Have you been to a QIPMO MDS Support Group Meeting lately??? You don’t have to be an MDS Coordinator to attend
Often, the topics discussed are beneficial not only for MDS Coordinators but also for floor nurses, Social Services staff, DONs, ADONS and Administrators. You can find a schedule of meetings and topics by going to the Nursing Home Help website found at http://www.nursinghomehelp.org/supgr.html. Some past topics have included Quality Measures, QRP requirements, Phase 1 and 2 Regulation Implementation, discussions with the State RAI Coordinator and State Surveyors, PPS Scheduling, CAA documentation, Care Plans, MDS Review for Social Workers, Wounds, Section GG Coding, Behavior Documentation and ICD-10 Coding. You are welcome to attend any meeting anywhere in the state, no RSVP needed.
QIES Security Notice: Disabling and Deleting Accounts (posted 05/16/2017)
To better secure our applications, QIES security will require each user to successfully login every 60 days, effective June 26, 2017. If this does not occur, the account will be disabled and can only be re-enabled by contacting the QTSO Help Desk at (800)339-9313.
Accounts that have no activity for more than 365 days will be deleted. Once your account is deleted, you will not be able to use or re-enable the account. If your account is deleted, you will need to request access through CMS as you did originally; you will be assigned a new User ID and password when the access is granted.
If you have any questions concerning this information, please contact the QTSO Help Desk at email@example.com or (800) 339-9313.
New SNF QRP Report Category and SNF Review and Correct Report
Effective June 1, 2017, a new report category called the SNF (Skilled Nursing Facility) Quality Reporting Program is available in the CASPER Reporting application. This report category contains the new SNF Review and Correct report.
The SNF Quality Reporting Program report category and SNF Review and Correct Report are available to all certified nursing-home and swing bed-based SNFs, corporate and third-party users responsible for submitting MDS 3.0 data for SNF providers, state users; QIO users, CMS Central Office and Regional Office users.
Data Calculation and Display
The SNF Review and Correct report displays facility-level results for the assessment-based quality measures listed below. MDS 3.0 data are used to calculate the quality measures.
- Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678).
- Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674).
- Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631).
If you have any questions concerning this information, please contact the QTSO Help Desk at firstname.lastname@example.org or 1 (888) 477-7876.
Delayed-Egress Locking Systems
National Fire Protection Association (NFPA) 101 2012 Delayed-Egress Locking Systems. 220.127.116.11.1.1 shows: Approved listed delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved supervised automatic sprinkler system in accordance with Section 9.7 and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:
- The door leaves shall unlock in the direction of egress upon actuation of one of the following:
- Approved, supervised automatic sprinkler system in accordance with Section 9.7
- Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6
- Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6
- The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.
- *An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 18.104.22.168.10 under all of the following conditions:
- The force shall not be required to exceed 15 lbf (67N).
- The force shall not be required to be continuously applied for more than 3 seconds.
- The initiation of the release process shall activate an audible signal in the vicinity of the door opening.
- Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
- *A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1⁄8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 (or 30) seconds.
Facilities may receive approval for 30 second release egress doors from the Authority Having Jurisdiction. For the facility to receive 30 second release approval, the facility must submit in writing to the Section for Long-Term Regulation (SLCR), a letter detailing the risk(s) to the residents and/or hardship. It will be the SLCR’s final decision on the approval of the extension and will be reflected in a letter to the facility. It will be the facility’s responsibility to retain the SLCR approval letter for future reference.
Failure to obtain an approval letter from the SLCR will place the facility in noncompliance with Federal participation requirements and in the event of a recertification survey or federal monitoring survey for life safety code, result in a citation.
The facility letter detailing the risk(s) to the residents and/or hardship and facility layout indicating affected doors, can be submitted to be Scott.Wiley@health.mo.gov
Lacoba Homes (II)
While attending an MC5 Southwest regional meeting in Springfield, Lacoba Homes Administrator Mike Baldus invited me to visit to see their new addition and renovations. I had previously visited Lacoba in 2013…read more and view photos, click here: Lacoba II
MANHA Annual Convention
- June 4-7, 2017: Taking Charge In A Whole New World
- Location: Camden on the Lake, Lake Ozarks
Please see the brochure on the MANHA event page.
HealthCare-Associated Infections Summer Workshops
- June 6-7, 2017: Central District HAI, Primaris, Columbia
- June 20-21, 2017: Southeastern District HAI, Saint Francis Medical Center, Cape Girardeau
- June 27-28, 2017: Eastern District HAI, Forest Park Drury Inn, St. Louis
- July 20-21, 2017: Northwestern District HAI, St. Joseph Medical Center, Kansas City
- July 25-26, 20107: Southwestern District HAI, Cox North Hospital, Springfield
Healthcare-Associated Infections (HAIs) cut across all care settings – acute, ambulatory and long-term. All settings are currently (or soon will be) required to have an infection control and prevention program including an antimicrobial stewardship plan. These workshops will provide the latest evidence regarding the prevention of HAIs across settings with a strong focus on incorporating this evidence in clinical practice. Regulatory considerations and specific strategies to bridge the gap in coordinating care when patients transition from one setting to another will be included.
Please see more information including the brochure and registration on the MU Sinclair School of Nursing’s page.
- June 8-9, 2017: 2017 Changing the Landscape of Long Term Care Conference
- Location: Renaissance St. Louis Airport Hotel and Friendship Village Sunset Hills
Hear national and local experts discuss dynamic strategies, innovative tools and available long-term care options.
The format has been set with two educational tracks throughout the day; one for professionals working in long-term care and one for the general public who are looking for answers to the complexity of long-term care.
See the registration packet for the full description of the topics and the national and local expert speakers.
Throughout the day there are multiple opportunities to interact with exhibitors who showcase long-term care services across Greater St. Louis.
In addition to hearing thought-provoking speakers, facility administrators and social workers earn 7.25 CEUs.
Registration for all includes breakfast and lunch.
Please see the VOYCE event page for more information.
2017 ALF Resident Assessment Trainings
- June 26-28, 2017: Best Western Capital Inn, Jefferson City
- October 30-31, 2017: Best Western Capital Inn, Jefferson City
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 Resident Assessment Training satisfies this regulatory requirement.
DON/Charge Nurse/CNA Conference – Readiness: Make it Happen!
- September 20-21, 2017: St. Louis
We are excited to invite Directors of Nursing, Charge Nurses, and Certified Nursing Assistants to attend an educational event catered to YOUR needs! This conference will be energetic and hands-on all while being in a learning environment. You will be given useful information to take back and implement in your home right away to better serve your residents. We will give you the confidence, knowledge, direction, and motivation needed to help you enhance your role of caring for the elderly.
Please see the full details including registration on MLN’s conference webpage.
New QIPMO Newsletter – May 2017
The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls – Volume 4, Issue 3.
Please visit QIPMO’s website here for this and other previous newsletters.
The National Consumer Voice for Quality Long-Term Care – New Briefs Available
- Three New Briefs Available in Series on Revised Nursing Facility Regulations
Consumer Voice, along with the Center for Medicare Advocacy and Justice in Aging, has released three new briefs in their issue brief series, “A Closer Look at the Revised Nursing Facility Regulations.”
- Return to Facility After Hospitalization – This brief explains bed hold rights when a resident returns to a facility after a hospitalization. The brief provides information on advance notification of bed hold rights and residents’ rights if they return to a facility after a bed hold period has been exceeded.
- Grievances and Resident/Family Councils – This brief covers the resident’s right to file grievances and the facility’s requirement to work to resolve those concerns promptly. Each facility must have a grievance policy and provide residents with information on how to file a grievance. Also, residents have a right to form a resident council, and family members and resident representatives have the right to form a family council. The facility must act upon council concerns and recommendations.
- Quality of Care – The substantive requirements for quality of care are retained in the revised regulations, and CMS has affirmed the regulations’ goals of supporting person-centered care and enabling each resident to attain his or her highest level of well-being. This brief covers those regulations as well as providing information on how the quality of care provisions have been reorganized in the revised regulations.
Read the other issue briefs in the series here.
Crimes Against Persons List
- Crimes Against Persons List
On January 1, 2017, revisions to the Revised Statutes of Missouri (RSMo) resulted in changes to the list of disqualifying crimes.
Involuntary Manslaughter, prior to January 1, 2017, could have been a Class A or B felony under Chapter 565, making it a disqualifying crime. On January 1, 2017, the classification of Involuntary Manslaughter was changed to a C or E felony, making it no longer disqualifying. Any A or B felony conviction of Involuntary Manslaughter prior to January 1, 2017 remains disqualifying.
Criminal Water Contamination was listed as a disqualifying crime in RSMo Chapter 569 prior to January 1, 2017. On January 1, 2017, it was moved to RSMo Chapter 577, making it no longer disqualifying. However, convictions prior to January 1, 2017, remain disqualifying.
Because of the potential confusion, SLCR is removing the list of disqualifying crimes from the website. Providers must review the criminal background check to determine if the crime is disqualifying. Disqualifying crimes are any A or B felony violation of Chapter 565, 566 or 569, RSMo, or any violation of subsection 3 of section 198.070, RSMo, or of section 568.020, RSMo.
An individual who has been disqualified from employment with any Long Term Care provider type has the right to apply for a Good Cause Waiver (GCW), which, if granted, would not correct or remove the finding, but would remove the hiring restriction and allow the individual to be employed. This includes those individuals who have committed a disqualifying crime and thus have been disqualified from employment in a regulated nursing home. More information about Good Cause Waivers can be found on the DHSS website at: http://health.mo.gov/safety/goodcausewaiver/.
If a provider has a question about a disqualifying crime or Good Cause Waivers, please feel free to contact the Section at 573-522-6228.
Top Deficiencies Report- 1st Quarter 2017
Please see the attached top deficiencies report from the first quarter of 2017.
IRF, LTCH, SNF QRP: Registration Open for Review and Correct Reports Provider Training – Live Webcast on May 2, 2017
CMS is hosting a live webcast for Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs) on Tuesday, May 2, 2017, from 2:00 to 3:30 p.m. ET.
This training will assist providers in better understanding how Review and Correct Reports fit within the overall Quality Reporting Programs. Additionally, the training will provide information about re-submitting data to correct errors prior to the quarterly submission deadlines to ensure the accuracy of the data which will ultimately be publicly displayed.
Visit the following webpages for more information and to register:
IRF Quality Reporting Training: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Training.html
LTCH Quality Reporting Training webpage
SNF Quality Reporting Training webpage
Effective April 13, 2017, questions regarding any of the Fee For Service Beneficiary Notice Initiative (BNI) notices may be sent to our new mailbox: BNImailbox@cms.hhs.gov.
The BNI notices are:
- FFS Advance Beneficiary Notice of Noncoverage (FFS ABN)
- FFS Home Health Change of Care Notice (FFS HHCCN)
- FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN) and SNF Denial Letters
- FFS Hospital-Issued Notices of Noncoverage (FFS HINNs)
- FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility (FFS Expedited Determination Notices)
- Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) (Hospital Discharge Appeal Notices)
- FFS Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (FFS NEMB SNF)
There is an exception for the Medicare Outpatient Observation Notice (MOON). Continue to send questions regarding the MOON to MOONMailbox@cms.hhs.gov.
A Quick Reference Guide for Skilled Nursing Facilities (SNFs) is now available. This guide include frequently asked questions, information on QRP help desks, and helpful links to additional resources for the QRP.
QRP – MDS Submission
The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Set (MDS) assessment data for October-December (Q4) of calendar year (CY) 2016 are due with this submission deadline. All data must be submitted no later than 11:59 p.m. Pacific Standard Time on May 15, 2017.
View the list of measures required for this deadline on the SNF Quality Reporting Program Measures and Technical Information webpage.: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html.
As a reminder, it is recommended that providers run the applicable CMS CASPER validation reports prior to each quarterly reporting deadline to ensure that all required data has been submitted. Providers are also encouraged to verify all facility information prior to submission, including their CCN and facility name. Only successful submissions will count toward your Annual Payment Update requirement.
For more information, view https://www.qtso.com/download/mds/MDS_3.0_Helpful_Hints.pdf
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.