Category: Nursing Home Administrators

CMS Memo: QSO-25-11-NH: Long-Term Care (LTC) Facility Acute Respiratory Illness Reporting Requirements

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Memorandum Summary

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

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

NHSN LTC component: Respiratory Pathogens and Vaccination Updates

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

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

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

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

Center of Excellence – Webinar Opportunity

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

Holiday Seasonal Depression: Ways to Support Nursing Facility Residents

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

Enhanced Barrier Precautions (EBP) Resource

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

MDS Documentation Requirements Refresher

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Myers and Stauffer to conduct MDS Documentation Requirements Refresher

Please see the attached flier for the MDS Documentation Requirements Refresher scheduled for December 17, 2024 from 9:00 AM – 10:30 AM CST. Please click the link within the flier (or below) to register for the webinar. Registration is required.

Link to Register: https://mslc.webex.com/weblink/register/rc0eb002a1e79b4ee18d8f94400fe85b4

The training materials and recorded webinar will be available for download after the training should you be unable to attend the live session. Please direct any questions to MO_MDSINFO@mslc.com.

Updated COVID Reporting Info

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Special Information Related to COVID-19 Reporting:

  • Facilities performing their own COVID-19 testing must report positive results to DHSS unless they are reporting lab tests via the National Healthcare Safety Network (NHSN) or the Association of Public Health Laboratories (APHL) Informatics Messaging Services (AIMS) Platform.
  • Submitters preferring to send COVID-19 testing records in bulk via HL7 instead of using MODROP should contact the Missouri Data Exchange Team to be onboarded for bulk reporting. This e-mail account is monitored from 8AM-5PM CST Monday-Friday.
  • All entities ordering COVID-19 tests from an external laboratory should enter positive case information into MODROP/ShowMe WorldCare.

The original MODROP portal was developed in conjunction with the EpiTrax application. DHSS transitioned from EpiTrax to the ShowMe WorldCare application on August 26, 2024. A new version of MODROP is now available through ShowMe WorldCare: The Missouri Disease Reporting Online Portal (MODROP).

Active users of the earlier version of MODROP were notified of the system transition via the email address linked to their MODROP account. These users were provided with new account credentials prior to the launch of ShowMe WorldCare in August 2024. If an individual needs to utilize MODROP and has not already received this information via email, a new request for an account must be submitted.

Use this link for more information on electronic laboratory reporting and electronic case reporting for reportable conditions: Electronic Laboratory Reporting and Electronic Case Reporting for Reportable Conditions in ShowMe WorldCare.

For the state regulations regarding reporting infectious, contagious, communicable, or dangerous diseases go to Missouri Secretary of State: Code of State Regulations.

NOMNC

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SLCR recently had an opportunity to meet with Livanta, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) that receives the appeals of non-coverage (SNF ABN and NOMNC) required in F582. A couple items to note- the required forms are updated periodically- so please make sure the most recent forms are being used. The most recent forms and instructions for their use can be found here: Beneficiary Notices Initiative (BNI) | CMS. Changes were made in November 2024 and additional changes will be effective beginning January 1, 2025.

SLCR has heard recent concerns from facilities and residents regarding Medicare Advantage beneficiaries being denied services or delays in services. If you hear these concerns, please share with Medicare Advantage residents and/or families that the NOMNC has been modified to reflect regulations providing enrollees additional fast-track appeal rights when they untimely request an appeal to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or still wish to appeal after they end services on or before the planned termination date (See: CMS-4205-F, p. 30827).

These notices should be provided timely to beneficiaries whose Medicare covered services will end to inform them of their rights and protections related to financial liability and appeals under the Fee-for-Service Medicare and Medicare Advantage (MA) programs.

Additionally, facilities and beneficiaries can find contact information for Missouri’s BFCC-QIO, Livanta, here: https://www.livantaqio.cms.gov/en/states/missouri.

NHSN – LTC 2024 Annual Facility Survey

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The 2024 Long Term Care Annual Facility Survey will become available in the NHSN application, January 2025. Facilities that currently, or plan to, participate in the Healthcare Associated Infection (HAI) modules, such as urinary tract infections, laboratory-identified events for C. difficile and/or multidrug resistant organisms, and/or prevention process measures are required to complete the survey by March 1, 2025.

Facilities that complete the annual survey help drive significant improvements within the NHSN surveillance system, enabling the development of targeted resources, surveillance guidance, and meaningful performance comparisons among Long-Term Care Facilities.

Here are a few reasons why completing the 2024 Annual Facility Survey is important:

  • Infection Prevention & Control: The survey provides valuable data to help identify areas where LTCFs may need additional support in infection prevention and control activities.
  • Antibiotic Stewardship: It offers insights into the resources needed to implement or improve antibiotic stewardship programs, which are vital for resident safety and effective care.
  • Resident and Care Services: It helps gather essential information about types of residents your facility serves, as well as specific care services provided.

Please note that for facilities primarily reporting in the Respiratory Pathogens Vaccination module, the annual survey is not mandatory. However, we strongly encourage all Long-Term Care Facilities (LTCFs) to complete the survey, as it provides valuable benefits, as outlined above, for your facility.

If you have questions, please contact NHSN-ServiceNow and include “2024 LTCF Annual Facility Survey” in the subject line. The portal can be accessed here or through your SAMS account. After logging into SAMS, the NHSN-ServiceNow link is located at the bottom of the page.

If you are unable to access ServiceNow, you can email the NHSN Help Desk at nhsn@cdc.gov.

Thank you for your continued commitment to improving care in long-term care settings.
The NHSN LTCF Team

An Engaged Medical Director: A Real Asset to a LTCF Webinar Presentation

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DHSS Section for Long Term Care would like to say thank you to all that were able to take time out of their busy schedules to attend the webinar, “An Engaged Medical Director: A Real Asset to a LTCF,” on 11/20/2024, presented by Dr. Michael Nash. We would like to extend this thank you to Dr. Nash for sharing his wealth of knowledge and passion with us at DHSS, LTCF staff, educators, and providers. We believe the insights shared will be greatly beneficial for long-term term care facilities and Medical Directors.

This recorded presentation is now available on demand, along with the slides from the presentation.
Recording Link: “An Engaged Medical Director: A Real Asset to a LTCF”
Presentation Slides: Engaged Medical Director Presentation for MO DHSS 11-20-24 v2 MN edits

Pneumococcal Vaccine Recommendations Update

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CDC recommended lowering the age for routine adult pneumococcal vaccination from 65 to 50 years old. Adults who are 19 through 49 years old with certain risk conditions should continue to get vaccinated against pneumococcal disease. There are now three pneumococcal conjugate vaccines (PCV15, PCV20, PCV21) available for adult vaccination. Healthcare providers can use any of these products to vaccinate adults against pneumococcal disease. Typically, only one dose of pneumococcal vaccine is needed as an adult. However, if PCV15 is used, a second type of vaccine (pneumococcal polysaccharide vaccine, PPSV23) is needed.

Job aids for adult pneumococcal vaccination‎
Shared clinical decision-making: This job aid should assist vaccine providers in discussions with older adults considering PCV20 or PCV21 vaccination.
Vaccine timing for adults: This job aid should help vaccine providers interpret adult pneumococcal vaccine recommendations.

COMRU Update

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During the Summer of 2024, COMRU implemented several enhancements to the online application system. To test the effectiveness of those enhancements, on September 1, 2024, COMRU began reviewing newly submitted applications as well as reviewing applications submitted prior to September 1.

COMRU is current with reviewing newly submitted applications and has made significant progress in reviewing applications submitted prior to September 1. Only applications submitted July 22 to August 31, 2024, are pending review. COMRU expects to have all applications submitted prior to September 1 reviewed by the end of the calendar year.

Please note: Applications returned to the submitter for correction will be deleted from the online application system if corrections are not made and resubmitted to COMRU within 60 days. he submitter may access the online application at any time to check the status of a pending application. Training on how to check the status of an application can be located on COMRU’s webpage (Under Trainings/WebEx Training – Level One Online Form Feb 2024).

 

Tips and Reminders

  • All attachments to the online application must be in PDF format – please do not include web links. Applications including web links will be returned for correction. All application documents are scanned by COMRU for retention purposes; web links are not stable and cannot be scanned.
  • For Level 1 applications, attachments should be a limited number of pages and only include the information requested. For example, if an applicant is in the hospital, the submitter must either type in the date/reason for hospitalization or attach a hospital H&P that includes this information. The entire H&P from the hospital is not necessary – only those pages that include the date/reason for hospitalization are required.
  • Please review all diagnoses for the applicant including those on the diagnosis list and those listed in any other attachments and answer the application questions accordingly. The most common errors related to diagnoses are:
    • Section D, Question 6: Does the individual have a diagnosis of Major Neurocognitive Disorder (MDNC), i.e., dementia or Alzheimer’s?
    • Section E, Question 2a: Does the individual have a suspected diagnosis or history of an Intellectual Disability/Related Condition?

Many applications have one of these diagnoses listed and this question is answered “no” when the answer should be “yes”. When the question is marked “yes” follow-up questions populate; marking “no” results in an incomplete application which will be returned for correction.

For additional information and answers to frequently asked questions, please review the online training posted on the COMRU webpage.

MDS INFO

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Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 7/1/24 through 9/30/24 is due November 14, 2024. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on November 18, 2024:

  • MDS data for 4/1/24 through 6/30/24;

  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 4/1/24 through 6/30/24;

 

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

Dementia Care & Antipsychotic Medication Resources

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Dementia care and antipsychotic medication resources, tools, and data reports are now housed on the CMS Quality Improvement Organizations website. Helpful information is also available on the CMS National Partnership website. Below are direct links to this information.

CMS National Partnership to Improve Dementia Care in Nursing Homes Website: https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/national-partnership-improve-dementia-care-nursing-homes

CMS Quality Improvement Organizations Website: https://qioprogram.org/landing-page – Search with the keywords ‘dementia’ and ‘antipsychotic’

Antipsychotic Medication Use Data Report: https://qioprogram.org/tools-resources/antipsychotic-medication-use-data-report

Antipsychotic Use by State: https://qioprogram.org/tools-resources/antipsychotic-use-state

If you have additional questions, please let us know. Specific questions related to the data reports can be directed to CMSQINQIOProgram@cms.hhs.gov.

Residents Have the Right to Vote

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Election Day is Tuesday, November 5th.

Individuals receiving long-term services and supports retain their voting rights, no matter where they live or what type of care they receive. Federal regulations guarantee residents’ rights, including their rights as citizens, which includes the right to vote. As local elections approach, now is the time for residents of long-term care to make a plan for voting.

Visit our website for information on preparing to vote, finding voting rules in your area, learning what is on your ballot, and suggestions for ways facilities can support residents’ right to vote.

Staying Engaged: Using the Power of My Voice

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The 2025 edition of the Staying Engaged enrichment booklet has a variety of activities aiming to keep long-term care consumers mentally engaged, prompt self-reflection, and remind consumers of the importance of advocating for your rights, especially your right to make choices about how to live your life.

Included in the activities are a maze, a word search, a crossword, word unscramble puzzles, sudoku, self-reflection prompts, an ice breaker scavenger hunt, and an art page.

Download for free or pre-order a hard copy – the booklets will be available to ship in a couple weeks.

Reporting Annual Healthcare Personnel Influenza Vaccination Data through NHSN (Long-Term Care Facilities)

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Initial Webinar

November 19, 2024: 1:00 PM Eastern Time (US and Canada)

Register in advance for the initial webinar on November 19: https://cdc.zoomgov.com/webinar/register/WN_3AMj__gqSkarSwKquC-T3A

 

Replay Session

December 3, 2024: 1:00 PM Eastern Time (US and Canada)

Register in advance for the webinar replay on December 3: https://cdc.zoomgov.com/webinar/register/WN_84q-qGZ3RHWOxlL7jhnPhQ

 

The content of both webinars is the same. After registering, you will receive a confirmation e-mail containing information about joining the webinar.

Life Safety Code Regulation Info

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Sometimes it can be difficult to find a Life Safety Code regulation. Are you aware most of code references used by surveyors are printed on the bottom of the tags in the 2786R? This document also serves as a quick reference to all of the Life Safety Code tags.

Emergency preparedness requirements are found in Appendix Z. SNFs are required to review and update their emergency preparedness policies and procedures at least annually. It is always a good idea to look at Appendix Z during this time not only to ensure compliance, but you may also get some other ideas from the text which includes multiple examples.