking the progress of the National Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In 2011Q4, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 40.1 percent to a national prevalence of 14.3 percent in 2019Q2. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 45 percent. CMS acknowledges that circumstances exist where clinical indications for the use of antipsychotic medications are present and does not expect that the national prevalence of antipsychotic medication use will decrease to zero. 

     

    National Partnership to Improve Dementia Care in Nursing Homes: Late Adopter Data Report (October 2019) 

    CMS announced that the National Partnership met its goal of reducing the national prevalence of antipsychotic medication use in long-stay nursing home residents by 30 percent by the end of 2016. It also announced a new goal of a 15 percent reduction in those homes with currently limited reduction rates. Nursing homes with low rates of antipsychotic medication use are encouraged to continue their efforts and maintain their success, while those with high rates of use are to work to decrease antipsychotic medication use by 15 percent for long-stay residents by the end of 2019, using the prior baseline rate (2011Q4). These homes have been identified as late adopters.

    Nursing homes were identified as late adopters, based upon 2017Q1 data. These nursing homes continued to have a high rate of antipsychotic medication use, their percentage of change from 2011Q4 to 2017Q1 increased or decreased very little, and they remained above the national average in 2017Q1. This quarterly data report is specific to the progress of the late adopters. In 2011Q4, 21.4 percent of long-stay nursing home residents, living in a nursing home identified as a late adopter, were receiving an antipsychotic medication; since then there has been a decrease of 13.7 percent to a national prevalence, among late adopters, of 18.5 percent in 2019Q2. For more information on the National Partnership, please send correspondence to dnh_behavioralhealth@cms.hhs.gov. 

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  • March 3 CMS Quarterly Dementia Care Call to Target Infection Prevention, Staffing, Restful Environment: Register Now

    By CMS - January 05, 2020
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  • CMS QSO Memo Sets Up Pending Emergency Preparedness Changes (12/19)

    By CMS - December 21, 2019

    The vast majority of this doesn’t apply directly to long-term care. Emergency preparedness is included, and obviously it does apply. However, most of the guidance for the LTC-specific emergency preparedness changes is still to come.

    Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-20-07-ALL

    DATE: December 20, 2019

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

    SUBJECT: Burden Reduction and Discharge Planning Final Rules Guidance and Process

    Memorandum Summary

    • On September 30, 2019, the Centers for Medicare & Medicaid Services (CMS) published the Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule, as well as the Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies Final Rule.

    • This policy memorandum provides guidance to the CMS Regional Offices (ROs), the State Survey Agencies (SAs) and the Accrediting Organizations (AOs) regarding the changes to the regulations and our approach for updating the State Operations Manual (SOM) and applicable surveyor systems.

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  • Top Ten Citations Part Three – Why Facilities Get Cited for F684 and F761

    By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - December 17, 2019

    A few months ago, we provided members with a list of the top ten federal deficiencies since January of 2019. Since then, articles have delved deeper into the top four citations. This month, we will examine the number five and six top citations, explore common reasons that facilities struggle to meet these regulations, and discuss why surveyors cite them.

     

    As a reminder, the top ten deficiencies are:

    1. F880 - Infection prevention and control

    2. F689 - Free of accidents, hazards/supervision/devices

    3. F812 - Food procurement/storage

    4. F656 - Develop/implement comprehensive care plan

    5. F684 - Quality of care

    6. F761 - Label/storage of drugs and biologicals

    7. F657 - Care plan timing and revision

    8. F758 - Free from unnecessary psychotropic med/prn use

    9. F677 - ADL care for dependent residents

    10. F550 - Resident rights

    (The citations above in red have the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)

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