S&C Memo: 17-43-ALL: Quality and Certification Oversight Reports (QCOR) Website Launch
New Website Platform and Data System: The Centers for Medicare & Medicaid Services (CMS) is releasing information related to the new QCOR website in an overarching initiative for increased transparency.
Please see the full memo at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-43.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending.
S&C Memo: 17-25-NH: Electronic Staffing Submission – Payroll-Based Journal Update
- Mandatory staffing data submission through the Payroll-Based Journal began July 1, 2016. Providers are reminded that they have until the 45th day after the end of each quarter to submit data.
- To help providers improve their submissions, the Centers for Medicare & Medicaid Services (CMS) is providing feedback on each facility’s data through their monthly Provider Preview reports.
- The Nursing Home Compare website now reflects whether providers have submitted data by the required deadline. Additionally, providers that have not submitted any data for two consecutive deadlines will have their overall and staffing star ratings suppressed.
- We are updating the data submission requirements related to hire and termination dates, and converting three job codes as optional for submission.
Please see the memo attached for more details or visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-25.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C 17-22-ALL: Save the Date- Medicare Learning Network (MLN) Conference Call National Provider Call (NPC) for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
- The Centers for Medicare & Medicaid Services (CMS) MLN will host a NPC for the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule.
- The calls are open to providers, suppliers, State Survey Agencies (SAs), Regional Offices (ROs) and the general public.
- CMS has received multiple requests by providers, suppliers, States and associations to present at annual conferences regarding the new final rule for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers. Due to the large number of speaking requests, CMS is offering an additional learning session through the MLN. During the additional session, we will provide an overview of the final rule and discuss the requirements for meeting the training and testing requirements by the implementation date of November 15, 2016.
Date: Thursday, April 27, 2017
Time: 2:30pm-3:30pm ET
Topic: Review of provisions and focus on Training and Testing Requirements
Please see the attached memo or 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-17-22.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C 17-21-ALL: Information to Assist Providers and Suppliers in Meeting the New Training and Testing Requirements of the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule
- Information for Implementation: The Centers for Medicare & Medicaid Services (CMS) is providing information to assist providers and suppliers in meeting the Training and Testing requirements of the new Emergency Preparedness Final Rule that was published on September 16, 2016 (81 FR 63860) and became effective on November 15, 2016.
Please see the S&C attached or 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-17-21.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C Memo 17-20-NH: Fiscal Year (FY) 2017 Special Focus Facility (SFF) Program Update
- Total SFF slots and candidates for each State: The number of designated slots and candidates for FY 2017 (see Appendix A) will not change from those effective since May 1, 2014.
- Initial selection notice: The State Survey Agency (SA) must notify the provider in writing of their SFF selection and conduct a meeting (either onsite or via telephone) with the nursing home’s accountable parties, and the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO), if the RO wants to be included.
- Graduation from the SFF program: Once an SFF has completed two consecutive standard surveys with no deficiencies cited at a scope and severity of “F” or greater (or “G” or greater for Life Safety Code (LSC) deficiencies), and has had no complaint surveys with deficiencies at “F” or greater (or “G” or greater for Life Safety Code (LSC) deficiencies) in between those two standard surveys, the facility will graduate from the SFF program. However, if the only deficiency preventing graduation is an “F” level deficiency for food safety requirements (42 CFR §483.60(i) Tag F371), the RO has discretion to allow the facility to graduate from the SFF program. F371 deficiencies at a “G” level or greater will prevent the facility from graduating from the SFF program.
- Authority for termination: Consistent with longstanding authority, the CMS ROs may use discretionary termination for SFFs (or any facility) if necessary to protect resident health and safety.
Please see the S&C memo and appendices attached for more details or visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-20.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
CMS Direction Regarding IDR’s
The Section for Long Term Care had a conversation with CMS in 2016 regarding the IDR/IIDR Review Release Process. CMS Regions V and VII recently provided guidance on this topic. The Missouri IDR process for certified homes has been to send the Primaris decision letter along with our own letter upon review and completion of the IDR process. We have been instructed by CMS that the third party (Primaris) decision and rationale can no longer be shared with the providers. Following is an excerpt of this guidance. The S&C referenced below is attached for your review.
S&C Memo 12-08-NH provided Interim Advance Guidance for IIDRs and provided some information that is one of the bases for our decision to take this approach: “[T]he documents and written report created by the Independent IDR entity, the State and CMS, other than the final decision of the Independent IDR process, are pre-decisional and deliberative, and therefore are protected from disclosure under the deliberative process privilege. See EPA v. Mink, 410 U.S. 73, 88 (1973); see also 5 U.S.C. § 522(b)(5) (inter-agency and intra-agency memoranda and letters generated before adoption of final agency policy or decision are protected from disclosure under Exemption 5 of the Freedom of Information Act).” (Please note the correct U.S. Code citation is actually 5 U.S.C § 552(b)(5).) Therefore, CMS asserts this privilege to not disclose documents used in our deliberative processes. Although the quoted language from the S&C Memo is not in SOM Chapter 7, the rationale remains sound.
We have communicated with the IDR Contractor about this change. Primaris will no longer prepare a letter to the provider and will simply provide their decision and rationale through memo format. Our office will continue to review the Primaris information and prepare a letter to the providers with the final decision. The Section will then forward the SLCR Decision letter to the provider. At no time can we disclose the Primaris decision and rationale. This change applies only to certified facilities. The process will not change for those facilities that are state-licensed only.
S&C: 17-17-ALL: Recommendations to Providers Regarding Cyber Security
Recommendations for Providers and Suppliers for Cyber Security: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.
Please see the attached for more information. The S&C can also be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-17.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C: 17-12-NH: Long-Term Care (LTC) Regulation: Enforcement of Rule Prohibiting Use of Pre-Dispute Binding Arbitration Agreements is Suspended so Long as Court Ordered Injunction Remains in Effect
- Enforcement Suspended Until and Unless Injunction is Lifted: The Centers for Medicare & Medicaid Services (CMS) will not enforce the new rule prohibiting skilled nursing facilities, nursing facilities and dually-certified facilities from using pre-dispute binding arbitration agreements while there
Please see the S & C attached or you may view it online at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-12.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending.
S&C 17-09-ALL: Infection Control Pilot: 2017 Update
Project Overview: The Centers for Medicare & Medicaid Services (CMS) is in the second year of a three year pilot project to improve assessment of infection control and prevention regulations in Long Term Care (LTC) facilities, hospitals, and during transitions of care. All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor.
Second Year Activities: Using draft surveyor Infection Control Worksheets (ICWS) based on the new Long Term Care regulation as well as a revised hospital surveyor ICWS, 40 hospital surveys will be paired with surveys of LTC facilities, in order to provide an opportunity to assess infection prevention during transitions of care. In addition, CMS will pilot technical assistance opportunities for facilities in efforts to improve their infection control programs to meet these new regulations. The draft ICWSs are attached to provide transparency of CMS pilot expectations.
Please see the S&C including all documents below or view it online at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-09.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending.
S&C 17-08-NH: Civil Money Penalty (CMP) Reinvestment Resource Web Page
A web page to house general information on the reinvestment of State CMP funds is now available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/LTC-CMP-Reinvestment.html. This web page serves as a location to house pertinent information for entities interested in applying for State CMP funds, States and Regional Offices (ROs), and other stakeholders.
CMS S&C Memo 17-05-ALL: Information on the Implementation Plans for the Emergency Preparedness Regulation
- Information for Implementation: The Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group is providing general information regarding the implementation plans for the new Emergency Preparedness Rule. The information addresses the implementation date for providers and suppliers, the development of Interpretive Guidelines (IGs), surveyor training and resources available to assist in the implementation of this regulation.
- Affects all 17 providers and suppliers: The regulation affects all 17 providers and suppliers and must be fully implemented by November 15, 2017.
The CMS memo is here 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-17-05.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending.
CMS S&C Memo 17-03-NH: Save the Date: Training for Phase 1 Implementation of New Nursing Home Regulations
- Need for Training: The Centers for Medicare & Medicaid Services (CMS) is developing an online training for Regional Offices (RO), State Survey Agencies (SA), providers and other stakeholders on the new Nursing Home Regulations.
- Training Content and Availability: The online training will include information about Phase 1 of new Nursing Home Regulations, and will be available to all parties starting November 18, 2016.
- Mandatory Requirement: All Long Term Care (LTC) surveyors are required to complete this training in order to be able to conduct any LTC surveys after November 28, 2016.
The CMS memo is 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-17-03.html?DLPage=1&DLEntries=10&DLFilter=nh&DLSort=2&DLSortDir=descending.
- This version of the MDS 3.0 RAI Manual incorporates the new Section GG: Functional Abilities and Goals, the new Part A PPS Discharge assessment, and clarifications to existing coding and transmission policy; it also addresses clarifications and scenarios concerning complex areas.
CMS Provider Training Regarding the new Section GG can be found on You Tube:
If you have any questions, please feel free to contact Stacey Bryan at (573)751-6308 or Stacey.Bryan@health.mo.gov.
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 attached or you may visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-33.pdf
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.
Please see the attached memo or 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
The Centers for Medicare & Medicaid Services (CMS) made several changes to the quality measure (QM) domain of the Five Star Nursing Home Quality Rating System. These include the addition of five new measures and several methodological changes.
The manual is available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf