The Office of Dental Health conducted a dental screening survey of residents at 22 random long-term care facilities starting in 2020 and ending the summer of 2022. For those 22 long-term care facilities that participated-Thank you for allowing us into your facility in order to gather the necessary information for the dental screenings. We appreciate your willingness to allow us to come and visit your residents, especially after COVID. We know these past few years have been difficult with the pandemic, but we appreciate you working with us for this important information.

Attached is a break-down of what was found in those random nursing homes. While this is not looking at every older adult resident in the state, it is felt it represents a good amount to make assumptions on what would possibly be found if we conducted this screening on every older adult resident. As noted in the attachment, of those older adults with teeth, 40% of them have untreated decay and 29% are in need of periodontal care. The Office of Dental Health has been working with clinics to encourage them to provide care to this underserved population. We will also be developing some training for staff and caregivers on the importance of proper dental care.

Again, thank you for allowing us to conduct this screening. If you have any questions, please contact us at oralhealth@health.mo.gov or 573-751-5874. We wish everyone a safe, enjoyable and healthy holiday season!

In-person Adult MHFA Courses:
December 3, 2022 | 9:30a – 5:30p | Doniphan – Register Here
December 7, 2022 | 9:00a – 5:00p | St. Joseph, MO – Register Here
December 12, 2022 | 9:30a – 5:30p | Cape Girardeau – Register Here

In-person Youth MHFA Courses:
December 6, 2022 | 10:00a – 4:30p | Cape Girardeau – Register Here
December 7, 2022 | 8:30a – 3:30p | St. Louis – Register Here

Virtual Adult MHFA Courses:
December 9, 2022 | 8:30a – 3:30p | Virtual – Register Here
December 15, 2022 | 8:30a – 3:30p | Virtual – Register Here

Free trainings sponsored by Missouri’s Department of Mental Health and other sponsors. They are only available to individuals who live or work in Missouri. To find additional courses click here.

February 1-3, 2023: Navigating the Storm

Missouri Association of Nursing Home Administrators is pleased to invite you to attend our Winterfest Convention and Trade Show. The goal of this conference is to provide long-term care administrators and their staff practical and inspirational education hours along with the opportunity to network and socialize with colleagues. It is also the only MANHA sponsored conference that provides you a chance to view the latest technology, products, and services offered by suppliers.

Memorandum Summary

  • Providers and suppliers, especially those delivering care in congregate care settings, should ensure their patients and residents are protected against transmission of COVID-19 within their facilities, as well as receiving appropriate treatment when tested positive for the virus.
  • Further, all providers and suppliers should continue to implement appropriate infection control protocols for COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html) and Influenza (https://www.cdc.gov/flu/professionals/infectioncontrol/index.htm).
  • This memo discusses the importance of the timely use of available COVID-19 therapeutics, particularly for high-risk patients who test positive for the virus.

Please see the full memo for complete details at https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/importance-timely-use-covid-19-therapeutics.

The fire alarm annual inspection, semi-annual inspection, and repairs must be performed by a qualified individual. Recently, SLCR has observed several instances across the state of unqualified individuals inspecting/repairing fire alarm systems. NFPA states the qualifications needed for the inspector performing these types of services.

NFPA 72, 2010 edition:

10.4.3 Inspection, Testing, and Maintenance Personnel. (SIGTMS)
10.4.3.1* Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:
(1)*Personnel who are factory trained and certified for the specific type and brand of system being serviced
(2)*Personnel who are certified by a nationally recognized certification organization acceptable to the authority having jurisdiction
(3)*Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of this Code (The State of Missouri does not have its own certification program, therefore this option is not applicable.)
(4) Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code
10.4.3.2 Evidence of qualifications shall be provided to the authority having jurisdiction upon request.

When completing the LSC portion of the survey, LSC surveyors must verify the inspections and maintenance performed on the fire alarm system(s) were completed and signed off by a qualified person from the listed qualifications in NFPA. The facility is required to provide this certification to the surveyors at the time of the survey. Some companies list the inspector qualifications on the inspection and maintenance reports. These same regulations do not apply to the sprinkler system.

National Institute for Certification in Engineering Technologies (NICET) is not the only option available for certifications, as inspectors can be qualified by other means; however, it is the most common nationally recognized certification. For NICET, the individual must be a Fire Alarm Systems Level II or higher. SLCR staff can search for an individual through the NICET website at: https://nicet.useclarus.com/view/verify/.

Please contact Scott Wiley (573-526-8552 or Scott.Wiley@health.mo.gov) and/or Steven Vest (573-526-8608 or Steven.Vest@health.mo.gov) with any questions regarding the qualifications of fire alarm inspectors.

The Centers for Medicare & Medicaid Services (CMS) has developed a series of interactive videos called “Quality in Focus” (QIF) on the Quality, Safety & Education Portal (QSEP). The 10-15 minute videos are self-paced. They will help providers and suppliers participating in the Medicare and Medicaid programs better understand how to improve health and safety in facilities.

The QIF series aims to increase the quality of care for people with Medicare and Medicaid by reducing the deficiencies most commonly cited during the CMS survey process, such as infection control and accident prevention. These resources will help providers and suppliers better understand surveyor evaluation criteria, recognize deficiencies, and incorporate solutions into their facilities’ standards of care, so they are more equipped to meet health and safety guidelines.

The QIF interactive videos are tailored for specific provider and supplier types, with 1-3 videos per type. Each interactive video focuses on a specific health or safety citation with the goal of identifying and resolving these deficiencies. QIF interactive videos are currently available for:

  • Long Term Care (LTC) Treatment and Prevention of Pressure Ulcer Citations
  • LTC Free of Accident Citations
  • LTC Medication Error Citations
  • Intermediate Care Facility for Individuals with Intellectual Disabilities (IICF/IID) Program Implementation Citations
  • Ambulatory Surgical Center (ASC) Infection Control Citations
  • Community Mental Health Center (CMHC) Local, State, Tribal Collaboration Process Citations
  • Hospice Plan of Care Citations
  • Psychiatric Residential Treatment Facility (PRTF) Post-Intervention Debriefing Citations
  • Outpatient Physical Therapy (OPT) Equipment, Buildings, and Grounds Maintenance Citations
  • Comprehensive Outreach Rehabilitation Facility (CORF) Local, State, Tribal Collaboration Process Citations
  • Home Health Agency (HHA) Incomplete Individualized Plan of Care Citations
  • Rural Health Clinic (RHC) Preventative Maintenance Program Citations
  • Portable X-ray Personnel Monitoring Citations
  • End Stage Renal Disease (ESRD) Cleaning and Disinfecting Citations
  • Hospital Patient Safety

Please note that the information in the interactive videos is for informational purposes and is not meant to take the place of statutes, regulations, or official CMS policy.

Visit the Quality, Safety & Education Portal (QSEP) Training Catalog at https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx to access the “Quality in Focus” interactive videos. The videos can be found under the Quality in Focus tab.

Below is important information regarding modifications to the Point of Care Test Reporting Tool, the Long-term Care Facility COVID-19 Module, and the COVID-19 Vaccination Module. The changes described below took effect with the October 2022, NHSN release. Resources on the NHSN LTCF COVID-19 Module webpage and the COVID-19 Vaccination Modules webpage have been updated, where indicated, with revised forms, instructions, FAQs and CSV templates.

Point of Care (POC) Test Reporting Tool:
The following enhancements were made.

Additional POC devices were added to the NHSN system.
Although some are titled, “At-Home,” the devices below have been provided POC Emergency Use Authorization by the U.S. Food and Drug Administration. If you are using any of these devices, please check the model’s name and ensure you choose the correct device from the drop-down menu.

  • DxLab COVID-19 Test_ DxLab Inc.
  • MicroGEM Sal6830 SARS-CoV-2 Saliva Test_ MicroGEM U.S., Inc.
  • OHC COVID-19 Antigen Self Test_ OSANG LLC
  • QuickVue At-Home OTC COVID-19 Test_ Quidel Corporation
  • Rapid SARS-CoV-2 Antigen Test Card_ Xiamen Boson Biotech Co., Ltd.

COVID-19 Pathway Data Reporting:
Please refer to the data reporting pathways below to learn about enhancements that were made within each pathway.

Resident Impact and Facility Capacity Pathway:
No enhancements

Staff and Personnel Impact Pathway:
No enhancements

Supplies and Personal Protective Equipment (PPE) Pathway:
No enhancements

Therapeutics Pathway:
An issue regarding csv upload for group and facility users was recently identified and a resolution has been implemented. Facility and group users are now able to successfully upload csv files.

State Veterans Homes COVID-19 Event Reporting Tool:
No enhancements

Weekly NHSN COVID-19 Vaccination Data Modules

Person-Level COVID-19 Vaccination Forms
If you use the optional Person-Level COVID-19 Vaccination Forms to submit your weekly COVID-19 vaccination data, demographic variables are now required for individuals currently in the facility (i.e., those without an end date or discharge date) to save and submit data. Please keep in mind that if you are unable to obtain this information, you can select ‘Unknown.’

Analysis Reports
The Long-Term Care COVID-19 Vaccination Coverage bar chart reports are once again available for use. These reports are called “Bar Chart – LTC HCP COVID-19 Vaccination Coverage” and “Bar Chart – LTC Resident COVID-19 Vaccination Coverage”.

CMS Reporting Deadline
The deadline for quarterly reporting of COVID-19 vaccination coverage data for long-term care facilities to fulfill CMS Quality Reporting Program requirements covering Quarter 2 of 2022 (April 1, 2022-June 30, 2022) is November 15, 2022.

For questions about any of these updates, please send an e-mail to the NHSN Helpdesk at NHSN@cdc.gov with the subject line identifying the topic of the message.

As previously announced, CMS is preparing to release the Internet-facing, cloud-based system, referred to as the Internet Quality Improvement and Evaluation System (iQIES) for Minimum Data Set (MDS) submission in early 2023.

Although the MDS submission functionality will not be available immediately, we strongly encourage Provider Security Officials (PSOs) to request access to iQIES as soon as possible, as doing so will allow for a smoother transition prior to the go live date. The individual designated as the PSO must work for the provider and will be responsible for approving or rejecting iQIES user access requests for their respective organizations, including vendors. A user will not be granted access unless a PSO approves the request. The first PSO for your provider will need to be approved by CMS. Once approved, PSOs can approve additional Provider Security Official role requests.

Organizations must complete the steps below to register a Provider Security Official as soon as possible:

 ***IMPORTANT: General user onboarding begins November 15, 2022. At that time, if your organization has not yet successfully registered at least one PSO, users will not be able to complete their access requests. The delay for assigning a PSO places an organization in jeopardy of a smooth transition to iQIES.***

  1. Identify at least one individual who will be the Provider Security Official (PSO). Note: At a minimum, at least one PSO needs to be selected, but CMS highly recommends at least two PSOs are designated so there is a higher likelihood that someone will be available to approve/reject iQIES access requests. The PSO must work for the provider and cannot be a vendor.
  2. Create an account in the HARP system using your corporate email address* at: https://harp.cms.gov/register. Note: HARP User IDs cannot be adjusted. As such, please refrain from using facility names or any special characters (such as # or &) when creating the HARP User ID. *If the facility handles 2 or less providers and does not have a corporate email domain, the PSO may use a personal email address.
  3. Access iQIES at: https://iqies.cms.gov/ and log in with your HARP credentials (completed in step 2 above) to request the Provider Security Official role for YOUR specific provider CMS Certification Number (CCN).
  4. Once the PSO role request has been submitted AND approved, you will receive notification via email. At this point you will be one of the designated PSOs for your CCN and have the authority to approve/reject subsequent requests for access of various role types to your provider’s CCN.

Please see iQIES Quick Reference Guide – Provider Security Official for more information to onboard the PSO Role in iQIES: https://qtso.cms.gov/software/iqies/reference-manuals

Please Note: Currently, we are only onboarding MDS. You do not need to register for a HARP/iQIES account for Payroll Based Journal (PBJ) submissions.

Resources

For more information on HARP or iQIES, please refer to the following resources:

 HARP

 iQIES

If you have questions or require assistance, please contact the iQIES Service Center at iqies@cms.hhs.gov or by phone at (800) 339-9313.

Administrators due to renew in 2023 and forward are required to complete all required continuing education (CE) clock hours in-seat or can complete a maximum of half of the total required hours through online continuing education programs (web-based, teleconference, self-study and webinar).

Refer to the “License Renewal Checklist” on the website https://health.mo.gov/information/boards/bnha/.

Please contact the Board of Nursing Home Administrators with any questions or concerns at BNHA@health.mo.gov.

Applications Being Deleted

Please ensure all processed online applications and Level 2 screenings have been printed/saved for your records. Facilities (SNFs) will need to have copies of these documents prior to them being deleted.

Processed applications will be deleted from the COMRU online system 60 days after completion.

Additionally, effective November 4, 2022, if a correction has not been resubmitted back to COMRU within 60 days of notification, the online application will be deleted.

COMRU Webinar Training

There will be a webinar/Q&A session regarding the online process on Tuesday, November 15, 2022, 1:00 pm – 2:30 pm.

Join from the meeting link
https://stateofmo.webex.com/stateofmo/j.php?MTID=m2db3a8d7a9ebb09de234b4a6b7672597

Join by meeting number
Meeting number (access code): 2474 027 7616
Meeting password: W4mbfuJ2Hk5

Join by phone
1-650-479-3207 Call-in toll number (US/Canada)
+1-312-535-8110 United States Toll (Chicago)

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. MDS and NHSN data for 4/1/22 through 6/30/22 must be submitted no later than 11:59 p.m. on November 15, 2022.

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Assessment Submission and Processing (ASAP) system to the Quality Improvement Evaluation System (QIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable CASPER reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

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.

More information about SNF QRP can be found on the following webpages:
CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

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 7/1/22 through 9/30/22 is due November 14, 2022.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

More information about PBJ can be found on the following webpages:
CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

November 8, 2022: Protecting Seniors from Financial Abuse and Fraud
Presenter: Lauree Peterson-Sakai, VOYCE Board Chair

Financial fraud is the fastest-growing form of elder abuse. Broadly defined, financial elder abuse is when someone illegally or improperly uses a vulnerable senior’s money or other property. Financial scams targeting seniors are prevalent and costly. The FBI estimates that seniors lose more than $3 billion each year to fraudsters. Scammers go after seniors because they believe older adults have a significant amount of money in their accounts. Unfortunately, seniors are susceptible to financial fraud due to higher levels of trust in those appearing to be official representatives of legitimate organizations and due to the ever increasingly complex methods fraudsters use to appear legitimate.

 

December 13, 2022: Signs of Abuse – How to Identify the Signs of Abuse and Protect Your Loved One
Presenter: Robin Pendelton, Training Technician, Missouri Department of Health and Senior Services

Abuse can happen to any older person. Knowing how to identify the different types of abuse, how to recognize the signs, and where to get help is vital. Abuse can happen to any older person, by a loved one, a hired caregiver, or a stranger. Abuse can happen at home, at a relative’s home, or in an eldercare facility. There are many different types of abuse including physical, emotional, sexual, abandonment, financial, and neglect.

November 15, 2022: Implementation and Use of Enhanced Barrier Precautions in Nursing Homes
Presenters: Abimbola (Bola) Ogundimu, DrPH, RN, CIC, CPHQ; Division of Healthcare Quality Promotion, CDC; Heather Jones, DNP, NP-C; Division of Healthcare Quality Promotion, CDC; and Linda Behan BSN, RN, CIC; Consultant; Long Term Care Infection Prevention, LLC
Moderator: Kara Jacobs Slifka, MD, MPH; Division of Healthcare Quality Promotion, CDC

You are invited to a webinar discussing Enhanced Barrier Precautions in nursing homes. Enhanced Barrier Precautions protect nursing home residents and staff from germs that can cause serious infections and are hard to treat.

Join for a detailed review and discussion about this CDC infection prevention and control recommendation. In addition, hear directly from a long-term care Infection Preventionist about her successes and challenges implementing Enhanced Barrier Precautions in several nursing homes. Presentations will be followed by a conversation with the experts about frequently asked questions from the field.

November 18, 2022: Person Centered Care While Individualizing Activities Year Round
Location: Cape Girardeau

This group of activities professionals will share ideas on how to individualize an activity program to meet resident’s needs. With the upcoming holiday season, they will focus on activities that are fun, engaging, and person centered throughout the holiday season as well as throughout the entire year. Come prepared to share your robust activity program ideas and learn how to develop activities program that residents can’t resist.

Memorandum Summary

  • CMS is committed to taking critical steps to protect vulnerable individuals to ensure America’s health care facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE).
  • On November 5, 2021, CMS published an interim final rule with comment period (IFC). This rule establishes requirements regarding COVID-19 vaccine immunization of staff among Medicare- and Medicaid-certified providers and suppliers.
  • CMS is revising its guidance and survey procedures for all provider types related to assessing and maintaining compliance with the staff vaccination regulatory requirements.
  • This memorandum replaces memoranda QSO 22-07-ALL Revised, and QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised to consolidate the information into a single memorandum. The guidance in this memorandum applies to all states.

Please view the latest CMS memo regarding revisions to SSF program at https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/revised-guidance-staff-vaccination-requirements.

Please be aware that the upcoming NHSN application update has been pushed back, so the demographics fields (gender, race, and ethnicity) in the Person-Level (Event-Level) COVID-19 Vaccination Forms will not become required for existing records to save and submit data until after the application release, the evening of October 27, 2022.

As a reminder, the demographics fields will only be required for all individuals without an end date or discharge date. These fields will not be required for individuals who are no longer in the facility (i.e., those with an end date or discharge date). Please keep in mind that you may select ‘Unknown’ if you are unable to obtain this information.

Please note that the use of the Person-Level Vaccination Forms remains optional, and facilities are welcome to continue using the aggregate weekly summary forms to submit COVID-19 vaccination data.

New Person-Level Vaccination Form Resources

We are also excited to let you know that two new resources are being posted to the NHSN Long-Term Care Vaccination website by the end of this week:

  • Person-Level (Event-Level) Vaccination Form Table of Instructions: Healthcare Personnel
  • Person-Level (Event-Level) Vaccination Form Table of Instructions: Residents

These new Table of Instructions (TOI) documents can be used to help users enter and manage their person-level vaccination data and contain instructions for each column you see on the Person-Level Vaccination Forms.

Additional NHSN Resources: Person-Level Vaccination Forms

Training:

CSV Materials:

If you have any questions, please reach out to nhsn@cdc.gov and include the subject line “Person-Level Vaccination Forms”. Thank you for your continued efforts to report vaccination data in NHSN.

This message contains reporting deadline reminders for the CMS Quality Reporting Programs. The National Healthcare Safety Network (NHSN) encourages facilities to enter data in timely manner ahead of the deadlines in order to ensure data completion and accuracy. Make sure to allow ample time before the deadline to review, and if necessary, correct your HAI data. Data entered in NHSN after the submission deadline are not sent to CMS and will not be used in CMS pay-for-reporting or pay-for-performance programs. Data can be reviewed by using the Analysis reports within NHSN.

If you are unable to enter data into NHSN, it is possible that your Facility Administrator or Patient Safety Primary Contact has not accepted the updated NHSN Agreement to Participate and Consent. For questions or assistance with the updated Consent form and/or reassignment of the Facility Administrator or Primary Contact, please contact nhsn@cdc.gov as soon as possible.

The following data must be entered into NHSN by November 15, 2022, for facilities that participate in certain CMS quality reporting programs.

Long-Term Acute Care Facilities (LTACs/LTCHs) that participate in the Long-Term Care Hospital Quality Reporting Program:
2022 Quarter 2 (April 1 – June 30) CLABSI and CAUTI data (all bedded inpatient locations)
2022 Quarter 2 (April 1 – June 30) C. difficile LabID Events (FacWideIN, all healthcare-onset, and community-onset)
2022 Quarter 2 (April 1 – June 30) COVID-19 Vaccination Coverage Among Healthcare Personnel

Skilled Nursing Facilities (SNFs) that participate in the Skilled Nursing Facility Quality Reporting Program:
2022 Quarter 2 (April 1 – June 30) COVID-19 Vaccination Coverage Among Healthcare Personnel

Please ensure that at least one individual at your facility can access NHSN via their Secure Access Management Services (SAMS) account and has been assigned appropriate user rights in NHSN to enter and view your facility’s data. To guarantee that your data is accurately entered into NHSN, verify that; 1) your monthly reporting plans are complete; 2) you’ve entered appropriate summary and event data or checked the appropriate no events boxes; and 3) you’ve cleared all alerts from your NHSN facility homepage. For additional guidance on ensuring your data are accurately sent to CMS for Quality Reporting purposes, please visit our website and navigate to the appropriate section(s) for your facility type: https://www.cdc.gov/nhsn/cms/index.html.

If you have any questions, please contact the NHSN Helpdesk: NHSN@cdc.gov. The NHSN Helpdesk is staffed Mondays thru Fridays, 7 am-5 pm ET, excluding Federal Holidays.

As noted in the CMS memo QSO-22-19-NH Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide, CMS revised the guidance in Chapter 5 and related exhibits of the State Operations Manual (SOM) to strengthen the oversight of nursing home complaints and Facility Reported Incidents (FRIs). Beginning October 24, 2022, nursing homes will be required to submit the following information:

FRI – Initial Report

When reporting FRIs to the state agency, nursing homes must provide as much information as possible, to the best of its knowledge at the time of submission of the report, so the state agency can initiate action necessary to oversee the protection of nursing home residents. Initial reports must be reported immediately but not later than two hours if the allegation is abuse or the incident resulted in serious bodily injury, or not later than 24 hours if the allegation is not abuse or the incident did not result in serious bodily injury. “Serious bodily injury” means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse.

Information to include in the initial report:

  • Facility name, address, and contact information of the reporter (including email address and after hours phone number if not in the facility);
  • Type of allegation (physical abuse, sexual abuse, mental/verbal abuse, deprivation of goods and services by staff, neglect, misappropriation of resident property or exploitation, injury of unknown source, suspected crime);
  • Date and time when staff became aware of the incident, name of staff person to whom the information was reported, and name of person who made the allegation;
  • Date and time administrator was notified of the incident and by whom;
  • Alleged victim(s) name, date of birth, and current location;
  • Alleged perpetrator(s) name, position, contact information;
  • When and where the incident occurred and names of any witnesses;
  • Brief description of the incident;
  • Describe any type of injury (bruise, scratch, laceration, puncture wound, fracture, bleeding, redness on the skin, etc.);
  • Describe any changes in resident behavior indicating a change in the resident’s normal baseline (crying, expressions or displays of fear, cowering, anger, withdrawal, difficulty sleeping, etc.);
  • Describe all steps taken to immediately ensure protection of resident(s), such steps could include:
  • Immediate assessment of the alleged victim and provision of medical treatment as necessary;
  • Evaluation of whether the alleged victim feels safe and if he/she does not feel safe, taking immediate steps to protect the resident, such as a room relocation and/or increased supervision;
  • Immediate notification to the alleged perpetrator’s (if a resident) and/or the alleged victim’s physician and the resident representative when there is injury, a significant change in condition or status, and/or a need to alter treatment significantly;
  • If the alleged perpetrator is facility staff, removal of the alleged perpetrator’s access to the alleged victim and other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents;
  • If the alleged perpetrator is a resident or visitor, removal of the alleged perpetrator’s access to the alleged victim and, as appropriate, other residents and assurance that ongoing safety and protection is provided for the alleged victim and other residents;
  • Other measures the facility is taking to prevent further potential abuse, neglect, exploitation, and misappropriation of resident property.
  • Notification to law enforcement (if applicable), including date/time, agency name, report number, and name/title of person who reported to law enforcement;
  • Other agencies notified (Ombudsman, Adult Protective Services), including date/time and agency name.

Follow-up Investigation Report

Within five business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to, the following:

  • Additional/updated information (any additional outcomes to the resident(s) such as physical or mental harm, whether it was reported to the resident’s representative);
  • Steps taken to investigate the allegation including a summary of interview(s) with the resident/responsible party, witnesses, alleged perpetrator, other residents in contact with the AP, staff responsible for oversight and supervision of residents and the AP;
  • If available, include summary of hospital/medical progress notes, discharge summaries, law enforcement reports, and death reports;
  • Provide a brief conclusion of the investigation and indicate if the findings were verified, not verified, or inconclusive and how this was determined;
  • Provide in detail all corrective actions taken;
  • Describe any action(s) taken as a result of the investigation or allegation;
  • Describe the plan for oversight of implementation of corrective action, if the allegation is verified;
  • As a result of a verified finding of abuse, such as physical, sexual or mental abuse, identify counseling or other interventions planned and implemented to assist the resident;
  • If systemic actions (e.g., changes to facility staffing patterns, changes in facility policies, training) were identified that require correction, identify the steps that have been taken to address the systems;
  • If the allegation was reported to law enforcement or another state agency, where applicable and if available, what is the status or provide conclusions of their investigation.
  • Name of the facility individual primarily responsible for conducting the investigation;
  • Name of person submitting report, date and time of submission, and contact number/email address.

Please note: We are in the process of developing forms for initial reporting and for follow-up reporting that all Missouri LTC homes (including state-licensed only) will be able to utilize for FRIs. We will release these forms at a later date and will also schedule a webinar to discuss this information. Please review the memo in its entirety and reach out to your regional office with any questions.

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/revised-long-term-care-surveyor-guidance-revisions-surveyor-guidance-phases-2-3-arbitration

CDC hosted a webinar on the NHSN surveillance definition of up to date COVID-19 vaccination status on October 13, 2022. We would like to provide some important reminders on how to apply these definitions for the purpose of NHSN surveillance.

NHSN’s surveillance definition of up to date COVID-19 vaccination status is based on CDC’s clinical considerations and up to date definition for the first day of the reporting quarter. Please be sure to report up to date vaccination status in NHSN according to the definition for the reporting period associated with the reporting weeks you are submitting data for. Please refer to the definitions of key terms related to COVID-19 vaccination for the purpose of NHSN public health surveillance: https://www.cdc.gov/nhsn/pdfs/hps/covidvax/UpToDateGuidance-May2022-508.pdf.

New Up to Date Definition for Quarter 4

Individuals are considered up to date with their COVID-19 vaccines during the NHSN surveillance period of September 26, 2022-December 25, 2022 if they have received an updated (bivalent) booster dose OR if they received their last monovalent booster dose less than 2 months ago, OR if they completed their primary series less than 2 months ago. See table below. Changes for Quarter 4 of 2022 are highlighted in yellow.

Reporting deadline for Quarter 2 of 2022

As a reminder, for facilities participating in a CMS quality reporting program, the reporting deadline for COVID-19 Vaccination Coverage among Healthcare Personnel for Quarter 2 2022 (April 1, 2022-June 30, 2022) is on November 15, 2022. Highlighted in yellow below.

Data Tracking Worksheet

We are currently working to update the Data Tracking Worksheet. Stay tuned to CDC NHSN emails and check the CDC NHSN webpage often for updates.

Frequency of Reporting COVID-19 Vaccination Data:

The frequency of reporting COVID-19 vaccination data has not changed. NHSN allows for, and encourages, weekly submission of COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module.

Beginning on October 1, 2021, facility types that are part of the CMS Inpatient Quality Reporting Program, Inpatient Psychiatric Facility Quality Reporting Program, Inpatient Rehabilitation Facility Quality Reporting Program, or Long-term Acute Care Quality Reporting Program will need to submit COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module for at least one week per month to fulfill CMS reporting requirements. Beginning on January 1, 2022, ambulatory surgery centers are also required to submit COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module for at least one week per month to fulfill CMS reporting requirements.

Facilities can select any week within the month to report data. A week is designated as belonging to the month of the week-end date. For example, reporting data for the week of September 27-October 3 is considered as submitting data for a week in October.

COVID-19 vaccination data should be submitted by the end of the quarter as defined by CMS.

NHSN COVID-19 Vaccination Resources:

Please visit the Weekly HCP COVID-19 Vaccination Resource page for additional information: https://www.cdc.gov/nhsn/hps/weekly-covid-vac/index.html#anchor_93402.

Please pay particular attention to the COVID-19 Vaccination Modules Key Terms: https://www.cdc.gov/nhsn/pdfs/hps/covidvax/UpToDateGuidance-May2022-508.pdf.

During the webinar we received some questions about COVID-19 Hospital Data. Please send any questions related to the upcoming transition of COVID-19 hospital data to NHSN@cdc.gov using the subject line “COVID-19 Hospital.” Resources and information can be found on the transition webpage: https://www.cdc.gov/nhsn/covid19/transition.html.

West Central MC5 Region

November 2, 2022: Are We Making Progress or Spinning Our Wheels?
Presenter: Carol Scott, BS, Former MO Ombudsman, Trainer

This presentation will take a look at the past and discuss what the future can hold. Culture change doesn’t have an end date. It’s a continuous road that organizations must commit to on a daily basis.

 

Farmington MC Region

November 4, 2022: Psychiatry and Culture Change
Presenter: Gabe Crawford, NP

This program will give attendees the opportunity to learn new approaches to psychiatry related to culture change. Attendees will learn alternate treatments for dementia residents and will learn how to decrease the use of psychotropics.