January 4, 2023: 2023 Train the Trainer
March 1, 2023: 2023 Train the Trainer
May 10, 2023: 2023 Train the Trainer
July 12, 2023: 2023 Train the Trainer
September 20, 2023: 2023 Train the Trainer
December 6, 2023: 2023 Train the Trainer
Participants must receive approval in order to attend this workshop. Those wishing to attend must submit the application and all other necessary paperwork to MALA at least two weeks prior to the workshop date.
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.
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.
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.
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.***
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.
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.
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.
Show-Me ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing to connect interdisciplinary teams of experts with clinicians and other healthcare professionals. Together participants and teams collaborate in interactive, individualized, case-based learning environments to develop skills and discuss best practices. Some ECHOs meet every week, some twice a month, and some have a completely different timeline. We know how challenging it can be to commit time away from your other responsibilities, but by building and supporting a strong community of learners, the ECHO model improves care access, quality, and efficiency. Show-Me ECHO learning sessions offer free continuing education and are provided at no cost to participating sites and individuals. Check out the ECHO schedule to see when you can attend the next session!
PAC/LTC: Post-Acute & Long-Term Care
2nd & 4th Thursdays: 9:30 am – 10:30 am
Topics or Learning and Discussion:
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.
October 11, 2022: Residents’ Rights and the Intersection of State Policy
Presenters: Chien Y. Hung, MSW, MA-G, RYT, Program Director, VOYCE; and Nicole Lynch, Policy and Advocacy Director, VOYCE
October is Residents’ Rights Month, an annual initiative highlighting the legally enshrined rights of long-term care residents throughout the United States. Residents’ Rights Month is an annual event designated by the Consumer Voice and is celebrated to honor residents living in all long-term care facilities and consumers receiving services in their home or community. It is a time for celebration and recognition, offering an opportunity for every facility to focus on and celebrate awareness of dignity, respect, and the value of each resident. Residents’ Rights are guaranteed by the federal 1987 Nursing Home Reform Law.
In this presentation, we will explore Residents’ Rights and examine some of the state laws VOYCE has successfully advocated for, including the Essential Caregivers Program Act and the Authorized Electronic Monitoring in Long-Term Care Facilities Act.
We are aware that some providers are experiencing issues with the link to the COMRU online application. We apologize for this inconvenience. Please first try the following alternative link to see if this will work to access the online application: https://redcapdrlltc.azurewebsites.net/redcap/surveys/?s=RNMP48LRWY.
If this link does not work, please contact COMRU at COMRU@health.mo.gov for assistance.
We want to provide an update on the issues related to the Person-Level (Event-Level) COVID-19 Vaccination Forms that occurred following the recent NHSN application update. These issues are now resolved, and users can do all of the following:
As a reminder, users cannot delete rows. If you have incorrect data that needs to be removed, please do one of the following:
In addition, updated CSV materials for the Person-Level (Event-Level) COVID-19 Vaccination Forms are now posted to the website, and links are provided below. Please note that is it optional to use the CSV materials, as users can manage all data within the application without using the CSV files.
Resources:
All resources: https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html
Trainings:
Guidance:
.CSV variable description and file layout:
.CSV template and example – HCP:
.CSV template and example – Residents:
Please contact NHSN@cdc.gov with “COVID-19 Person-level Vaccination Forms” in the subject line with any additional questions or concerns. Thank you for your efforts with submitting data to the Weekly COVID-19 Vaccination Modules.
Below is important information regarding modifications to the Long-term Care Facility COVID-19 Module, and COVID-19 Vaccination Module. The changes described below will take effect after the September 2022 NHSN release. Resources on the NHSN LTCF COVID-19 Module webpage and the COVID-19 Vaccination Module webpage will be updated, where indicated, with revised forms, instructions, FAQs, and .CSV templates.
Point of Care (POC) Test Reporting Tool:
No enhancements
COVID-19 Pathway Data Reporting:
Please refer to the below data reporting pathways to learn about enhancements that will be made within each pathway.
Resident Impact and Facility Capacity Pathway:
The Primary Series Vaccination Status section of the Resident Impact and Facility Capacity Pathway has been revised with simplified language to account for the recent approval of the Novavax Vaccine. The reporting process for this pathway has not changed and users will not need to go back and make any revisions to their data. Please continue using the Table of Instructions, found on the LTCF COVID-19 Webpage, as a guide while reporting data for this pathway.
Staff and Personnel Impact Pathway:
No enhancements
Therapeutics Pathway:
For those that upload data via CSV files, please be sure to use the templates that are posted on the LTCF COVID-19 Module Webpage. The following therapeutics must be listed for each submission date within the CSV file.
Each Therapeutic should have a line within the CSV file:
State Veterans Homes COVID-19 Event Reporting Tool
No enhancements
Weekly NHSN COVID-19 Vaccination Data
Optional NHSN Person-Level (Event-Level) Vaccination Forms
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.
Beginning October 3, 2022, the Level 2 determination letters will be sent from Bock Associates instead of COMRU. The Level 2 determination letter will continue to be uploaded to the online application. If you have any questions regarding the change in the determination letter, please contact COMRU at 573-522-3092 (option #4).
Please ensure the processed online application and Level 2 screening has been printed/saved for your records. COMRU will begin purging the online system in October, so all Skilled Nursing Facilities (SNF) will need to have copies of these documents prior to them being deleted.
September 27, 2022: Person-Directed Leadership: Creating a Coaching Culture
October 4, 2022: Invest in Your Workforce for 2023
October 11, 2022: Communicating for Policy Success
Join Amanda Loomis of SWBR for a dynamic exploration of the ways that design can promote vitality and wellbeing for elders – and how small touches can go a long way toward revitalizing a nursing home, assisted living community, or other eldercare setting.
October 25, 2022: Oasis, Springfield
November 1, 2022: Holiday Inn Route 66, St. Louis
November 10, 2022: Stoney Creek, Independence
Co-sponsored by Missouri Health Care Association and Missouri Association of Nursing Home Administrators. For more info, please see the full brochure including registration here.
November 9, 2022: Missouri Alliance for the Dually Diagnosed (MOADD) Summit
Location: Holiday Inn Executive Center, Columbia
MOADD (Missouri Alliance for Dual Diagnosis) established in 2018, is a collaborative effort between Department of Mental Health (DMH) staff and DMH providers with interest in developing expertise in supporting individuals with dual intellectual/developmental disabilities (I/DD) and behavioral health diagnosis.
MOADD provides resources to assist providers to:
November 29-December 1, 2022: 2022 ALF Community Based Assessment Training
As required by 198.005 RSMo and 19 CSR 30‐86.047, residents of Assisted Living Facilities are required to undergo a community-based assessment performed by an appropriately trained and qualified individual. This individual must complete a DHSS approved 24‐ hour training program prior to performing resident assessments. The MALA ALF Assessment Training satisfies this regulatory requirement.