CMS Direction Regarding IDR’s

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.

2017 Annual Provider Meetings Input

2017 Annual Provider Meetings Input

It’s a new year and your 2017 Provider Meetings are already in the works!  The Quality Assurance and Education Unit staff are currently in the planning phase and are considering the best topics to provide the most beneficial information.  We would like to hear from you about what LTC related topics you believe would be helpful, informative, and  ‘worth the drive’.  If you’ve also been thinking- Gee I wish they would do a presentation on……., then you are cordially invited to be part on our planning team!  Please feel free to forward your suggestions to:

Emergency Protocol Update/Reminder

Emergency Protocol Update/Reminder

SLCR developed a protocol for communication between long-term care homes and the Section for Long-Term Care Regulation (SLCR), in the event a disaster occurs that results in a loss of a necessary service (electricity, water, gas, telephone, etc.). This protocol was established to streamline communication so that homes can focus on what is most important – the safety and well-being of the residents.


The phone number for Region 5 (Macon) has changed. This is the only change to the document attached.



In just a few minutes, nurses can self-enroll into Nursys e-Notify for free and take advantage of a quick and convenient way to keep up-to-date with their professional licenses. They can receive licensure status updates, track license verifications for endorsement and create and manage multiple license expiration reminders. Keeping on top of license status can help nurses prevent fraudulent licenses or certificates being issued in their names.


If you only have one license, you may question why you need to do this. We have had cases come before the board where a nurse unknowingly practiced while his/her license was expired. This system will notify you before your license expires and when it expires. It is also possible that your license could be suspended for failure to comply with the tax law. You would receive a notification any time any discipline is attached to your license. Missouri is a member of the nurse licensure compact. Your multi-state license is tied to your primary state of residence. A change to your primary state of residence could change your multi-state license status. This system will notify you if that status changes. When you apply to renew your license or submit your license renewal online, your license is not automatically renewed. If you enroll in this system, you will be notified when your license is renewed. Those are just a few examples of how enrolling yourself in this system will protect the license you have worked so hard to obtain. This system pushes notification of changes to you rather than you having to continually re-query the system.


Creating an account is quick and easy. Enroll at and select “As a Nurse” to complete the registration process. Learn more about Nursys e-Notify by viewing an introductory video or visiting the Nursys website. For questions, contact


Nursys is the only national database for licensure verification for registered nurses (RNs), licensed practical/vocational nurses (LPN/VNs) and advanced practice registered nurses (APRNs). Nursys is designated as a primary source equivalent database through a written agreement with participating boards of nursing (BONs). Nursys is live and dynamic, and all updates to the system are reflected immediately, pushed directly from participating BON databases through frequent, secured data updates.

NEW FTags and Regulation Text

NEW FTags and Regulation Text

This attachmentcontains the new regulatory language for long term care.  The new regulations will be implemented in three phases.  The document is color-coded for ease of identifying the requirements in each phase.  The color codes are:

  • Phase 1 – Red – effective 11/28/16
  • Phase 2 – Blue – effective 11/28/17
  • Phase 3 – Green – effective 11/28/19

The training for Phase I is available to providers at the following link:

Self-Reporting Update

Self-Reporting Update

SLCR has revised the Self-Reporting guidance (attached) to reflect the new regulatory requirements effective 11/28/16 regarding reporting of allegations of abuse or incidents that result in serious bodily injury. The self-reporting timeframes for these two areas has been reduced significantly.  Please make sure these new requirements are implemented and policies and procedures are modified to reflect the changes.

ALERT: ICAPP Voluntarily Recalls Certain Lots of Frozen Strawberries

ICAPP Voluntarily Recalls Certain Lots of Frozen Strawberries

  • Some facilities in Missouri were identified on ICAPP’s Distribution List.  Please check your inventory if you received shipments from ICAPP.

The International Company for Agricultural Production & Processing (ICAPP) is voluntarily recalling certain lots of its frozen strawberries out of an abundance of caution in response to a U.S. Food and Drug Administration (FDA) investigation of an outbreak of Hepatitis A. For more information about this investigation, please visit FDA’s outbreak investigation website at The recalled products were all distributed for sale to and use in food service establishments nationwide — not for use in food products offered for retail sale to consumers. Nonetheless, ICAPP is issuing this news release publicly to help mitigate any possible risk to the public health and to fully ensure that all recalled products are recovered. Although none of ICAPP’s own testing through an established surveillance program or through third party testing of retained samples has identified the presence of Hepatitis A in any of its products, ICAPP has decided to recall all frozen strawberries that it has imported into the United States since January 1, 2016 out of an abundance of caution. No other ICAPP products, frozen or fresh, are covered by this voluntary recall. ICAPP is conducting this voluntary recall after learning that frozen strawberries that it distributed may be linked to a recent Hepatitis A outbreak in the United States. ICAPP has been engaged with FDA in its investigation of this outbreak and is taking this action in consultation with FDA because Hepatitis A virus was detected in four lots of frozen strawberries that were exported to the U.S. by ICAPP. ICAPP is working closely with all of the U.S. distributors of this product to ensure that this recall is effective. Hepatitis A is a contagious liver disease that results from exposure to the Hepatitis A virus, including from food. It can range from a mild illness lasting a few weeks to a serious illness lasting several months. Illness generally occurs within 15 to 50 days of exposure and includes fatigue, abdominal pain, jaundice, abnormal liver tests, dark urine and pale stool. Hepatitis A vaccination can prevent illness if given within two weeks of exposure to a contaminated food. In rare cases, particularly consumers who have a pre-existing severe illness or are immune compromised, Hepatitis A infection can progress to liver failure. Persons who may have consumed affected product should consult with their health care professional or local health department to determine if a vaccination is appropriate, and consumers with symptoms of Hepatitis A should contact their health care professionals or the local health department immediately. ICAPP is fully committed to producing safe and high quality products; consumer safety is its top priority. ICAPP is conducting a comprehensive review of all of its operations and its suppliers to ensure that the food it produces is safe. ICAPP continues to work closely with federal and state authorities and is conducting this recall in cooperation with FDA. For questions or more information, consumers may contact ICAPP by email at or by phone, between 9:00 am and 5:00 pm Cairo local time, at (201)-541-1624.

Reminder to Use Forms for Administrator and Director of Nursing Change

Use Forms for Administrator and Director of Nursing Change

  • Please remember the SLCR has developed forms for your convenience to use to notify the Licensure and Certification Unit if a change in Administrator or Director of Nursing has occurred in your facility.
  • The forms are located on LTC Application and Forms web page. The instructions for submission are included on the bottom of each form.

Oral Liquid Docusate Sodium Recall

The FDA and CDC announced the voluntary nationwide recall of oral liquid docusate sodium manufactured by PharmaTech and distributed by Rugby Laboratories.  The agency confirmed the product has been contaminated with Burkholderia cepacia, a bacteria linked to an outbreak in five states.  The bug, with resistance to some antibiotics, is more harmful in immunocompromised individuals.


More information can be found here.

Region 6 –Manager

Laura Smith

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

New State Law Effective August 28, 2016

Senate Bill 732

  • Senate Bill 732 established requirements for long-term care facilities to have policies and procedures that require the facility to give advance notification to emergency medical services personnel prior to the transportation of any at-risk behavioral health patient. An at-risk behavioral health patient is defined as any patient who displays violent, homicidal, or suicidal ideation or behavior.
  • There are other provisions of this law regarding emergency transports of at-risk behavioral patients that are of interest, but do not impose additional requirements on long-term care facilities.
  • Please review the bill and ensure appropriate policies and procedures are developed and implemented by the effective date of the legislation. Please contact Shelly Williamson, Assistant Administrator of the Section, at with any questions regarding these new requirements.

2016 Annual Provider Meetings

Please join us for one of the 2016 Annual Long Term Care Provide Meeting.

  • Region 1 –September 15, 2016-
    Cox Medical Center, South Foster Auditorium
    3801 South National Avenue, Springfield
  • Region 2 –November 4, 2016-
    Southeast HEALTH, Harrison Room
    1701 Lacey Street Cape Girardeau
  • Region 3 –September 28, 2016-
    Hilton Garden Inn Independence, Independence Room
    19677 E. Jackson Drive, Independence
  • Region 4 –September 27, 2016-
    Stoney Creek Inn, Frontier Room
    1201 Woodbine Road, St. Joseph
  • Region 5 –September 22, 2016-
    Macon Comfort Inn, Trophy/Maple Room
    1821 North Missouri, Macon
  • Region 6 –October 17, 2016-
    Governor’s Office Building, Room 450
    200 Madison Street, Jefferson City
  • Region 7 –October 6, 2016-
    Embassy Suites St. Louis Airport, Missouri Ballroom
    11237 Lone Eagle Drive, Bridgeton

The Provider Meetings will continue to be held in two sessions, the first session will be for Residential Care Facilities/ Assisted Living Facilities and the second session will be for the Skilled Nursing Facilities/Intermediate Care Facilities.  This year in order to avoid repetition in the program we will conduct a combined session for all provider types to cover topics of interest relevant to all.  The combined session will run from 10:15 until noon.  This session will include a presentation by the Missouri State Highway Patrol as well as a presentation regarding involuntary discharge.  Registration is not required.  CEU’s will be available for Nursing Home Administrators.

Presentation handouts will not be available on the day of each meeting but may be printed from the attachments.  Please see the attached 2016 Provider Meeting Agenda and Handouts.