Please see the most frequently cited deficiencies report from the third quarter of 2024.
Category: Nursing Home Administrators
Reporting Annual Healthcare Personnel Influenza Vaccination Data through NHSN (Long-Term Care Facilities)
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
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.
COMRU PASRR and Level of Care Orientation Training
The Central Office Medical Review Unit (COMRU) has scheduled monthly orientation training to review the requirements of the Pre-Admission and Resident Review (PASRR) and Nursing Facility Level of Care (LOC) application process. These on-line trainings will be one-hour in length and hosted by Ammanda Ott, RN Supervisor for COMRU. Each training is limited to 50 individuals, so register soon!
Webinar series registration link: https://stateofmo.webex.com/webappng/sites/stateofmo/webinar/webinarSeries/register/cc01ce6f1d64435db3a716b6c489bf51
Upcoming Training Dates/Times
November 5, 2024: 11:00 am
December 10, 2024: 11:00 am
January 14, 2025: 11:00 am
February 11, 2025: 11:00 am
March 11, 2025: 11:00 am
Why We Are Conducting These Trainings?
• The LOC/PASRR process is complex and can be overwhelming if individuals do not receive sufficient training. We want to make it easier for you!
• Approximately 50% of applications are returned for corrections. This results in delays to the review and approval process – which directly impacts Medicaid payment to nursing facilities and can result in prolonged hospital stays.
• COMRU receives an average of 30-40 calls per day – many of the answers to the questions asked are contained in information accessible online. A decrease in phone calls will allow additional time for COMRU to review pending applications.
Training Agenda
• Overview of the PASRR and LOC requirements.
• Review of the application process from application submission to approval, including recent enhancements made to the online application system.
• Review of common errors that result in the application being returned for correction.
• Discussion of critical information needed to determine whether the application triggers for a Level 2 evaluation and the impact to the nursing facility and hospital.
Who Should Attend
• Individuals who are new to completing the LOC/PASRR application.
• Individuals who want a refresher of the requirements.
Benefits of Attending
• Familiarity with the process and information included online to assist with completing the application.
• Decrease in returned applications and reduction of processing times.
Prior to attending, please review both on-line trainings (New LOC Webex Training Oct 2021 and Level One Online Form Training Feb 2024) located on COMRU’s webpage https://health.mo.gov/seniors/nursinghomes/pasrr.php.
Please see the flyer
Free Fall Vaccine Season Clinics
HQIN is offering your facility a unique opportunity to receive support from local community pharmacies for the current fall COVID-19 vaccine season.
HQIN will connect you with a local pharmacy that will provide highly trained pharmacists, pharmacy technicians or community health workers (CHWs) to work directly with you to provide:
- COVID-19 vaccination clinics for your residents and staff.
- Accurate information about vaccinations.
Your Facility Will:
- Be offered assistance to improve vaccination rates.
- Be positioned to connect with and establish relationships with local pharmacy providers.
- Benefit from added support, services and more!
Take advantage of this offer by clicking the link below to provide us with a few details. You will then receive an email from the team, who will facilitate connecting you with a local pharmacy.
HQIN Nursing Home COVID-19 Vaccine Clinic Support Request Form
These Programs End October 31. Don’t Miss Out!
Vaccine Billing Challenges?
Help is Available
With the latest FDA approval of the 2024-25 COVID vaccines, McKnights Long Term Care News published an article related to billing challenges. In it, Chad Worz, PharmD, BCGP, FASCP and Executive Director/CEO of the American Society of Consultant Pharmacists (ASCP) explains billing and payment challenges in long-term care related to the COVID vaccine.
Fortunately, HQIN has partnered with ASCP to offer support with billing challenges related to the COVID vaccine. Through this partnership, ASCP contacts will provide technical assistance for vaccine billing questions and process options to ease your immunization systems and efforts. Email your questions to get started.
CMS Memo: QSO-24-21-NH: Compliance with Residents’ Rights Requirement related to Nursing Home Residents’ Right to Vote
Memorandum Summary
- The Centers for Medicare & Medicaid Services (CMS) is affirming the regulatory expectation that ensures nursing home residents have the unimpeded ability to exercise their right to vote as a citizen of the United States.
- Nursing homes must ensure residents are able to exercise their Constitutional right to vote without interference, coercion, discrimination, or reprisal from the facility.
- States, localities, and nursing home owners and administrators should collaborate to support a resident’s right to vote.
Please see the full memo for details located.
Updated FFS SNF ABN
With the help of contractors, CMS revised the SNF ABN, Form CMS-10055, and the form instructions. The SNF ABN form and instructions are located in the download section of the CMS FFS SNF ABN website and are available for immediate use, but will be mandatory for use on 10/31/2024.
CNA Training Reimbursement Opportunity for SNFs
Did you know… skilled nursing facilities can receive reimbursement for CNA training?
The Health Education Unit hosted a webinar along with Mo HealthNet to provide information regarding the amount of reimbursement, instructions related to the submission and important data to consider for reimbursement.
Didn’t get to attend? No problem, watch it now!
For questions, contact the Health Education Unit at 573-526-5686 or email at CNARegistry@health.mo.gov.
NHSN Reporting Essentials for Long-Term Care Facilities
September 17 at 2 p.m. ET
Register Now
National Healthcare Safety Network (NHSN) reporting is the top citation for long-term care facilities and potentially one of the costliest for your facility.
Join this hour-long webinar next week to learn ways that ensure accurate, timely NHSN reporting to avoid citations and Civil Money Penalties (CMP).
Infection Prevention and Control Office Hours
Sessions Begin on September 18 at 12 p.m. ET
Register now to join free virtual Infection Prevention and Control Office Hours, which address topics concerning respiratory virus season.
The focus will be on COVID-19 and strategies to decrease transmission among nursing home residents and staff. This series is tailored specifically for long-term care facilities, providing valuable support in areas such as COVID-19 prevention, immunization strategies and strategies to stay healthy. These sessions will help you discover ways to enhance care for both residents and staff.
Please see this flyer for details and registration
Healthcare Quality and Worker Safety Information from CDC
Exciting News! CORHA Launches Newly Redesigned Website – CORHA, The Council for Outbreak Response: Healthcare-Associated Infections (HAIs) and Antimicrobial-Resistant Pathogens (AR) (CORHA) has recently launched a newly redesigned website. The new site offers enhanced features and expanded information to improve user experience, accessibility, and functionality.
Long-Term Care Webinar: 2024-2025 Respiratory Virus Season Updates – Please join CDC’s Division of Healthcare Quality Promotion (DHQP) on Monday, September 16, 2024, at 1 p.m. EDT for an overview of the latest respiratory virus vaccination recommendations, testing and treatment guidance, and infection prevention strategies. Long-term care facility residents are often at high risk of respiratory infections and severe disease due to respiratory viruses. A combination of interventions can protect residents and staff health during respiratory virus season.
Register: https://cdc.zoomgov.com/webinar/register/WN_H4-bbiGEQyOCaP7YUT8Jng
ICYMI: CDC and AMA Respiratory Virus Season latest information – During the event, speakers from CDC, including CDC Director Dr. Mandy Cohen, provided important updates on protecting patients and others against influenza, COVID-19, and RSV. Updates included:
- Emerging immunization issues, as well as recommendations and resources for providers.
- Reminders about treatments available for patients at increased risk of severe COVID-19 illness.
Preview of new HHS vaccination education campaign – Risk Less. Do More.
Mouthcare Without a Battle Webinar
The presentation co-hosted by the Section for Long-Term Care Regulation and the Office of Dental Health, on August 20, 2024 is now available for viewing online under Trainings on the Provider Information webpage.
Antimicrobial Stewardship for LTCF
NEW FREE RESOURCE
The Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) Program has created a free antimicrobial stewardship playbook made for long-term care facilities (LTCF). This playbook includes background information on the state of antimicrobial stewardship in LTCF in Missouri and includes 17 ready-to-use tools and templates to help with antimicrobial stewardship efforts within your facility. Please share this playbook with anyone in your facility that is involved with antimicrobial stewardship activities and efforts.
A link to the playbook is provided here: https://health.mo.gov/professionals/antibiotic-stewardship/pdf/asp-playbook-ltc.pdf.
A link to the MODHSS LTC Antimicrobial Stewardship webpage is provided here: https://health.mo.gov/professionals/antibiotic-stewardship/tools-ltc.php.
Also of news, the HAI/AR program now has an antimicrobial stewardship pharmacist on staff to help answer questions, provide educational content, and help collaborate with antimicrobial stewardship projects and initiatives within your facilities, along with all healthcare facility types in the state. This can also be a great opportunity to participate in a free, non-regulatory assessment of your stewardship program efforts to try and meet antimicrobial stewardship requirements.
If you are interested in hearing more about this, or have questions about healthcare-associated infections, Candida auris, or other multidrug-resistant organisms, please reach out to the DHSS HAI/AR program for more information.
HAI/AR Program Contact Information
Phone: 573-751-6113
Email: HAI_Reporting@health.mo.gov
New QIPMO Newsletter – August 2024
The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls (Volume 11, Issue 4).
In this issue:
Welcome, Julie!
Meeting Regulatory Standards
ICAR Corner
Abuse. Misappropriation. Neglect.
Hip, Hip, Hooray
Thoughts on….Success
Notice of Spam Emails
The Licensure and Certification Unit has been notified of administrators receiving spam emails. The subject line contains the name MO DHSS and the emails are from a Yahoo email account. The emails also include a .pdf attached titled License Document. Please do not open the emails and notify your IT staff at once.
COVID-19/Flu Test Kits
DHSS has a limited quantity of Acon FloFlex home test and plenty of COVID/Flu combo clinical tests available for request at the following link for LTCF. Requests for Acon FlowFlex are currently limited to one case of 300 tests per request.
Application Site: https://www.arcgis.com/apps/dashboards/52138a04a74e448284e6280770d722ad
Questions related to COVID? The ICAR team can help. ICAR Project | Nursing Home Help
Billing Medicare for Respiratory Vaccines
This document explains how Medicare pays for vaccines administered during a patient’s stay in a nursing home. Vaccine payment depends on the type of vaccine and whether the patient is using their Skilled Nursing Facility (SNF) Part A benefit. This document doesn’t cover vaccine payment by Medicare managed care, Medicaid, or commercial insurance.
Top Deficiencies Report – 2nd Quarter 2024
Please see the most frequently cited deficiencies report from the second quarter of 2024.
Mouthcare Without a Battle ~Free Webinar~
“Mouth Care Without a Battle” is an evidence-based program designed to educate healthcare staff on providing effective oral healthcare for residents with dementia and other chronic illnesses. Providing daily oral healthcare is crucial for maintaining overall health and well-being in long-term healthcare facilities. Good oral hygiene can prevent infections, reduce the risk of chronic diseases, and improve the quality of life for residents.
Please join the Section for Long-Term Care Regulation along with the Office of Dental Health, on August 20, 2024 at 10:00 a.m. for this FREE webinar. A link will be sent to the email address given at registration. Please register by 5:00 p.m. August 16, 2024 in order to get your link prior to this webinar.
2024 Enhanced Leadership Development Academy for LTC Leaders
Do you…..
❍ need a leadership course that addresses the unique challenges SNF leaders face?
❍ want to feel inspired and passionate about leading your SNF?
❍ want to connect with other SNF leaders and have access to free professional development, tools, and resources?
❍ want free CE credit without sacrificing quality and practical application?
❍ want to have the flexibility to learn at the pace and place the works best for you?
If you answer YES to any of these questions, this course may be for YOU!
For more information visit our web site, or contact Todd Winterbower at winterbowert@missouri.edu.
Take the survey now to see if you qualify for FREE registration.
Senior Day at the State Fair
August 14, 2024
9:00 a.m. – 3:00 p.m.
Mathewson Building
Join DHSS and the Missouri Area Agencies on Aging on the Missouri State Fairgrounds. Senior Day festivities include FREE BINGO, line dance lessons, and much more! The dance contest, open to those aged 60+, has cash prizes for the top three places in each of the categories of Missouri Waltz, Polka, Jitterbug, Two-Step and Line Dancing.
For more information, please visit our website at health.mo.gov/seniorday.
2024 NHSN Annual Training Platform is now Open
The NHSN Annual Training platform is now open! You can now register, access all pre-recorded videos for viewing and start preparing for our live presentations starting July 23, 2024, at 9:00 am EST.
We are officially 1 week away. Log in today to view videos and download slide decks for live sessions. Please note that the pre-recorded sessions kicked off July 15, 2024 and the live virtual training starts next Tuesday, July 23, 2024, at 9:00AM EST.
You can log in to gain access and review the sessions at your convenience.
Click here https://2024nhsntraining-pac.vfairs.com/ to register and confirm your attendance.
We hope that you are getting excited because we are excited and ready!
“See” you soon!
The NHSN Team
HQIN: Simple Strategies for Summer Emergency Preparedness
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Quality Reporting Program: Non-Compliance Letters for FY 2025 APU
CMS is providing notifications to facilities that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2023, which will affect their FY 2025 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were placed into facilities’ My Reports folders in the Internet Quality Improvement and Evaluation System (iQIES) for SNFs on July 03, 2024. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 14, 2024.
If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.








The Health Quality Innovation Network’s (HQIN) Prepare, Prevent, Protect (3P) Top Performer Program recognizes participating nursing homes who are proactive in delivering high quality care to their residents and ensuring a safe environment for residents, staff and visitors.



