Laura Smith is the new Section for Long-Term Regulation Region 6 Program Manager. Laura has been with the Section for over 16 years, and has held various positions as a Facility Advisory Nurse. She has served as the interim Region 6 Program Manager in the past and most recently has been the complaint supervisor. Laura may be reached at 573-751-2270 or by email at laura.smith@health.mo.gov.
Category: SLCR Guidance
The Section for Long-Term Care Regulation has created a Guidelines for Facility Self-Reporting
This document summarizes the reporting requirements of certified and state only facilities and provides contact numbers and other important information. The Guidelines for Facility Self Reporting is attached.
FCSR IMPORTANT NOTICE – Registration Fee increase
Effective October 1, 2016, the Family Care Safety Registry Worker Registration fee will increase to $13.00. The fee increase results from a change in state law and is required by the Missouri State Highway Patrol.
The Family Care Safety Registry will return Worker Registration forms, submitted with the incorrect fee, that are postmarked on or after 10/01/2016. Updated Worker Registration forms will be available to download at http://health.mo.gov/safety/fcsr no later than September 15, 2016, or may be obtained by contacting the FCSR toll free at 866-422-6872.
This information is available on the FCSR website and the Registration and Background Screening System (BSEES).
CMS Memo S&C 16-21-ALL: Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals
Surveyor Guidance: The Centers for Medicare & Medicaid Services (CMS) are clarifying requirements for providing services to justice involved individuals in skilled nursing facilities (SNFs), nursing facilities (NFs), hospitals, psychiatric hospitals, critical access hospitals (CAHs), and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID). Specifically, this guidance seeks to assure high quality care that is consistent with essential patient rights and safety for all individuals.
Please see the attached memo and scenarios below 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-16-21.html?DLPage=3&DLEntries=10&DLSort=3&DLSortDir=descending.
SC16-21.01 Final Memo Justice-Involved
SC16-21.02 Scenarios Justice-Involved Individuals
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.
CMS Memo S&C 16-22-LSC: Notification of Final Rule Published: Adoption of 2012 Life Safety and Health Care Facilities Code
Fire Safety Requirements for Certain Health Care Facilities: On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published a final rule titled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities,” which updates the fire safety requirements for health care providers and suppliers. This regulation requires certain providers and suppliers to meet the requirements of the 2012 edition of the Life Safety Code (LSC), National Fire Protection Association (NFPA) 101 and the 2012 edition of the Health Care Facilities Code, NFPA 99.
Please see the Press Release attached stating health care providers affected by this rule must comply with all regulations within 60 days of the date of the publication of the final rule (May 4, 2016). More information is coming from CMS and we will provide updates as we receive them.
SC16-22 – Release of Final Rule LSC
Press Release for Fire Safety Requirements
Most Frequently Cited Deficiencies Report – 1st Quarter 2016
Please view the quarterly report from the Section for Long-Term Care Regulation attached.
Administrator Licenses Expire June 30, 2016
Administrator licenses expiring June 30, 2016 are up for license renewal. Renewal reminder postcards were mailed early April. Please visit the Missouri Board of Nursing Home Administrator’s web page for the renewal instructions and renewal application at health.mo.gov/bnha.
LPN Licenses Expire May 31, 2016
LPN licenses expire May 31, 2016. Approximately 25,000 renewal postcards were mailed to LPNs in early March. The postcard provides online renewal instructions, including the PIN you need to renew online.
Please visit the Missouri Division of Professional Registration, Board of Nursing’s web page here for details.
CMS Memo S&C 16-11 ALL: Exit Conferences- Sharing Specific Regulatory References or Tags
The Centers for Medicare & Medicaid Services (CMS) has clarified guidance to surveyors regarding the procedures for conducting exit conferences, specifically related to the sharing of regulatory tags. There are significant changes to the exit conference process in this memo. In addition to the guidance in this memo, CMS has also given direction that the staff identifier list is not to be released even if requested. This guidance applies to Medicare/Medicaid certified homes only. The Section for Long-Term Care Regulation will implement these changes no later than March 31, 2016.
Please see the memo and attachments below or visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-16-11.html?DLPage=2&DLEntries=10&DLSort=3&DLSortDir=descending.
SC16-11-ALL Memo
SC16-11-ALL.02 SOM Chapter 2
SC16-11-ALL.03 SOM Chapter 5
SC16-11-ALL.04 SOM Appendix P
CMS Memo S&C 16-13-NH: Payroll-Based Journal (PBJ) – Implementation of required electronic submission of Staffing Data for Long Term Care (LTC) Facilities
Information about the requirement for LTC facilities to electronically submit staffing data through the PBJ:
- We remind providers of the voluntary submission period ending June 30, 2016, and the mandatory submission period beginning July 1, 2016.
- Restate instructions on how to register and where to find instructions to submit data.
- Notify stakeholders of the posting of the revised and final PBJ policy manual and related information at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html
- Note, the Centers for Medicare & Medicaid Services (CMS) may use its enforcement authority for noncompliance with the requirement to submit data.
Please see the memo here for details.
CMS Five-Star Quality Rating System Improvements
Please see the PowerPoint presentation below regarding improvements to the Nursing Home Compare Five-Star Quality Rating System.
Most Frequently Cited Deficiencies Report – 4rd Quarter 2015
Please view the quarterly report from the Section for Long-Term Care Regulation here.
New Licensure and Certification Unit Manager
The Section for Long Term Care Regulations welcomes Shay Patterson as the manager for the Licensure and Certification Unit. Shay has been with the Section for several years, starting in Region 6 as a Facility Surveyor and most recently as part of the Regulation and Compliance Unit. Shay is replacing Tracy Niekamp who accepted a position with the Department of Mental Health. Please contact Shay with any licensure or certification questions; she will be happy to assist you.
Most Frequently Cited Deficiencies Report – 3rd Quarter 2015
Please view the quarterly report from the Section for Long-Term Care Regulation here.
Submitting Exceptions & Second Business Requests
The Regulation Unit has established an email account that providers can now submit all their requests to one email address: RegulationUnit@health.mo.gov. Providers are to begin utilizing this email as soon as possible.
The main number for contacting the Regulation Unit has also been updated.
The instructions for submitting the Exceptions and Second Business requests have both been updated. Please see those instructions below.
Instructions for Exceptions Request
Instructions for Second Business Request
Region 7 – 2015 Annual Long-Term Care Provider Meeting
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
November 4, 2015: Region 7
Location: St. Louis, MO
As requested, SLCR will be hosting separate meetings for ICF/SNF and RCF/ALF care providers this year. Advance registration is not required.
Please see the agenda and handouts for this specific location attached. These handouts attached will not be provided at the meeting so please print them and bring them with you.
2015 Provider Meeting Agenda- Region 7
Ameren Missouri
Money Follows the Person
Social Media in Long-Term Care
Path to Safety, Minimal Assistance, More than Minimal Assistance
Region 4 – 2015 Annual Long-Term Care Provider Meeting
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
October 28, 2015: Region 4
Location: St. Joseph, MO
As requested, SLCR will be hosting separate meetings for ICF/SNF and RCF/ALF care providers this year. Advance registration is not required.
Please see the agenda and handouts for this specific location attached. These handouts attached will not be provided at the meeting so please print them and bring them with you.
The agendas and handouts for the other provider meeting locations will be announced closer to their meeting dates.
2015 Provider Meeting Agenda- Region 4
Request Denied- Simple Environmental Changes to Increase Active Engagement
Money Follows the Person
Social Media in Long-Term Care
Path to Safety, Minimal Assistance, More than Minimal Assistance
Region 3 – 2015 Annual Long-Term Care Provider Meeting
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
October 29, 2015: Region 3
Location: Kansas City, MO
As requested, SLCR will be hosting separate meetings for RCF/ALF and ICF/SNF care providers this year. Advance registration is not required.
Please see the agenda and handouts for this specific location below. These handouts attached will not be provided at the meeting so please print them and bring them with you.
The agendas and handouts for the other provider meeting locations will be announced closer to their meeting dates.
2015 Provider Meeting Agenda- Region 3
Money Follows the Person
Social Media in Long-Term Care
Path to Safety, Minimal Assistance, More than Minimal Assistance
Region 1 – 2015 Annual Long-Term Care Provider Meeting
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
October 23, 2015: Region 1
Location: Springfield, MO
As requested, SLCR will be hosting separate meetings for RCF/ALF and ICF/SNF care providers this year. Advance registration is not required.
Please see the agenda and handouts for this specific location below. These handouts attached will not be provided at the meeting so please print them and bring them with you. **The Partnering for the Protection of the Vulnerable Population presentation handouts are not included but will be provided at the meeting.
2015 Provider Meeting Agenda- Region 1
Path to Safety, Minimal Assistance, More than Minimal Assistance
Social Media in Long-Term Care
Money Follows the Person
Partnering for the Protection of the Vulnerable Population
Certificate of Need (CON) Quarterly Survey
The 3rd Quarter 2015 CON quarterly survey opened on October 1, 2015 and is due by October 15, 2015. Facility administrators will be receiving a post card in the mail with the Facility Number and PIN, which are needed to log in. This information can be found above the facility name on the post card. The Facility Number and PIN have not changed, so you can also obtain this information from past survey letters. Be sure to record and save these numbers for future surveys.
Survey instructions are available once you are logged in, and can be found by pressing HELP at the bottom of the survey. If you have any questions, please send an email to consurvey@health.mo.gov or call 573-526-8553.
Per 19 CSR 30-82.010 (8) Every skilled nursing facility, intermediate care facility, residential care facility and assisted living facility issued a license or temporary operating permit by the department shall submit the required certificate of need quarterly surveys to the department on or before the fifteenth day of the first month following the previous Social Security quarter.
Failure to respond could cause the facility to become ineligible for expansion under CON law. It could also result in a competitor being granted a CON to build or expand in the facility’s service area.
SLCR Region 1 Manager Announcement
It is with great pleasure that SLCR announces the appointment of Ruth Tuttle as the SLCR manager for Region 1 located in Springfield. Ruth’s promotion was effective September 16, 2015. Ruth has been with the section for several years and has held positions as a Facility Inspector, Facility Surveyor II and most recently as a Facility Surveyor III. In her most recent role as an FSIII, Ms. Tuttle supervised the Complaint Team and the Assisted Living and Residential Care Inspection Team. Ms. Tuttle welcomes your telephone calls at (417)895-6435.
Region 5 – 2015 Annual Long-Term Care Provider Meeting
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
October 2, 2015: Region 5
Location: Macon, MO
As requested, SLCR will be hosting separate meetings for ICF/SNF and RCF/ALF care providers this year. Advance registration is not required.
Handouts will not be provided at the meeting so please print them and bring them with you. Please see the agenda and handouts for this specific location below.
2015 Provider Meeting Agenda- Region 5
Misappropriation: Medication Theft
Money Follows the Person
Social Media in Long-Term Care
Path to Safety, Minimal Assistance, More than Minimal Assistance
Most Frequently Cited Deficiencies Report – 2nd Quarter 2015
Please view the quarterly report from the Section for Long-Term Care Regulation here.
2015 Annual Long-Term Care Provider Meetings – Save the Date Updated
*UPDATED*
Sponsored by the Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation
Coming to the following locations:
October 2, 2015: Region 5 – Macon, MO
October 23, 2015: Region 1 – Springfield, MO
October 28, 2015: Region 4 – St. Joseph, MO
October 29, 2015: Region 3 – Kansas City, MO
November 3, 2015: Region 2 – Cape Girardeau, MO
November 4, 2015: Region 7 – St. Louis, MO
November 16, 2015: Region 6 – Jefferson City, MO
As requested, SLCR will be hosting separate meetings for ICF/SNF and RCF/ALF care providers this year! Advance registration is not required. Times for each meeting have been set and added to the flyer. Please see the updated flyer here for more details.