Please see the most frequently cited deficiencies report from the fourth quarter of 2019.
Category: Nursing Home Administrators
SSN-based HICN No Longer Accepted on MDS or Medicare Claims
This is a reminder that providers will no longer be able to submit a Social Security Number (SSN)-based Health Insurance Claim Number (HICN) or Railroad Retirement Board (RRB) number on the MDS in item A0600B or on the Medicare claim beginning January 1, 2020. Instead, the Medicare Beneficiary Identifier (MBI) must be used.
For additional details and resources regarding use of the MBI, please refer to the MLN Matters Article to learn how to get and use MBIs.
Five-Star Preview Report Update
Due to the holidays, there will not be a Five-Star provider preview report deposited in CASPER for December 2019 and Nursing Home Compare will not be updated on its normal schedule. The next scheduled refresh will occur January 29, 2020.
Pioneer Network’s Hot Topics: Culture Change in Action Webinar
January 23, 2020: Resources You Can Use to Educate, Advocate, Warm the Soil, Advance Person-Centered Care and Accelerate Culture Change (And They’re Free!)
Guides: Kim McRae, Co-Founder, Culture Change Network of Georgia and President, Have a Good Life; Rose Marie Fagan, A Co-Founder and Founding/Former Executive Director, Pioneer Network and Steering Committee, Culture Change Network of Georgia; and Joan Devine, Director of Education, Pioneer Network
Do you need some new resources to help educate and inspire the general public, care partners and change agents about the WHO, WHAT and WHY of culture change and person-centered care? Well, look no further! The Culture Change Network of Georgia (CCNG) may have just what you are looking for!
Through the generosity of a CMP grant, and through partnerships with organizations like Pioneer Network, they have produced short educational videos on topics from “What is Culture Change?” to “State Culture Change Coalitions: Key to Advancing Change at the Local Level” to “Culture Change and Person-Centered Care: What’s the Difference?” to “Why Worry About Words: WORDS MATTER.”
Join Kim McRae and Rose Marie Fagan as they share the story behind the videos and offer some ideas to spark a conversation about how you can use these free resources to advance culture change and person-centered practices.
And while we’re talking, Joan Devine, Director of Education with Pioneer Network will update you on the resources available through Pioneer Network in our Learning Resource Library and more.
MHCA – 2020 Master Class Webinars
February 4, 2020: Getting the PDPM Initial PPS Assessment Right! Best Practices for Pre-admission, Admission & Day 1-8 Processes
March 3, 2020: Applying Dollar Values to PDPM Characteristics & Avoiding Top Missed Opportunities with Case Studies
April 7, 2020: Effective Meetings for PDPM (UR/Medicare, Clinical, Triple Check
May 5, 2020: PDPM: Staff Development and Core Competency Essentials
June 2, 2020: Care Planning for the Complex Resident Under PDPM
July 7, 2020: All In! PDPM Supportive Documentation for Physicians, Nursing, Rehab, Dietary and Social Services
August 4, 2020: PDPM Quality Assurance and Outcomes Tracking
September 1, 2020: Addressing PDPM Medical Review Risks in the SNF Compliance and Ethics Work Plan
October 6, 2020: PDPM: Advancing Clinical Capabilities and Care Delivery
November 3, 2020: What We’ve Learned: Insights into Successful Providers from the First Year of PDPM
December 1, 2020: Year End PDPM Updates and 2021 Policy Changes
This series of webinars will focus on developing mastery of the skills required to successfully lead clinical reimbursement excellence under PDPM.
MHCA Mid-Year Conference & Lobby Day
March 2-3, 2020: 2020 Mid-Year Conference & Lobby Day
Location: Capitol Plaza Hotel, Jefferson City
Missouri Health Care Association strives to provide the best collective efforts directed towards delivering service excellence and high quality in the health care profession. Registration information and details are now available. Please join MHCA as we continue to ensure Missouri’s most vulnerable citizens are receiving the proper care and attention they deserve, the right way, the first time.
MHCA – 2020 Five-Star Insights Webinars
March 18, 2020: Developing a 5-Star Work Plan
April 22, 2020: 5-Star QMs: Increased ADL Help, Ability to Move Worsened & Improvement in Function
May 20, 2020: 5-Star QMs: Pressure Ulcers
June 17, 2020: 5-Star QMs: Catheter, UTI
July 22, 2020: 5-Star QMs: Falls with Major Injury
August 19, 2020: 5-Star QMs: Antipsychotic Use
September 16, 2020: 5-Star QMs: Re-Hospitalizations, ER Visits, Successful Return to Community
October 21, 2020: 5-Star Health Inspections: Top Citations & How to Avoid Them – Part 1
November 18, 2020: 5-Star Health Inspections: Top Citations & How to Avoid Them – Part 2
December 16, 2020: 5-Star Staffing Rating
This series of webinars will focus on advancing results in the three domains of the CMS 5-Star Quality Rating System: Health Inspections, Staffing, and Quality Measures. You will gain insight into how the health inspection, staffing, quality measure, and overall rating is calculated. Tips on how to analyze your data and develop an effective action plan to achieve 5-Star status will be emphasized, along with practical facility application of QAPI elements to drive your 5-Star Ratings.
MALA 2020 ALF Resident Assessment Training
March 30-April 1, 2020: ALF Resident Assessment Training
November 2-4, 2020: ALF Resident 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.
Department of Mental Health – Did You Know…?
The Department of Mental Health has a website with information on PASSR Level II Assessments that includes resources, interventions, and podcasts to assist in care planning. More info is available at www.dmh.mo.gov/dev-disabilities/programs/pasrr-level-ii-assessments.
DMH also has a Behavioral Health Crisis Hotline that is staffed by mental health professionals who can respond to crisis 24 hours per day 7 days per week. Information regarding the Behavioral Health Crisis Hotline can be found at www.dmh.mo.gov/mental-illness/program-services/behavioral-health-crisis-hotline.
Conversations with Carmen
January 17, 2020: Is Something Better Than Nothing?
Guest: Sonya Barsness, Gerontologist
Join Carmen and her guest Sonya Barsness as they think through this question. Not presuming to have the answers, they will examine the question through a range of common practices and. Building on former work together, we will look at customs such as folding towels or baby clothes that serve no purpose, fake animals and babies, fake plants, door covers, murals that disguise doorways and more. What are the pros and cons of fake life offerings and real life? Is something truly better than nothing? Are there unintended consequences?
MDS Trainings 2020
RAI Process from Start to Finish
January 21-22, 2020: St. Louis/St. Peters
June 16-17, 2020: Independence
August 4-5, 2020: Columbia
October 21-22, 2020: Osage Beach
Medicare from Start to Finish
March 10, 2020: Independence
April 14, 2020: Columbia
May 19, 2020: Osage Beach
September 23, 2020: St. Louis/St. Peters
MDS 3.0 QM (Quality Measurement) Report Updates
The MDS QM reports will be updated to reflect measure updates identified in the MDS 3.0 QM User’s Manual v12.1 available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html, effective October 1, 2019.
Additionally, the previous SNF QRP Percent of Residents with Pressure Ulcers That are New or Worsened (S002.02) has been added to the MDS QM reports and the MDS Provider Preview and Resident-level Preview Report to allow for continued tracking on this measure.
While being updated, the following reports will not be available from the CASPER system:
- MDS 3.0 Facility Level Quality Measure Report
- MDS 3.0 Resident Level Quality Measure Report
- MDS 3.0 Quality Measure Monthly Comparison Report
- MDS 3.0 Facility Characteristics Report (add CMS logo, update privacy statement)
Once the report updates have completed, an additional memo will be sent.
If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.
DRAFT version of the 2020 MDS item sets v1.18.0
A new DRAFT version of the 2020 MDS item sets (v1.18.0) has been posted. This version is scheduled to become effective October 1, 2020. Please note that Section G was removed from all Federal item sets.
The files are located in the Downloads section of the MDS 3.0 Technical Information webpage: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html.
Informal Dispute Resolution (IDR) Changes
Section 198.545, RSMo requires the department of health and senior services to contract with the federally designated Medicare Quality Improvement Organization (QIO) in this state to conduct IDR conferences. To comply with this requirement, the department contracted with TMF Health Quality Institute (the federally designated Medicare QIO) who subcontracted with Primaris Healthcare Solutions to conduct IDR conferences.
Effective November 8, 2019, CMS awarded the federally designated Medicare Quality Improvement Organization contract for Missouri to Health Quality Innovators (HQI). Because of this change, the department’s contract with TMF automatically terminated. The department is discussing a possible contract with HQI, but at this point there is no contract for IDR services. Should a facility request an IDR during this time, two options are available: 1) The department will conduct the IDR conference, or 2) The facility can delay the conference until a permanent solution is determined.
If you have any questions regarding this change in process, please contact Shelly Williamson at Shelly.Williamson@health.mo.gov or at 573-526-4872.
Online Reporting Now Available for Adult Abuse, Neglect and Financial Exploitation
In Missouri, during fiscal year 2019, the Department of Health and Senior Services (DHSS) received and investigated 39,144 reports of abuse, neglect, and exploitation involving seniors and adults with disabilities living in the community and in long-term care facilities.
The Department proudly announces the integration of a new online reporting system for mandated reporters which will ensure all concerns of abuse, neglect and financial exploitation of the elderly and adults with disabilities are reported quickly.
The new Adult Abuse and Neglect Hotline online reporting system will allow for secure electronic submission of adult abuse, neglect and exploitation report information, from mandated reporters and public citizens into a secure, encrypted database available 24/7 on a web-based platform as an alternative to calling the Adult Abuse and Neglect Hotline.
We ask all mandated reporters to please partner with us by entering reports online and allowing greater accessibility to the hotline for the public. In partnership, the Department would like to share the Online Reporting Flyer with you and encourage you to display it where it will serve as a reminder to mandated reporters.
The Adult Abuse Hotline is operational from 7 a.m. until midnight, seven days a week, 365 days a year. If you suspect abuse, neglect or financial exploitation of the elderly or an adult with a disability call the Adult Abuse Hotline at (800) 392-0210 or visit www.health.mo.gov/abuse to report online. The online reporting system is available 24/7; however, it is only monitored by intake staff during the hotline’s hours of operation.
If you have any questions regarding online reporting, please reach out to the Department at (573)751-2413 or DSDSOfficeofConstituentServices@health.mo.gov.
MALA Train the Trainer 2020
January 15, 2020: 2020 Train the Trainer
March 4, 2020: 2020 Train the Trainer
May 6, 2020: 2020 Train the Trainer
July 1, 2020: 2020 Train the Trainer
September 2, 2020: 2020 Train the Trainer
November 11, 2020: 2020 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.
MDS PDPM Webinar Series
January 17, 2020 – February 21, 2020: MDS PDPM 6-Week, 6 Session Webinar Series Assessment, Coding & Systems Orientation & Proficiency Series
This 6-week, 6 session webinar series provides MDS section-by-section coding guidance under PDPM and insights for optimal data collection, supportive documentation, and consistent coding accuracy. Live sessions are completed weekly over 6 weeks and review key MDS sections under PDPM. Recordings are provided with full-series purchase for ongoing on-demand access for new hire orientation and as a staff development resource. Reduce the learning curve for clinical reimbursement staff and drive PDPM coding accuracy and compliance with this MDS series taught by Proactive’s expert instructors.
2020 MLN Nursing Home Administrator Conference
February 27-29, 2020: 29th Annual Nursing Home Administrator Conference
Location: Lodge of the Four Seasons, Lake Ozark
Nursing Home Administrators will be provided with essential information needed to effectively serve long-term care residents and successfully perform their leadership role and job responsibilities. This conference was specifically designed to provide more than 20 hours of CE in 2 ½ days.
CMS Memo: QSO-20-03-NH
Updates and Initiatives to Ensure Safety and Quality in Nursing Homes
The Centers for Medicare & Medicaid Services (CMS) is announcing updates and initiatives aligning with the CMS strategic initiative to Ensure Safety and Quality in Nursing Homes. These updates and initiatives include:
- Phase 3 Interpretive Guidance: CMS will be releasing updated Interpretive Guidance and training for the Requirements for Participation for Long-Term Care (LTC) However, this guidance will not be released by the November 28, 2019 implementation date of the regulations. We will be releasing the guidance in the second quarter of calendar year 2020, along with information on training and implementing related changes to The Long Term Care Survey Process (LTCSP). While the regulations will be effective, our ability to survey for compliance with these requirements will be limited until the Interpretive Guidance is released.
- Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements: On July 18, 2019, the Department of Health and Human Services (HHS) published a final rule establishing requirements related to the use of binding arbitration agreements. This final rule amends the requirements that Long-Term Care (LTC) facilities must meet to participate with Medicare and Medicaid. The final rule can be found at: govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14945.pdf
- Actions to Improve Infection Prevention and Control in LTC Facilities: CMS has created a nursing home antibiotic stewardship program training; updated the Nursing Home Infection Control Worksheet as a self-assessment tool for facilities; and is reminding facilities of available infection control resources.
- Release of Toolkit 3, “Guide to Improving Nursing Home Employee Satisfaction”: CMS has created a toolkit that helps facilities improve employee satisfaction.
Please see the full memo download at www.cms.gov/updates-and-initiatives-ensure-safety-and-quality-nursing-homes.
MDS Support Group Meeting
November 26, 2019: CASPER, QM, and Survey
Location: E.W. Thompson Health & Rehabilitation Center, Sedalia
Stacey Bryan, State RAI Coordinator will be visiting our region the following dates to discuss CASPER and Quality Measure reports. Please bring your most recent CASPER/Quality Measure report and any questions you may have.
MANHA – Infection Preventionist Boot Camp
February 4-5, 2020: Infection Preventionist Boot Camp
Location: Harrah’s Casino & Hotel, North Kansas City
You have been named the Infection Preventionist for your facility. You have completed your certification for the IP but still aren’t sure where to start or how to go about doing the job with confidence. We are here to give you the confidence you need! Bring your laptop and your infection control policy and procedures and leave with assurance that you and your facility are where they need to be with IPCP and all its requirements.
We will review the CMS 23-hour training as the core to IPCP development and review your IPCP and its accompanying policy and procedures to improve your confidence. We’ll build your personal library of resource material, develop your tracking logs and QAPI communication tools and finally we will create a schedule of routine tasks for you to adhere to for purposes of maintaining compliances.
2020 MANHA Winterfest
February 5-7, 2020: 2020 MANHA Winterfest Conference & Trade Show
Location: Harrah’s Casino & Hotel, North Kansas City
Missouri Association of Nursing Home Administrators is pleased to invite you to attend our midyear conference, Winterfest. 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.
Updated MDS 3.0 Data Specification
On November 8, 2019, CMS posted an updated errata (V3.00.3) to their MDS Technical Information webpage (www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqimds30technicalinformation.html) for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. Two issues were identified. One edit, -3941, will be deleted, and one edit, -3965, will be added. These changes will go into production on December 3, 2019. Once in production, these two changes will be retroactive, applying to all assessments with target dates on or after October 1, 2019.
New QIPMO Newsletter – November 2019
The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls – Volume 7, Issue 1.
In this issue:
- Let’s Hire Great Employees!
- Interview/Hiring Process
- Nursing Home Compare Improvements
- That Ominous Dash
- Foot Care
- We Are First Responders
- Trauma-Informed Care
Please visit QIPMO’s website here for this and other previous newsletters.
MC5 Testimonials
MC5 is gearing up to celebrate 15 years as an organization! We are excited and invite you to celebrate by sharing YOUR story.
- How has MC5 impacted you or your organization?
- What features of MC5 do you enjoy most?
- What have you learned through a Regional Group training, Road Show or Conference?
Testimonials received from communities, businesses, or individuals will be featured on our website and social media. Send a short written paragraph or short video to MissouriMC5@gmail.com or directly post it on our Facebook Page.
We appreciate your partnership to help us continue our mission to promote and support ongoing collaboration within the adult care continuum to create environments where dignity and value of each individual who lives and works there is respected and celebrated.