QRP Updates
A Quick Reference Guide for Skilled Nursing Facilities (SNFs) is now available. This guide include frequently asked questions, information on QRP help desks, and helpful links to additional resources for the QRP.
Category: Long Term Care Blog
QRP – MDS Submission
QRP – MDS Submission
The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Set (MDS) assessment data for October-December (Q4) of calendar year (CY) 2016 are due with this submission deadline. All data must be submitted no later than 11:59 p.m. Pacific Standard Time on May 15, 2017.
View the list of measures required for this deadline on the SNF Quality Reporting Program 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.html.
As a reminder, it is recommended that providers run the applicable CMS CASPER validation reports prior to each quarterly reporting deadline to ensure that all required data has been submitted. Providers are also encouraged to verify all facility information prior to submission, including their CCN and facility name. Only successful submissions will count toward your Annual Payment Update requirement.
For more information, view https://www.qtso.com/download/mds/MDS_3.0_Helpful_Hints.pdf
S&C Memo: 17-25-NH: Electronic Staffing Submission – Payroll-Based Journal Update
S&C Memo: 17-25-NH: Electronic Staffing Submission – Payroll-Based Journal Update
Memorandum Summary
- Mandatory staffing data submission through the Payroll-Based Journal began July 1, 2016. Providers are reminded that they have until the 45th day after the end of each quarter to submit data.
- To help providers improve their submissions, the Centers for Medicare & Medicaid Services (CMS) is providing feedback on each facility’s data through their monthly Provider Preview reports.
- The Nursing Home Compare website now reflects whether providers have submitted data by the required deadline. Additionally, providers that have not submitted any data for two consecutive deadlines will have their overall and staffing star ratings suppressed.
- We are updating the data submission requirements related to hire and termination dates, and converting three job codes as optional for submission.
Please see the memo attached for more details or visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-25.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
Healthcare Associated Infections Survey
Healthcare Associated Infections Survey
The MU Sinclair School of Nursing invites your participation in a brief online survey to identify online educational materials you would find most helpful as you seek to prevent and manage healthcare associated infections (HAIs) in your particular work setting. Based on the results of the survey, selected learning resources will be developed and made available in an easily accessible format on the School’s HAI website.
This online survey is at https://muno.wufoo.com/forms/needs-assessment-for-hai-educational-resources/ and will take no more than 5 minutes of your valuable time.
The due date for your input is May 3, 2017.
If you have any questions, please feel free to email www.nursingoutreach.missouri.edu or call 573-882-0215 and ask for Todd. Thank you for your important input. We pledge to use as we attempt to provide what you ask for!
Farewell to Kristen Edwards
Farewell to Kristen Edwards
Kristen Edwards has accepted a position outside state government and will be leaving the Section on May 1. We will definitely miss Kristen and appreciate the fine work she has done for us. Shelly Williamson will serve as the Section’s Interim Administrator until the position is filled.
New Vulnerable Citizens Services Unit Within Securities Division
New Vulnerable Citizens Services Unit Within Securities Division
Secretary of State Jay Ashcroft announced that the Securities Division of the Office of the Secretary of State is boosting investor protection and education through the formation of its new Vulnerable Citizens Services unit.
Please see the Securities Release attached for more details.
S&C 17-22-ALL: Save the Date- Medicare Learning Network (MLN) Conference Call National Provider Call (NPC) for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
S&C 17-22-ALL: Save the Date- Medicare Learning Network (MLN) Conference Call National Provider Call (NPC) for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
- The Centers for Medicare & Medicaid Services (CMS) MLN will host a NPC for the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule.
- The calls are open to providers, suppliers, State Survey Agencies (SAs), Regional Offices (ROs) and the general public.
- CMS has received multiple requests by providers, suppliers, States and associations to present at annual conferences regarding the new final rule for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers. Due to the large number of speaking requests, CMS is offering an additional learning session through the MLN. During the additional session, we will provide an overview of the final rule and discuss the requirements for meeting the training and testing requirements by the implementation date of November 15, 2016.
Date: Thursday, April 27, 2017
Time: 2:30pm-3:30pm ET
Topic: Review of provisions and focus on Training and Testing Requirements
Please see the attached memo or you may visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-22.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C 17-21-ALL: Information to Assist Providers and Suppliers in Meeting the New Training and Testing Requirements of the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
S&C 17-21-ALL: Information to Assist Providers and Suppliers in Meeting the New Training and Testing Requirements of the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
- Information for Implementation: The Centers for Medicare & Medicaid Services (CMS) is providing information to assist providers and suppliers in meeting the Training and Testing requirements of the new Emergency Preparedness Final Rule that was published on September 16, 2016 (81 FR 63860) and became effective on November 15, 2016.
Please see the S&C attached or you may visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-21.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
RN Licenses Expire April 30, 2017
RN Licenses Expire April 30, 2017
Nurses may go to www.nursys.com and enroll in e-Notify in order to receive notification when their license is actually renewed. It takes 3-4 business days after the renewal is received before the license is renewed. The MO Board of Nursing no longer provides a license card.
NFPA Notes
NFPA Notes
All areas of the building shall be accessible: All areas of the facility must be accessible during all shifts by the charge nurse (or another designated staff, i.e. security) so that in the case of a fire, staff (including emergency response staff) can find and fight the fire (when possible). Reports show that recently facilities in varying areas of the country have had fires in areas that were locked (such as laundry rooms or the kitchen) during the evening/night shifts. When the fire alarm system sounded, staff did not have a key accessible to gain entry into the locked areas causing a delay in the response time.
- NFPA 2012 101, 19.7.2.1.1
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
- NFPA Standard: 2012 NFPA 101, 19.1.1.3.1
All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.
- NFPA 101 2012, 4.8.2.1
Emergency plans shall include the following:
(1) Procedures for reporting of emergencies
(2) Occupant and staff response to emergencies
(3) Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4) Appropriateness of the use of elevators
(5) Design and conduct of fire drills
(6) Type and coverage of building fire protection systems
(7) Other items required by the authority having jurisdiction
- NFPA 2012 101, 7.2.1.1.3.2
Where means of egress doors are locked in a building that is not considered occupied, occupants shall not be locked beyond their control in buildings or building spaces, except for lockups in accordance with 22.4.5 and 23.4.5, detention and correctional occupancies, and health care occupancies.
Fire Reporting
Fire Reporting
19 CSR 30-85.022 (2) (F) for Skilled Nursing Facilities/Intermediate Care Facilities (SNFs/ICFs) and 19 CSR 30-86.022 (2)(C) for Residential Care Facilities (RCFs) and Assisted Living Facilities (ALFs) require that all facilities shall notify the department immediately after the emergency is addressed if there is a fire in the facility or premises and shall submit a complete written fire report (attached) to the department within seven (7) days of the fire, regardless of the size of the fire or the loss involved.
The Section for Long-Term Regulation defines fire as used in relation to fire/safety requirements as follows: Fire is the active principle of burning, characterized by combustion. This energy is evident when heat and/or smoke and/or light are present as the result of combustion. Smoke is a product of combustion, and any time smoke is given off, combustion has occurred whether or not there has been a visible flame. Besides the obvious, some often-overlooked examples of fire include but are not limited to the following:
- Smoking air conditioner unit or heater (whether or not the fire department responded);
- Smoking pads or mop heads in the dryer (whether or not the fire department responded); and
- Smoking trash in a waste receptacle (whether or not the fire department responded).
The facility submitted fire report must include the following:
- A brief narrative of the event in the comments section of the report or in an attachment;
- Documentation regarding whether or not the fire alarm and/or sprinkler system activated (if applicable) and if/when the system was back in service (if applicable);
- In addition, the narrative must show whether or not fire extinguishers were used, and if so, when they were recharged or replaced;
- A copy of the fire department report if the fire department responded; and
- If a fire can be attributed to a particular person, the report must include identifying information for that person.
Expiring Administrator Licenses
Expiring Administrator Licenses
Administrator licenses expiring June 30, 2017 are up for license renewal. License renewal notifications were sent via email to the email address on file. Please note that once the renewal is complete, an electronic license will be issued via email. The Board office will no longer mail paper licenses.
Please visit the Missouri Board of Nursing Home Administrator’s web page for the renewal instructions and renewal application at http://health.mo.gov/bnha. Remember to notify the Board office at BNHA@health.mo.gov with changes in your contact information, especially the email address.
Regulation Unit: Exceptions & Second Businesses – Email Correspondence
Regulation Unit: Exceptions & Second Businesses – Email Correspondence
The Regulation Unit is issuing all approval letters, approval certificates, reminder letters, and any other correspondence related to exceptions and second businesses via email. This email process will be the primary mode of communication, when possible. The Regulation Unit staff will contact facility administrators/operators to obtain a viable email address in order to issue correspondence by email. Original approval letters/certificates will no longer be mailed.
For approvals received via email, the facility administrator/operator must complete the following for:
- Exception approval letters/certificates: Facility administrators/operators must print the approval certificate and post it alongside the facility license as required by regulation. The approval letter must be made available to SLCR staff, upon request.
- Second business approval letters: Facility administrators/operators must make the approval letter available to SLCR staff, upon request.
Should you have any questions about this process, please contact the Regulation Unit at (573) 526-8523 or email RegulationUnit@health.mo.gov.
HHS OIG Hotline Scam
HHS OIG Hotline Scam
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently confirmed that the HHS OIG Hotline telephone number is being used as part of a telephone spoofing scam targeting individuals throughout the country. These scammers represent themselves as HHS OIG Hotline employees and can alter the appearance of the caller ID to make it seem as if the call is coming from the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477). The perpetrator may use various tactics to obtain or verify the victim’s personal information, which can then be used to steal money from an individual’s bank account or for other fraudulent activity. HHS OIG takes this matter seriously. We are actively investigating this matter and intend to have the perpetrators prosecuted.
It is important to know that HHS OIG will not use the HHS OIG Hotline telephone number to make outgoing calls and individuals should not answer calls from 1-800-HHS-TIPS (1-800-447-8477). We encourage the public to remain vigilant, protect their personal information, and guard against providing personal information during calls that purport to be from the HHS OIG Hotline telephone number. We also remind the public that it is still safe to call into the HHS OIG Hotline to report fraud. We particularly encourage those who believe they may have been a victim of the telephone spoofing scam to report that information to us through the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477) or spoof@oig.hhs.gov. Individuals may also file a complaint with the Federal Trade Commission 1-877-FTC-HELP (1-877-382-4357).
More information is available on the OIG Consumer Alerts webpage.
Train the Trainer Workshop Series
Train the Trainer Workshop Series
- June 13-14, 2017: CNA/CMT Instructor
- June 15, 2017: Clinical Supervisor
VOYCE Conference
VOYCE Conference
- June 8-9, 2017: 2017 Changing the Landscape of Long Term Care Conference
- Location: Renaissance St. Louis Airport Hotel and Friendship Village Sunset Hills
Hear national and local experts discuss dynamic strategies, innovative tools and available long-term care options.
The format has been set with two educational tracks throughout the day; one for professionals working in long-term care and one for the general public who are looking for answers to the complexity of long-term care.
See the registration packet for the full description of the topics and the national and local expert speakers.
Throughout the day there are multiple opportunities to interact with exhibitors who showcase long-term care services across Greater St. Louis.
In addition to hearing thought-provoking speakers, facility administrators and social workers earn 7.25 CEUs.
Registration for all includes breakfast and lunch.
- Register online to join over 300 expected attendees
- Sign Up as a Sponsor to reach the long-term care community including families needing your services
Please see the VOYCE event page for more information.
MU Leadership Development Academy for Long-Term Care
MU Leadership Development Academy for Long-Term Care
- April 2016 – October 2016: Kansas City and Springfield
Enrollment is now open for the next professional development certificate program offered by the University of Missouri. Long-term care can be challenging, but the academy will help you better manage daily crises and get the most out of your employees. The academy has been proven to increase leadership skills and improve confidence, which will help to create a working environment that encourages teamwork and quality improvement.
Please see the brochure and registration details on the MU Leadership Development Academy’s web page here.
Conversations with Carmen
Conversations with Carmen
- April 14, 2017: From Annoyances to Conflict: How Much is Miscommunication Costing Your Organization?
- Guest Presenter: Ray Rusin, Quality Training Associates; Certified Workplace Conflict Mediator, retired RI Survey Agency Director
Day-to-day petty annoyances are experienced by each of us and are a fact of life. Without a strategic focus on recognizing and dealing with natural annoyances early, many grow into costly conflict events negatively impacting residents’ quality of care and quality of life. We will discuss how ordinary annoyances interrupt the smooth operation of any organization, how to best prepare team members for coping with annoyances and ways to wisely handle any resulting conflicts. Find out what conflict may be costing your organization.
For more information and registration, please see the event details here.
MALA Training & Events
MALA Training & Events
May 3, 2017: Level I Medication Aide / Insulin Administration Train the Trainer Workshop
More information about these and other training events can be found on MALA’s training & event webpage.
S&C Memo 17-20-NH: Fiscal Year (FY) 2017 Special Focus Facility (SFF) Program Update
S&C Memo 17-20-NH: Fiscal Year (FY) 2017 Special Focus Facility (SFF) Program Update
- Total SFF slots and candidates for each State: The number of designated slots and candidates for FY 2017 (see Appendix A) will not change from those effective since May 1, 2014.
- Initial selection notice: The State Survey Agency (SA) must notify the provider in writing of their SFF selection and conduct a meeting (either onsite or via telephone) with the nursing home’s accountable parties, and the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO), if the RO wants to be included.
- Graduation from the SFF program: Once an SFF has completed two consecutive standard surveys with no deficiencies cited at a scope and severity of “F” or greater (or “G” or greater for Life Safety Code (LSC) deficiencies), and has had no complaint surveys with deficiencies at “F” or greater (or “G” or greater for Life Safety Code (LSC) deficiencies) in between those two standard surveys, the facility will graduate from the SFF program. However, if the only deficiency preventing graduation is an “F” level deficiency for food safety requirements (42 CFR §483.60(i) Tag F371), the RO has discretion to allow the facility to graduate from the SFF program. F371 deficiencies at a “G” level or greater will prevent the facility from graduating from the SFF program.
- Authority for termination: Consistent with longstanding authority, the CMS ROs may use discretionary termination for SFFs (or any facility) if necessary to protect resident health and safety.
Please see the S&C memo and appendices attached for more details or visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-20.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
Nursing Home Quality Improvement Spotlight On…
Reducing Antipsychotic Medication Use – Additional Resources
Multiple resources are available to educate staff about reducing antipsychotic medication use. Click on the following links for more information:
Consumer Voice Webinar
Consumer Voice Webinar
- March 15, 2017: A Deeper Dive into the Revised Federal Nursing Home Regulations-Part II
- Presenters: Eric Carlson, Directing Attorney, Justice in Aging
Toby Edelman, Senior Policy Attorney, Center for Medicare Advocacy
Robyn Grant, Director of Public Policy and Advocacy, Consumer Voice
Lori Smetanka, Executive Director, Consumer Voice
The Consumer Voice, Justice in Aging, and Center for Medicare Advocacy are continuing to examine the revised federal nursing home regulations the Centers for Medicare & Medicaid Services released on October 4, 2016. In this webinar, we will take a closer look at the following sections of the revised regulations:
- Admission, Return, and Bedhold
- Visitation Rights
- Rehabilitation Services
Join this webinar to hear experts from all three organizations discuss changes in the regulations and their impact on the care delivered to consumers.
Space is limited. Register here.
Licensure and Certification Unit Update
Licensure and Certification Unit Update
Effective immediately the Licensure and Certification Unit will be conducting business primarily by email. Licensure and Certification Unit staff will be contacting facilities and/or operators to obtain email addresses. Items that will be emailed to providers include the facility license, relicensure application reminder letters, and any other correspondence when possible. Facility administrators/operators shall print the facility license and post as required in Chapter 198.015.5, RSMo., “Licenses shall be posted in a conspicuous place on the licensed premises”, as copies will not be mailed. If you have any questions about this process, please email ltcapplication@health.mo.gov.
New QIPMO Newsletter – February 2017
New QIPMO Newsletter – February 2017
The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls – Volume 4, Issue 2.
Please visit QIPMO’s website here for this and other previous newsletters.
Nursing Home Quality Improvement Spotlight On…
Reducing Inappropriate Use of Antipsychotic Medications – Full Assessment
To address the ongoing challenge of reducing inappropriate antipsychotic medications, staff on all shifts should fully assess and learn as much as possible about a resident, including interviewing the resident, family and friends. These steps assist staff in understanding the different behaviors a resident may exhibit. To learn more about assessing a resident’s goals and needs, click on the following links.