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!

  • MDS 3.0 Quality Measures (QM) User's Manual V12.1 Re-posted (10/19)

    By CMS - October 09, 2019

    Nursing Home Quality Measure Changes

     The following nursing home quality measures have been removed:

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

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

    This change supports the federal initiative to reduce opioid utilization by seeking to prevent a potential scenario where the performance of a facility on the pain quality measures may inappropriately contribute to their decision to seek the administration of an opioid. 

    MDS 3.0 QM User’s Manual Version 12.1 Now Available

    The MDS 3.0 QM User’s Manual Version 12.1 has been posted. The MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V12.1 can be found in the Downloads section of this page and the MDS 3.0 QM User’s Manual V12.0 has been moved to the Quality Measures Archive page.

    One file related to the MDS 3.0 QM User’s Manual has been posted:

    1.      MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures.

    2.      Quality Measure Identification Number by CMS Reporting Module Table V1.7 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.

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  • How to Avoid Citations for the Top Two Most-Cited Deficiencies

    By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - October 08, 2019

    The survey process can be overwhelming. Surveyors arrive and begin evaluating whether the facility has met specific quality standards. Often, even the prospect of an impending survey leads to anxiety and fear for facility leaders and staff. Being aware of common citations and proactively putting plans in place to avoid those findings can help lessen the anxiety. Knowing the most-cited deficiencies and being survey ready at all times can help reduce the number of and lower the scope and severity of common citations.

     

    Over the years, the top ten survey deficiencies have remained relatively constant, but the reasons that facilities receive a specific citation do vary across the country. Let’s look at the most-cited deficiencies across the nation since January 2019 and delve further into common reasons for the top two citations.

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  • Five-Star Technical User's Guide UPDATED (10/19)

    By CMS - October 08, 2019

    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 in October 2019.


    October 2019 Revisions


    In October 2019, several changes will be made to the Nursing Home Compare website and the FiveStar Quality Rating System. These changes will affect 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 is adding 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 12 to 24 months ago). 

    Nursing homes that receive the abuse icon will 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 has received the abuse icon can have is four stars.

    Removal of quality measures related to pain: CMS will be removing 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 will change starting in October. These changes will be 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. The new cut-points are shown in the table in the introduction. Note that this table will replace Table 6 in the Technical Users’ Guide (TUG) starting after these changes are implemented in October 2019.


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  • CMS QSO Memos Explain New Five-Star Changes (10/19)

    By CMS - October 08, 2019

    Updates to the Nursing Home Compare website and the Five Star Quality Rating System

    Memo #QSO-20-02-NH

    Posting Date 2019-10-07

    Fiscal Year 2020

    Summary

    • CMS is removing the quality measures related to residents’ reported experience with pain from the Nursing Home Compare website and the Five Star Rating System.

    • We are also advising providers we will be updating the thresholds for quality measure ratings, according to the plan introduced in CMS Memorandum QSO-19-08-NH, in which the thresholds will be updated every six months. The first update will take place April 2020.

    • We are listing the dates the Nursing Home Compare website and the Five Star Rating System will be updated over the next few months.

     

    Consumer Alerts added to the Nursing Home Compare website and the Five Star Quality Rating System

    Memo #QSO-20-01-NH

    Posting Date 2019-10-07

    Fiscal Year 2020

    Summary

    • Abuse Indicator –CMS is updating the Nursing Home Compare website to make it easier for consumers to identify facilities with instances of non-compliance related to abuse.

    • Consumer Alert for Oregon Nursing Homes – CMS will be adding a consumer alert on the Nursing Home Compare website for all Oregon facilities indicating that incidents of abuse may not be reflected on the Nursing Home Compare website. This action is in response to a recommendation by the Government Accountability Office (GAO).

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  • LTCSP Survey Resources: Surveyor Tools (9/19)

    By CMS - September 12, 2019
    This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP).
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  • LTCSP Revision History for Survey Tools and Files (9/19)

    By CMS - September 10, 2019
    CMS has created a document to track revisions to all Long-term Care Survey Process documents and files.
    Read more
  • CMS Beneficiary Notices Initiative (BNI) Mailbox Portal (9/19)

    By CMS - September 02, 2019

    Launch of the CMS Beneficiary Notices Initiative (BNI) Mailbox Portal for Beneficiary Notices and Related Policy Questions

    This message is to announce the launch of the new CMS Beneficiary Notices Initiative (BNI) mailbox portal for beneficiary notices and related policy questions.  Please note this mailbox portal replaces the BNI mailbox, BNImailbox@cms.hhs.gov.  The purpose of this new BNI mailbox portal is to provide a more efficient method for responding to provider, industry, and stakeholder questions. 

    The new BNI mailbox portal provides links to a variety of resources and links to other CMS mailboxes and e-mail addresses.  CMS encourages you to review the available resources before submitting a question to ensure that we have not already provided information on the specific topic in question.  Please also refer to the list of other CMS mailboxes and e-mail addresses to ensure that you direct your question to the most appropriate area of expertise. 

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  • New CDC Infection Control Training (9/19)

    By CDC - August 31, 2019

     

    We are pleased to announce the launch of the Environmental Cleaning and Personal Protective Equipment courses, the latest in a series of 11 new infection control training courses. These courses are part of the new States Targeting Reduction in Infections via Engagement (STRIVE) curriculum intended for the infection prevention team, hospital leaders, clinical educators, nurse and physician managers, environmental services managers, all patient care staff, and patient/family advisors. Additional courses will be launched in the coming months. 

    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).

     

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  • 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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  • 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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  • 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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