CMS S&C Memo 16-38-ALL

CMS S&C Memo 16-38-ALL:  Notification of Final Rule Published-Emergency Preparedness

 

CMS S&C Memo 16-37-ALL

CMS S&C Memo 16-37-ALL:  Office of Civil Rights (OCR) Clearance

LeadingAge MDS Webinar

Commonly Asked Questions on the MDS, M-Section

Webinar – November 10, 2016, 11:00 a.m. – 12:15 p.m. CT

Presenter: Pamela Scarborough,  American Medical Technologies

The purpose of this presentation is to provide education regarding commonly asked questions from clinicians about the MDS 3.0, M-Section and wounds.

 

Please find registration and more information here

RAI Manual Changes

QIPMO will be presenting two different webinars on changes to the RAI Manual that are being implemented October 1st, 2016.  One webinar will cover the new MDS Section GG and Delirium and the other webinar is on General MDS Manual Updates.  Both webinars will be presented on multiple days at different times.  There is no cost for the webinars.

To sign up for these webinars:

  • Section GG and Delirium, multiple dates and times from August 26, 2016 through September 9, 2016 visit enrollment webpage here .
  • General MDS Manual Updates, multiple dates and times from September 12 through September 28, 2016 visit enrollment webpage here.

CMS S&C Memo:16-33-NH: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff

  • Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s).
  • This CMS memo discusses the facility and State responsibilities related to the protection of residents

The CMS memo is available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-33.pdf.

CMS S&C Memo 16-31-NH: Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes

  • CMS is implementing a national policy that requires the use of federal enforcement remedies when one or more residents suffer significant harm.
  • This new policy is effective for all surveys completed on or after September 1, 2016.

For more information 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-16-31.html?DLPage=1&DLEntries=10&DLFilter=nh&DLSort=2&DLSortDir=descending.

CMS has published the updated Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual and forms which will be effective 10/1/2016

Section GG Part 1: www.youtube.com/watch?v=pNgQ3OSaxYg
Section GG Part 2: www.youtube.com/watch?v=M1JdQxjNOqE
Section GG Part 3: www.youtube.com/watch?v=ok3U2-mQymk
Section GG Part 4: www.youtube.com/watch?v=oRmMT_uYS8Y

New MDS Updates

Medication Classification Resources

The DRAFT RAI Manual v1.14 posted 5-11-16 and found at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html) and S&C 16-15-NH dated 3-25-16 and found at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-15.pdf include several websites CMS lists as resources for information on medications (including classification).

Page 881 of The Draft RAI Manual v1.14 includes the following medication resources:

Page 41 of S&C 16-15-NH includes the following medication resources:

If you have any questions about the above information, please contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail stacey.bryan@health.mo.gov.

New MDS Updates

New MDS 3.0 Quality Measure User’s Manual Available

The MDS 3.0 QM User’s Manual Version 10 was posted April 28, 2016, which includes new Quality Measures.  The MDS 3.0 QM User’s Manual v10.0 contains detailed specifications for the MDS 3.0 quality measures that are only MDS based.  The new manual can be found in the Download section at the bottom of the page at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/NursingHomeQualityInits/NHQIQualityMeasures.html.

 

New Measures Technical Specifications

There are also now QMs that are claims based in addition to being MDS based.  The specifications for these Quality Measures can be found in the download section at the bottom of the page at www.cms.gov/Medicare/Provider-Enrollment-and-certification/CertificationandComplianc/FSQRS.html.

 

Nursing Home Compare Five-Star Rating

Beginning in July 2016, five of the new measures (all except for the antianxiety medication measure), will be used in the calculation of the Quality Measure rating.  Gradual phase-in of the new measures will occur between July 2016 and January 2017.  Prior to July, the Technical Users’ Guide, which is also available in the downloads section of the CMS website (same link as above), will be updated to reflect the changes to the Quality Measure rating calculation.

 

Payroll-based Journal (PBJ)

Beginning in July 2016, all Medicare- and Medicaid-participating nursing homes must submit staffing

data to CMS through a new electronic system called the Payroll-based Journal (PBJ).  More information about staffing data submission is available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

For additional assistance with or questions related to PBJ registration process, please contact the QTSO Help Desk at 877-201-4721 or via email at help@qtso.com.

 

Draft RAI Manual v1.14

On May 11, 2016, CMS posted a new DRAFT RAI Manual v1.14 in the Related Links section at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html so that users can preview significant changes before they become effective October 1, 2016.  There are many item set changes, including the new Chapter 3, Section GG: Functional Abilities and Goals. Chapter 2 and Chapter 3, Section A provide information on the new Part A PPS Discharge assessment.  Please note that it does not include Appendices F and H or replacement pages, which will be published with the final version 1.14 in September 2016.

 

If you have any questions about the above information, please contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail stacey.bryan@health.mo.gov.

New MDS 3.0 Quality Measure User’s Manual Available

The MDS 3.0 QM User’s Manual Version 10 was posted April 28, 2016 which includes new Quality Measures.  The MDS 3.0 QM User’s Manual v10.0 contains detailed specifications for the MDS 3.0 quality measures.  The new manual can be found in the Download section at the bottom of the page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/NursingHomeQualityInits/NHQIQualityMeasures.html.

If you have any questions, please contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail stacey.bryan@health.mo.gov.

MDS Training

RAI Process from Start to Finish

                April 12-13, 2016:  Independence, MO
                June 28-29, 2016:  St. Louis, MO
                August 10-11, 2016:  Columbia, MO
                October 11-12, 2016:  Columbia, MO

This workshop will look at the RAI process from beginning to end.  The MDS is used for both a clinical assessment and a financial assessment and this workshop will discuss the rules on scheduling these assessments and meeting the requirements individually and combined. Item-by-item coding will be reviewed.  From coding the MDS, we will then look at the CAA to care plan process.

Medicare from Start to Finish

               March 22, 2016:  Columbia, MO
May 24, 2016:  Columbia, MO
July 13, 2016:  Blue Springs, MO
September 20, 2016:  St. Louis, MO
November 15, 2016:  Columbia, MO

This one day workshop will begin with how to gain access to and read the MDS reports from CASPER in order to self-audit your RAI process. The completion of the MDS is becoming more and more difficult and confusing. This workshop will help the MDS coordinator and other members of the interdisciplinary team to understand the admitting criteria and the ongoing documentation needs of the Medicare resident. The RAI process in relationship to Medicare is also confusing and errors can be a financial nightmare for facilities. This workshop will help clear up the confusion surrounding this process.

Please see the brochure here for more information.

ICD-10 CM Refresher

February 8-9, 2016:  Blue Springs, MO
February 10-11, 2016:  Springfield, MO
February 15-16, 2016:  St. Louis, MO
February 17-18, 2016:  Columbia, MO
This workshop is for long-term care staff, including nursing home administrators, MDS coordinators, medical records personnel, therapists, home health nurses and others who currently assign and/or use ICD-10 codes.

Please see the brochure here for more information including registration.

Updated MDS Information – additional

On October 1, 2015 a new version of the RAI Manual became effective, Version 1.13.  Most of the changes were minor but there is one important change to point out.  Prior to the update, Significant Change MDS’s were required if a resident enrolled in or discontinued hospice.  Those rules are still in effect, but now, a Significant Change MDS is also required when a resident changes hospice providers and remains a resident at the nursing home.  This new rule is in the RAI manual in Chapter 2 on page 21.  A Significant Change MDS may also be required in situations when the hospice providing services is purchased by another hospice provider.

The new manual can be found at:  www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.  Scroll to the bottom of the page.  The first link is the ENTIRE Manual.  The second link is just the pages that have been changed as of October 1, 2015.  You will also find a summary of the changes in the second link.

If you have any questions, you may contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail Stacey.bryan@health.mo.gov.

Updated MDS Information

Updated RAI Manual
On October 1, 2015, a new version of the RAI Manual became effective, Version 1.13.  The new manual can be found at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html towards the bottom of the page.  The first link is the ENTIRE Manual.  The second link is just the pages that have been changed.  Also, there is a summary of the changes with the second link.

Updated Quality Measure Manual
On October 1, 2015, a new version of the MDS 3.0 QM User’s Manual became effective, Version 9.0.  It can be found at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html towards the bottom of the page and click on the 4th download (MDS 3.0 QM User’s Manual V9.0) OR at the following address: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V90.pdf.

Updated MDS 3.0 Provider User’s Guide
Section 1 (Introduction), Section 5 (Error Messages) and Appendix A were updated in the MDS 3.0 Provider User’s Guide in September 2015.  The updated guide can be found at www.qtso.com/mdstrain.html.

If you have any questions regarding the updates, you may contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail stacey.bryan@health.mo.gov.

Nursing Home Quality Improvement Webinar

August 6, 2015:  Improving Immunizations in Nursing Homes (12:00 Noon-1:00 p.m. CT)

Join this webinar to learn how nursing homes can improve in immunization quality measures and processes.  You will hear nursing home leaders discuss best practices that can be implemented, as well as the Texas MDS clinical coordinator who will present additional information about MDS coding for these measures.

For more information, please visit the TMF website here and sign in.

CMS Memo S&C 15-40-NH: Information Only – Review and Status of Nursing Home Survey: Summary of Traditional and Quality Indicator Survey (QIS) Findings and Issues

For the past 10 years, the Centers for Medicare & Medicaid Services (CMS) and the States have used two standard survey processes that assess the quality of care and quality of life for nursing home residents.  The memo has a review of both the traditional survey and QIS processes.  CMS is continuing to make improvements to QIS to address the challenges, concerns and feedback we have received to optimize the effectiveness and efficiency of survey process.

The memo and attachment are both attached or you may visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-40.html?DLPage=4&DLEntries=10&DLSort=3&DLSortDir=descending.

Survey and Certification Memos

15-31:  Focused Dementia Care Survey Pilot (NH – 3/27/15)

Attached to this memo is a final report that outlines the basis for the Focused Dementia Care Survey Pilot, the process utilized, conclusions gathered based upon post-pilot data analysis, as well as next steps for the future.  The CMS plans to expand upon the work of the focused survey pilot and has invited States to conduct such surveys in FY2015 on a voluntary basis.  The expansion project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers.  Deficient practices noted during the surveys will result in relevant citations.  In the event that additional care concerns are identified during on-site reviews, those concerns will be investigated during the survey or will be referred to the SA as a complaint for further review.  The memo is attached here and one attachment is attached here.

15-34:  Grant Award: Reinvestment of Federal Civil Money Penalty (CMP) Funds to Benefit Nursing Home Residents (NH – 4/3/15)

The Centers for Medicare & Medicaid Services (CMS) invited proposals for a grant opportunity to utilize Federal CMP Funds for the support and further expansion of the National Partnership to Improve Dementia Care in Nursing Homes.  The Eden Alternative, Inc. was deemed to be the most eligible applicant and has been awarded a grant, in the amount of $293,129.00, for their project entitled, “Creating a Culture of Person-Directed Dementia Care.”  The memo is attached here.

15-35:  Implementation of Section 6106 of the Affordable Care Act – Collection of Staffing Data for Long Term Care Facilities (NH – 4/10/15)

In this memorandum, CMS notified States of the posting of technical specifications and related information for the electronic submission of staffing information based on payroll data.  This information is posted at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.  The memo is here.

MANHA’s Spring 1 day Seminars

  • April 9, 2015:  Nursing Home Compare 3.0 & New 5-Star Quality Rating Unveiled
    Location:  Ramada Oasis Hotel, Springfield, MO
  • April 10, 2015:  Nursing Home Compare 3.0 & New 5-Star Quality Rating Unveiled
    Location:  Harrah’s North Kansas City Hotel, North Kansas City, MO
  • April 15, 2015:  Nursing Home Compare 3.0 & New 5-Star Quality Rating Unveiled
    Location:  Comfort Inn, Macon, MO
  • April 16, 2015:  Nursing Home Compare 3.0 & New 5-Star Quality Rating Unveiled
    Location:  Sheraton Lakeside Chalet, St. Louis, MO
  • April 28, 2015:  Dementia:  Connecting Through Music
    Location:  Harrah’s North Kansas City Hotel, North Kansas City, MO
  • April 29, 2015:  Dementia:  Connecting Through Music
    Location:  Courtyard By Marriott, Columbia, MO
  • April 30, 2015:  Dementia:  Connecting Through Music
    Location:  Sheraton Lakeside Chalet, St. Louis, MO

The brochures are located here:  Nursing Home Compare 3.0 & New 5-Star Quality Rating Unveiled and Dementia: Connecting Through Music.
Please visit the MANHA’s Conventions & Seminars web pagefor more information.

QIPMO Newsletter – January 2015

The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls – Volume 2, Issue 2.  Topics in this issue include MDS Spotlight: Common Questions and Mistakes, Responsible Treatment of Urinary Tract Infections, the 3-D Picture, Let’s Hear it for Chapter Two, and Nicky Martin’s Questions from the Field.  Please visit QIPMO’s website here for this and other previous newsletters.

Long Term Care Facility Application for Medicare and Medicaid

Certified nursing facilities must complete the Long Term Care Facility Application for Medicare and Medicaid (CMS-671) at every annual resurvey.  At the time of the annual resurvey, the survey team leader provides the administrator with the application and instructions for its completion.  The application and instructions are also accessible at http://www.cms.hhs.gov/cmsforms/downloads/CMS671.pdf.

To avoid common errors when completing the application:

  • Fill out the form completely and answer every question. Print all numbers and other information legibly.
  • Facility staffing hours should only be reported for care provided in certified beds.  If a facility is distinct part (not fully certified), then staffing hours for the non-certified beds should not be reported.
  • Ensure all three boxes in each staffing category are completed under Column A, Services Provided. Enter a Y for Yes, or N for No.
    • Do not enter any information in the gray boxes.
    • If there are no staffing hours to report under Columns B, C and D leave the box blank – do not enter zeros in every blank box.
    • Enter all hours in whole numbers. Do not use decimals or fractions.
    • Staffing hours provided by hospice staff or private duty staff (not hired and paid for by the facility) should NOT be included.
    • Report actual hours worked (reference timesheets, electronic time records or calendar notes).
    • Salaried employees should report the actual hours they work.
    • The form must be signed.

It is very important to report data accurately on the application.  The Centers for Medicare & Medicaid Services (CMS) uses this data for calculation of staffing hours on Nursing Home Compare and the star ratings.  This information is available on line, http://www.medicare.gov/nursinghomecompare/search.html.

This coming year, CMS will require Missouri to conduct Minimum Data Set (MDS) Focused Surveys that will be sampled to verify the staffing data self-reported by a nursing home during the most recent recertification survey.

If you have any questions regarding completing the Long Term Care Facility Application for Medicare and Medicaid (CMS-671), please speak to the survey team leader during the survey, or contact Tracy Niekamp in the Licensure and Certification Unit at tracy.niekamp@health.mo.gov or 573-526-8522.

CMS Memo S&C 14-46-LSC: Categorical Waiver for Power Strips Use in Patient Care Areas

Memo Summary:

  • Categorical Waiver:  CMS has determined that the 2000 edition of the National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) contains provisions on the use of power strips in health care facilities that may result in unreasonable hardship for providers or suppliers.  Further, an adequate alternative level of protection may be achieved by compliance with the 2012 edition of the LSC, which has extended allowances on the use of power strips in patient care areas.

 

  • CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if the provider/supplier is in compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions.

 

  •  Resident rooms in long-term care or other residential care facilities that do not use line-operated electrical appliances for diagnostic, therapeutic, or monitoring purposes are not subject to the more restrictive NFPA 99 requirements regarding the use of power strips in patient care areas/rooms.  Resident rooms using line-operated patient-care-related electrical equipment in the patient care vicinity must comply with the NFPA 99 power strip requirement and may elect to utilize this categorical waiver.

 

  • Individual waiver applications are not required:  Providers and suppliers are expected to have written documentation that they have elected to use the waiver.  A provider or supplier must notify the LSC survey team at the entrance conference that it has elected the use the waiver permitted under this guidance and that it meets the applicable waiver requirements. The survey team will review the information and confirm the facility meets the conditions for the waiver.

Please see the complete memo here or visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-14-46.html?DLPage=1&DLFilter=14-46&DLSort=3&DLSortDir=ascending.

Revised RAI Manual

The complete set of RAI Manual v.1.12 pages and change tables and the Replacement Pages file, both in the Downloads section below, now contain revised versions of Chapter 2; pages A-8, A-10, and A-13 (Chapter 3 Section A); pages E-2 through E-8 (Chapter 3 Section E); page 6-12 (Chapter 6); the Appendix B, F, and H cover pages; and Appendix G. Files affected by this revision contain an R in the version number (“1.12R”) and pages affected include an “(R)” in the page footer.

This most recent version can be located at the following link: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.
The complete manual can be found in the box labeled “downloads” at the bottom
of that page.