Facilities required to report annual healthcare personnel (HCP) influenza vaccination data through NHSN must do so by May 15, 2025 to meet CMS reporting requirements for the 2024-2025 influenza season.

Below is a summary of key information about this requirement.

Which facilities are required to report these data?

  • The Influenza Vaccination Coverage among HCP measure was finalized in the FY 2023 SNF PPS Final Rule which was published in the Federal Register on August 3, 2022. As a result, CMS-certified skilled nursing facilities (SNFs) are required to report annual HCP influenza vaccination summary data through the NHSN Healthcare Personnel Safety (HPS) Component.

What data are submitted?

  • The reporting period for the 2024-2025 influenza season is from October 1, 2024, through March 31, 2025. Facilities are only required to submit one report that covers the entire reporting period by May 15, 2025.

How should facilities submit these data?

  • Facilities must report annual HCP influenza vaccination summary data through the NHSN HPS Component. 

Who can activate the HPS Component?

  • Only the NHSN Facility Administrator (FA) can activate a new component. The FA can then add users including the HPS Component Primary Contact once the component is activated.
  • If the NHSN FA leaves the facility but does not transfer the role of FA to another individual prior to leaving, please complete the NHSN FA Change Request Form: https://www.cdc.gov/nhsn/facadmin/index.html.
  • Please do not deactivate any other NHSN Components, such as the LTCF Component.

How can LTCFs add the HPS Component?

Where can facilities access training materials?

Who do facilities contact with questions?

Please use NHSN-ServiceNow (accessed here) to submit questions to the NHSN Help Desk. Users will be authenticated using CDC’s Secure Access Management Services (SAMS), the same way you access NHSN. If you do not have a SAMS login or are unable to access ServiceNow, you can e-mail the NHSN Help Desk at nhsn@cdc.gov.

Thank you for your efforts with reporting annual HCP influenza vaccination summary data through NHSN.

UPDATE: Skilled Nursing Facilities: Revalidation Deadline Extended to August 1

https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-04-17-mlnc#_Toc195616278

Enrolled skilled nursing facilities should collect data on ownership, managerial, and related party information and submit their revalidation. CMS extended the deadline to August 1, 2025. See the Become a Medicare Provider or Supplier webpage for more information.

CMS sent revalidation notices to enrolled skilled nursing facilities (SNFs) from October – December 2024 to collect data on ownership, managerial, and related party information. You must report this data on the revised Medicare Provider Enrollment Application Form (CMS-855A). Click here (PDF) for detailed information on the parties to be reported and here (PDF) for instructions on completing your application via PECOS. Please note that CMS will not be updating the online Medicare Revalidation List to include the SNF off-cycle revalidation schedule.

The Central Office Medical Review Unit (COMRU) has scheduled monthly orientation training to review the requirements of the Pre-Admission and Resident Review (PASRR) and Nursing Facility Level of Care (LOC) application process. These on-line trainings will be one-hour in length and hosted by Ammanda Ott, RN Supervisor for COMRU. Each training is limited, so register soon!

Please see the registration link here for complete details and ongoing dates.

The Spring 2025 issue of The Resident Advocate is now available. This newsletter provides information on residents’ rights and care issues; news and updates on national policy; and self-advocacy tips for obtaining person-centered, quality care.

This issue includes information on:

  • Nursing home residents right to language assistance
  • Tips for staying safe during outbreaks
  • How to join the Consumer Advisory Council, and
  • Participating in this year’s Residents’ Rights Month.

The Resident Advocate is a great resource to share with long-term care residents. Nursing home staff, long-term care Ombudsman programs, family members, and other advocates are encouraged to forward this newsletter to residents or print and share copies. Download this issue or past issues from the website.

Do you…..

❍ need a leadership course that addresses the unique challenges SNF leaders face?

❍ want to feel inspired and passionate about leading your SNF?

❍ want to connect with other SNF leaders and have access to free professional development, tools, and resources?

❍ want free CE credit without sacrificing quality and practical application?

❍ want to have the flexibility to learn at the pace and place the works best for you?

If you answer YES to any of these questions, this course may be for YOU!
Take the survey now to see if you qualify for FREE registration.

For more details, please visit the website.

Course ends: October 31, 2025

A reminder that residents may choose the pharmacy of their choice. State regulation that applies to all levels of care states:

19 CSR 30-88.010(40) Each resident shall be allowed the option of purchasing or renting goods or services not included in the per diem or monthly rate from a supplier of his or her own choice, provided the quality of goods or services meets the reasonable standards of the facility. Each resident shall be allowed the option of purchasing his or her medications from a pharmacy of his or her choice, provided the quality of the medications and packaging meets reasonable standards of the facility.

The Division of Senior and Disability Services (DSDS) is seeking additional Direct Service Workers to join the existing panel. Last year we received valuable information from our panelist and are excited to continue the work through this year. We are seeking Direct Service Workers currently working in the role with experience and knowledge to share. If you know of someone who would be a great contribution to this panel, please send this application information for consideration. Click the image below to learn more and apply.

Any questions should be directed to the Bureau of Policy and Quality Enhancements at LTSS@health.mo.gov.

 

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 10/1/24 through 12/31/24 is due February 14, 2025. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on February 18, 2025:

  • MDS data for 7/1/24 through 9/30/24.
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 7/1/24 through 9/30/24.

 

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

FREE THREE-PART VIRTUAL SERIES

All staff in CMS-certified nursing facilities across the U.S. are invited to join this three-part learning series to enhance skills in person-centered care, engaging with residents, and de-escalation with expert guidance and peer support.

More information including topics and specific dates for each can be found here.

The Medicare and Medicaid Poster is now updated for homes to print and display for residents. Note the asset limits for MO HealthNet are no longer provided on the poster, as they change every year. Please obtain the latest update on the Missouri Long-Term Care Ombudsman website. The Medicare and Medicaid Poster can be located under the Online Only section at: https://health.mo.gov/seniors/ombudsman/resources.php.

The Section for Long-Term Care Regulation’s Health Education Unit is excited to present this summer event.

 

July 10, 2025
Governor’s Office Building
Jefferson City

Register Here

 

Please stay tuned for more details including agenda!

 

Snow and ice are a mainstay of Missouri winter weather. Because of the variety of weather conditions as well as other events, facilities must have an emergency preparedness plan and be ready to act in an emergency to ensure they are to adequately prepared to meet the needs of patients, clients, residents, and participants during disasters and emergency situations.

If your facility experiences a loss of a necessary service (electricity, water, gas, phone, etc.), contact SLCR via the Regional Office emergency phone line and keep them informed of their status. If, for some reason, the facility cannot contact SLCR staff through the regional office phone number, you should contact the hotline. The emergency protocol is located here.

When you call, be prepared to answer to the following:

Facility name

  • Census, including staff assessment of current needs of the residents and monitoring of the ill.
  • Contact person and emergency contact number that is not the facility main line.
  • Has the facility called the fire department and central monitoring company if phones, alarm systems are down?
  • Generator: Y/N
    • If yes, what equipment does the generator serve (fire alarm, HVAC systems)?
    • If yes, amount of fuel onsite and/or system for delivery? How long will fuel last?
    • If no, what is fire watch plan?
    • If no, how will the facility ensure resident needs are met, including maintenance of room temperatures in a safe manner?
      • Obtain generator- is the home set up to receive generator power once delivered? Estimated time for delivery? Estimated time when generator power will be established.
      • Evacuation- Where is facility relocating to, distance from facility, transportation to get there, staffing, sufficient supplies/medications, how will the facility ensure resident needs are met, including maintenance of room temperatures in a safe manner (does the location have a functional emergency generator?) If relocating to a SNF – will the home be over capacity? Is there sufficient beds/space in the receiving facility to house the extra residents?
    • Documentation may be requested, including:
      • If evacuated, a list of residents and were they went
      • Room temperature logs
      • Fire watch documentation

Here are a few things to consider in examining your emergency preparedness plan, specifically as it relates to snow, ice, and power outages.

  • If there is a loss of the primary power, how will the facility ensure adequate temperatures of the facility will be maintained during the emergency situation?
  • Is the plan feasible?
    • Plan for the worst. Most events do not occur on a sunny Tuesday afternoon and the plan should account for things such as poor weather, road conditions, weekends/holidays, evenings, staff ability to travel to work, and other obstacles that may cause issue during the actual emergency.
  • Are staff knowledgeable of the plan and have access to what is needed in order to implement the plan?
    • Phone numbers, contact persons, contracts.
  • Do staff know what to do during an emergency and know who is in charge? If the administrator is not onsite, who is in charge and does that person know all their duties?
    • This may be the DON, but it may also be a charge nurse (or another designated onsite staff) if the event happens in the “middle of the night”. Depending on when the administrator or someone higher up on the order of succession can arrive at the facility, that person (i.e. night charge nurse) may be in charge for an extended amount of time.
  • Is the plan detailed enough?
    • Is there a detailed plan that describes when the residents will evacuate during an emergency? If loss of power, does the plan instruct the staff to start the evacuation prior to the point when the facility is below appropriate air temperatures and to maximize their safety during travel? What is the distance to the emergency evacuation site? What types of roads do they have to traverse, such as “side roads”, bridges, or interstates; all of these roads can have their challenges. Does the facility have more than one contracted emergency site?
      • Is it likely that emergency events will also impact the surrounding areas? It is also possible that the evacuation site may be so far away, residents may not be able to get there when road conditions are less than optimal. Does the contracted site meet all the criteria to allow the residents to shelter in place at that location?
    • Is there a contract for transportation and will that transportation be able to get the residents to and from their current location to the contracted emergency location in a snow/ice storm? If the services have other contracted uses, such as school buses, will they be available at 3:00 P.M. on a school day or can they get drivers at 3:00 A.M. on a Wednesday?
  • Does the facility have a generator?
    • Is there enough fuel, a contract to get more fuel, and a list of what it does and does not operate?
      • Facilities (and the staff in charge) need to know in advance, what their generator will operate. At a minimum, this listing must include whether it runs: Life safety equipment (such as E-lights and fire alarm system(s)), magnetic door locks/door alarms (where applicable for safety), HVAC systems, cooking systems, what outlets residents and staff will be able to be use, and computer equipment/Wi-Fi (if electronic medical records (EMR) are utilized).
      • This list needs to be detailed so staff will know specifically what items will and will not work during a power outage. Many generators will run every second or third ceiling light for emergency lighting, but not all lights in the facility will work during a power outage. This needs to be listed so all staff will know that information.
    • If a facility does not have a generator, what are the plans when it may not be easily able to evacuate due to poor road conditions or other factors that may prohibit a smooth transition from a facility to another location?
      • If the facility plans to have a generator delivered during a loss of power, does the facility have a contract with the generator company to deliver one to them? This contract should include the size of the generator that the facility will need in order to ensure the safety and care needs of the residents are met during the emergency.
        • The building will need to be wired and ready to accept the generator in advance. The facility will not be able to install a generator during the emergency event unless the wiring for the generator has already been completed.
      • Facilities must maintain at least their fire safety equipment (E-lights, fire alarm, sprinkler system, range hood (if any cooking occurs), food, water, heating and cooling, and sewage disposal to shelter in place.
        • There must be a plan of how this will be achieved, emergency supplies, the detailed list of what the generator will run, and any contracts that will be needed during the emergency to ensure these services can continue during the emergency event.
          • Sometimes trucks will not be able to run regular schedules and it may take several days before the facility can get their first delivery after an emergency starts; depending on the extent and severity of the disaster.
        • A power outage may be as simple as a blip, may last for hours, or may last for days – depending on the extent of the power grid damage and when the crews can access the problem(s).
          • The facility needs a plan of when, how, and where they will evacuate if they cannot provide at least the components of the previous bullet point.

During a disaster is the least ideal time to learn an emergency plan will not work or to search for a contracted service. All contracted services including, but not limited to, transportation, fuel needs, evacuation location, food, and water needs to be in the emergency plan. The emergency preparedness team needs to consider and plan all services and contract prior to an actual emergency. During an emergency, it may be very difficult or impossible to get a contracted service due to volume of request, road conditions, and/or other factors.

Thank you for preparing in advance and keeping us informed!

Memorandum Summary

  • Acute Respiratory Illness Reporting Requirements: The LTC facility requirements for reporting COVID-19-related data expired on December 31, 2024, except for reporting COVID-19 resident and staff vaccination status. On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2025 Home Health Prospective Payment System Rate Update. The rule broadens the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) reporting requirements for nursing homes. Beginning on January 1, 2025, LTC facilities are required to electronically report information about COVID-19, influenza, and respiratory syncytial virus (RSV) in a standardized format and frequency specified by the Secretary.
  • Survey Process and Enforcement: CMS expects LTC facilities to comply with all facility requirements. These requirements will be incorporated into the survey process once guidance to LTC facility surveyors is released.

Please see the full memo for details located at https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/policy-memos/policy-memos-states-and-cms-locations/long-term-care-ltc-facility-acute-respiratory-illness-reporting-requirements.

The NHSN Long-Term Care Team and Vaccination Team provided a refresher training about the newly combined reporting form for Respiratory Pathogens and Vaccination. The team also reviewed upcoming required reporting fields beginning January 1, 2025.

NHSN LTCF Component: Respiratory Pathogens & Vaccination Reporting Requirement Updates – December 2024

Register in advance for the webinar replay on January 7: https://cdc.zoomgov.com/webinar/register/WN_Sd8zLQXEQCWl9vKCrfJcpw#/registration.

More resources can be found at https://www.cdc.gov/nhsn/ltc/covid19/rpv-resources.html.

Center of Excellence for Behavioral Health in Nursing Facilities – Webinar Opportunity

Holiday Seasonal Depression: Ways to Support Nursing Facility Residents

The holidays can be tough for both residents and those who support them. The Center of Excellence of Behavioral Health in Nursing Facilities is hosting a live virtual event on 12/17/24 @ 1:00 PM CST to talk about the fundamentals of Seasonal Affective Disorder (SAD) and its effects on holiday depression. This training FREE, available to residential care, assisted living, skilled nursing, Ombudsman, and state survey agency team members. It is designed to provide participants with a basic understanding of depression, seasonal onset, symptoms, and treatments to support residents experiencing challenges from SAD. Register today- as space may be limited.

Please see the attached as a similar letter is being sent out by DHSS and the Healthcare-Associated Infections & Antimicrobial Resistance team of epidemiologists regarding some education for C auris (emerging fungal infection).

The Association for Professionals in Infection Control and Epidemiology along with American Association of Post-Acute Care Nursing, has released a practice guidance tool and resource guide to help implement EBP in skilled long-term care facilities. The practice guidance tool outlines when EBP should be implemented for residents, provides infection control recommendations for routine care activities, and includes case study examples with a self-quiz to help reinforce learning. The resource guide also provides a comprehensive list of infection control websites and references. More information including the guide can be found here.