• Advocating for Change: ICD-10 Mapping, Office of Management and Budget (OMB) Decreases, and COVID-19

    By Jessie McGill, RN, RAC-MT, RAC-MTA - June 16, 2020

    Rulemaking is the result of an extensive process. First, CMS proposes a change and allows for a comment period. After reviewing the submitted comments, CMS publishes the final rule. As a professional association, the American Association of Post-Acute Nursing (AAPACN) represents our members through collaboration and advocacy during this process. AAPACN, with expert panel members from both subsidiary associations—the American Association of Directors of Nursing Services (AADNS) and the American Association of Nurse Assessment Coordination (AANAC)—contributed comments to CMS on behalf of our members. The SNF PPS Proposed Rule for FY 2021 was released early this spring and comments were submitted by the June 9 deadline. Here is an overview of the topics in the proposed rule and AAPACN’s collaborative response:  

     

    The proposed rule covers the following areas:

    • Proposed SNF PPS Rate Setting Methodology and FY 2021 Updates

    • Consolidated Billing

    • Revisions to Regulation Text

    • Other Issues: Office of Management and Budget (OMB) Delineations

    • Technical Updates to Patient Driven Payment Model (PDPM) ICD-10 Mappings

    • SNF Value-Based Purchasing (SNF VBP)

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  • COVID-19: How to Prepare for a Second Wave

    By Caralyn Davis, Staff Writer - June 16, 2020

    The first wave of SARS-CoV-2, the virus that causes COVID-19, is diminishing in many of the states that were hit first (e.g., New York) but growing in other states that initially escaped the worst of the outbreak (e.g., Arkansas) and in some states that are moving to reopen quickly (e.g., Georgia). COVID-19 remains an unpredictable virus, says Alice Bonner, PhD, APRN, GNP, senior advisor for aging at the Institute for Healthcare Improvement in Boston, MA, and a member of the board of directors at AMDA – The Society for Post-Acute and Long-Term Care Medicine.

     

    “We can take our best experience and expertise and be logical and thoughtful, but we still don’t know what will happen next,” explains Bonner. “For example, as states move through the three phases of reopening, some states have seen an uptick in COVID-19 cases, and we don’t know if those upticks will flatten out or if those states will see new peaks in an extended first wave. Consequently, it’s important to think ahead, plan, and be strategic in planning for another outbreak.”

     

    No matter what happens with the ongoing first wave, most infectious disease specialists predict that a second wave will occur sometime this fall or winter, adds Laura Hofmann, MSN, RN, director of clinical and nursing facility regulatory services for LeadingAge Washington in Tacoma, WA. To prepare for another surge in COVID-19 cases, many providers are focused on establishing a testing program. However, nursing homes also can take the following steps:

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  • The Reality of the CMS Five-Star Program – Frozen or Not?

    By Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA - June 10, 2020

    The COVID-19 pandemic has inspired a flurry of news, updates, and clarifications as regulators and facilities alike attempt to respond to an evolving situation. Keeping straight what is happening in the world of long-term care has become even more of a challenge. One area nurse leaders and nurse assessment coordinators should be paying attention to concerns the Centers for Medicare & Medicaid Services (CMS) and what is happening to the Five-Star ratings for long-term care facilities.

    Before we break it down domain-by-domain, note that the Five-Star Quality Rating System is not totally frozen! For the present, only the health inspection domain rating will not change.

    Some of the numerous recent notices affecting the Five-Star program domains are:

    March 4, 2020 – Ref: QSO-20-12-All. Suspension of Survey Activities. CMS stated its commitment to taking critical steps to ensure America’s healthcare facilities were prepared to respond to the threat of the 2019 Novel Coronavirus (COVID-19). The memorandum announced that CMS was suspending non-emergency inspections. It also contained protocols for conducting the surveys and a copy of the Critical Element Pathway (CEP) for Infection Prevention Control & Immunization.

     

    March 23, 2020 – Ref: QSO-20-20-All. Prioritization of Survey Activities. The targeted plan for surveys was implemented to allow CMS to focus inspections on the most urgent situations. The 28-page document contained the COVID-19 Focused Survey for Nursing Homes tool (3/20/20) and a summary of the protocols for off-site activity, onsite survey activity, and facility self-assessment. Over a three-week timeframe, the types of inspections that were prioritized and conducted were:

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  • How Therapy Can Support Reimbursement and Care Planning

    By Caralyn Davis, Staff Writer - June 10, 2020

    In the COVID-19 pandemic, some states now are seeing a decrease in cases, while others have continued growth, especially in rural and suburban areas. Much of the COVID-19 response is becoming localized to meet these varying caseloads, but one consistent factor nationwide for nursing homes is the continuing need for vigilance and preparedness given how quickly an outbreak can spread among residents and staff. The expectation among public health experts is that all states will see at least a second wave and perhaps multiple waves of cases before a vaccine is available to force a slowdown and potentially eradicate the spread of SARS-CoV-2, the virus that causes COVID-19.

     

    “This pandemic has brought to the forefront the need to have all hands on deck,” says Amy Hobbs, PT, a board-certified clinical specialist in geriatric physical therapy and National Business Leader of Clinical Operations for Accelerated Care Plus in Reno, NV. “Providers must have a strategic and aligned interdisciplinary approach to provide a resident-centered plan of care in spite of all the environmental challenges that come with COVID-19 response.”

     

    An optimal interdisciplinary approach requires that providers put into practice the strong communication and teamwork processes that sometimes fall by the wayside when staff are stressed and stretched thin, says Hobbs. “You want to make sure that each discipline is both documenting their observations and assessments and reaching out to the appropriate nursing staff when they recognize any changes of condition. This applies not only to physical therapy (PT), occupational therapy (OT), and speech-language pathology services (SLP) but also to activities, dietary, social work, and all other team members who are active participants in the resident’s care. With the crush of COVID-19, the onus is on the whole team to make sure quality-of-life and quality-of-care needs are identified on the care plan and provided on the floor.”

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  • COVID-19 NHSN Nursing Home Data Will Be Publicly Reported Weekly (6/20)

    By CMS - June 08, 2020
    On June 4, 2020, the Centers for Medicare & Medicaid Services (CMS) posted the first set of underlying coronavirus disease 2019 (COVID-19) nursing home data. This data shows that as of May 31, 2020, about 13,600 nursing homes – approximately 88 percent of the 15,400 Medicare and Medicaid nursing homes – had reported the required data to the (CDC). These facilities reported over 95,000 confirmed COVID-19 cases and almost 32,000 deaths. The next set of data will be updated in two weeks.  Going forward after that date, CMS plans to update the data weekly.
    On June 4, 2020, the Centers for Medicare & Medicaid Services (CMS) posted the first set of underlying coronavirus disease 2019 (COVID-19) nursing home data. This data shows that as of May 31, 2020, about 13,600 nursing homes – approximately 88 percent of the 15,400 Medicare and Medicaid nursing homes – had reported the required data to the (CDC). These facilities reported over 95,000 confirmed COVID-19 cases and almost 32,000 deaths. The next set of data will be updated in two weeks.  Going forward after that date, CMS plans to update the data weekly.
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  • COVID-19 Targeted Inspection Results Will Post Monthly (6/20)

    By CMS - June 08, 2020

    On June 4, 2020, the Centers for Medicare & Medicaid Services (CMS)announced the release of the results from the targeted inspections announced on March 4, 2020, to allow inspectors to focus on the most serious health and safety threats like infectious diseases and abuse during the pandemic. Since March 4, CMS and its network of state-based inspectors have conducted over 8,300 surveys with the results of a total of 5,700 available as of June 4. CMS plans to post the results of the inspections monthly on an ongoing basis as they are completed.

    While the results of health inspections conducted on or after March 4, 2020 will be posted publicly, they will not be used to calculate a nursing home’s health inspection star ratings. Per CMS's April 24, 2020 memorandum, the inspection domain of the Nursing Home Compare website will be held constant temporarily due to the recent prioritization and suspension of certain surveys, to ensure the rating system reflects fair information for consumers.

    Targeted Inspection Results

     

    Memo # QSO 20-33-NH

    Posting Date 2020-06-04

    Fiscal Year 2020

    Summary

    • Nursing Home Inspections: CMS will post health inspection (i.e., surveys) results that were conducted on or after March 4th, 2020, which is the first date that CMS altered the way that inspections are scheduled and conducted. This includes inspections related to complaints and facility-reported incidents (FRIs) that were triaged at the Immediate Jeopardy (IJ) level, and the streamlined Infection Control inspection process that was developed based on the guidance for preventing the spread of COVID-19.

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  • October 1, 2020, Final Section S Items for the MDS 3.0 (6/20)

    By QTSO - June 04, 2020
    • October 1, 2020 Final Section S Items Revised [PDF 136 KB] (posted 06/04/2020) There are no new Section S items being added for 2020. There are revisions to the existing Section S items.
    • Additional Items Required by States [PDF 46 KB] (posted 06/04/2020)
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  • May and August 2019 SNF QRP Provider Training Q&As Available (6/20)

    By CMS - June 04, 2020
    A Q&A document supporting the SNF QRP Provider Trainings that took place May 7 and 8, 2019 and August 13 and 14, 2019 is now available.
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  • CMS QSO Memo: Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results (6/20)

    By CMS - June 02, 2020

    The Centers for Medicare & Medicaid Services (CMS) unveiled enhanced enforcement for nursing homes with violations of longstanding infection control practices. The enhanced and targeted accountability measures are based on early trends in the most recent data regarding incidence of COVID-19 in nursing homes, as well as data regarding the results of the agency’s targeted infection control inspections. CMS is increasing enforcement (e.g., civil money penalties (CMPs)) for facilities with persistent infection control violations, and imposing enforcement actions on lower level infection control deficiencies to ensure they are addressed with increased gravity.

    The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) provided additional funding to CMS for necessary survey and certification work related to COVID-19, of which $80 million in new resources will be available for states to increase surveys. To ensure effective oversight is achieved, CMS will allocate the CARES Act funding based on performance-based metrics. States that have not completed 100 percent of focused infection control surveys of their nursing home by July 31, 2020 will be required to submit a corrective action plan to their CMS location outlining the strategy for completion of these surveys within 30 days.  If, after the 30-day period, states have still not performed surveys in 100 percent of nursing homes, their CARES Act fiscal year 2021 allocation may be reduced by 10 percent.  Subsequent 30-day extensions could result in an additional 5 percent reduction. These funds would then be redistributed to those states that completed 100 percent of their focused infection control surveys by July 31.

    Utilizing the CARES Act funding, states will be required to perform on-site surveys of nursing homes with previous COVID-19 outbreaks and will be required to perform on-site surveys (within three to five days of identification) of any nursing home with new COVID-19 suspected and confirmed cases.

    To help nursing homes implement infection control best practices, CMS will provide technical assistance through Quality Improvement Organizations (QIOs). CMS and the Centers for Disease Control and Prevention (CDC) will continue to monitor the data it receives through the new nursing home COVID-19 surveillance system to identify nursing homes with outbreaks and work with Governor’s offices and states to keep nursing home residents safe.

    Since April 19, 2020, CMS has required nursing homes to inform, residents, their families, and representatives of COVID-19 cases in their facilities. For the first time, nursing homes are required to report COVID-19 cases and deaths directly to the CDC on an ongoing basis as the result of an unprecedented CMS regulatory requirement issued on May 1, 2020. The Trump Administration implemented the new reporting requirement to develop a robust federal disease surveillance system to quickly identify problem areas and inform future infection control actions. The reporting requirement applies to long-term care facilities only (also known as skilled nursing facilities and nursing facilities, and generally as nursing homes). By law, CMS regulates and oversees nursing homes, which are certified to provide Medicare and/or Medicaid skilled nursing facility services. Therefore, the data does not include COVID-19 data from assisted living facilities, which are not regulated at the federal level.

    As of May 24, 2020, about 12,500 nursing homes – approximately 80 percent of the 15,400 Medicare and Medicaid nursing homes – had reported the required data to the CDC. These facilities reported over 60,000 confirmed COVID-19 cases and almost 26,000 deaths. Of the nursing homes that reported data, approximately one in four facilities had at least one COVID-19 case, and approximately one in five facilities had at least one COVID-19 related death.  Early analysis shows that facilities with a one-star quality rating were more likely to have large numbers of COVID-19 cases than facilities with a five-star quality rating. CMS will take enforcement action against the nursing homes that have not reported data into the CDC as required under CMS participation requirements.

    CMS will post the underlying CDC-collected data on a link on Nursing Home Compare later this week, so the public can view general information of how COVID-19 has impacted nursing homes in a user-friendly format. The data will be broken down by state, number of residents and number of staff.  The data will be searchable by facility name and will be downloadable so researchers and other stakeholders can perform their own in-depth analysis.  CMS will update the data weekly. CMS will also post a link to the data on the home page of the Nursing Home Compare website so patients, residents, and families can easily find it. Nursing Home Compare is a valuable tool for patients, residents, and families to understand the quality of nursing homes and to support their healthcare decisions. Adding this information only increases its value and reinforces CMS’s commitment to transparency.

    CMS is ratcheting up penalties for noncompliance with infection control to help prevent backsliding, improve accountability, and ensure prompt compliance. Since February 2020 CMS has provided over 13 guidance documents and facts sheets pertaining to infection control and conducted weekly calls with nursing homes to share best practices from the field. The enhanced enforcement actions will increase penalties for nursing homes have had past infection control deficiencies.

    As part of CMS’s response to the COVID-19 pandemic, the agency prioritized the types of nursing home inspections that take place. On March 4, 2020 CMS prioritized inspections to allow inspectors to focus on the most serious health and safety threats like infectious diseases and abuse. On March 23, CMS suspended certain inspections to increase our focus on preventing the spread of COVID-19. Since March 4, CMS and its network of state-based inspectors have conducted over 8,300 surveys with the results of a total of 5,700 available today. There is currently wide variation in the number of focused infection control surveys of nursing homes performed by states, between 11.4 percent and 100 percent, with a national average of approximately 54.1 percent. CMS plans to post the results of the inspections later this week, on a monthly basis as they are completed.

    All of this information are being used to strengthen CMS enforcement action going forward, such that nursing homes are held accountable for resident care. Older Americans are particularly vulnerable to complications arising from the virus and nursing home residents have been uniquely affected. The Trump Administration is intensely focused on protecting this population, but it ultimately falls to the nursing homes themselves to ensure they provide care compliant with essential health and safety requirements.

    CMS is also providing additional support and technical assistance to low performing nursing homes through its QIOs. QIOs are organizations composed of health quality experts and clinicians that have experience in helping healthcare provider to improve the quality of care delivered to people with Medicare. CMS has now charged the QIOs to focus their efforts on providing education and training to all nursing homes in the country.  This will include weekly National Infection Control Training, which focuses on all aspects of infection control, prevention and management to help nursing homes prevent the transmission of COVID-19. 

    QIOs are also providing direct assistance to small and rural nursing homes and those serving vulnerable populations in areas where access to care is limited. The QIOs will help them understand and comply with CMS and CDC reporting requirements and, in some cases, they will provide on-site support to help nursing homes that have been identified as having the greatest needs in infection control. CMS will be working with Governors’ offices to direct QIOs to those nursing homes that have significant needs and have had outbreaks. QIOs will help these facilities create an action plan and implement specific steps to establish a strong infection control and surveillance program.

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  • Medicaid Program Integrity Manual update re: how UPICs do fraud referrals (6/20)

    By CMS - June 01, 2020

    SUBJECT: Update to Chapter 1 of Publication (Pub.) 100-15

    I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to update section 1.19 within Chapter 1 in Pub. 100-15.

    EFFECTIVE DATE: July 21, 2020 *Unless otherwise specified, the effective date is the date of service.

    IMPLEMENTATION DATE: July 21, 2020

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  • PBJ Provider User Guide V3.0.1, Incl. Error Messages / Descriptions - UPDATED (5/20)

    By QTSO - May 30, 2020
    This manual explains how to connect to the Payroll-Based Journal (PBJ) system and submit data. It also defines error messages and descriptions, identifying errors by number, severity, error message, and error description. The description section includes potential corrective actions for providers to take to resolve the errors.
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  • AAPACN Joins Coalition in Urging Congress to Enact Temporary and Targeted Liability Relief Legislation

    By AAPACN - May 27, 2020

    AAPACN joins coalition in urging Congress to enact temporary and targeted liability relief legislation related to the COVID-19 pandemic. 

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  • What the MDS Changes to Pressure Ulcers Means for Care Processes

    By Emily Royalty-Bachelor, Staff Writer - May 21, 2020

    The way the nurse assessment coordinator (NAC) is tracking pressure ulcers may have changed, but that doesn’t mean the nursing team’s care process should.

    As part of its annual October updates to the RAI User’s Manual, the Centers for Medicare & Medicaid Services (CMS) made some changes to how pressure ulcers are referred to and how they are coded.

    First and foremost, the RAI manual has broadened the scope of its terminology, to include pressure injuries rather than just pressure ulcers.

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  • What Is That Annoying Noise?

    By Jane Belt, RN, MS, RAC-MT, QCP - May 21, 2020

    Visitors to nursing facilities often say, “What is that noise I keep hearing? It is so loud!” For those of us who work in the facilities, we get so that we hardly notice it. You know, of course, that “that noise” is the nerve-rattling sound of personal alarms.

     

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  • Three Ways to Guard Against a COVID-19 Surge in Your Building

    By Caralyn Davis, Staff Writer - May 20, 2020

    COVID-19 can spread like wildfire. In some facilities, the number of suspected or confirmed cases has surged from zero to fifty or more seemingly overnight. Here are three steps that nurse assessment coordinators (NACs) can take to mitigate the risk of severe COVID-19 spread among residents:

     

    Do COVID-19 surveillance on an independent track

    The Centers for Disease Control and Prevention (CDC) recommends that nursing homes that have no suspected COVID-19 residents actively screen all residents upon admission and at least daily for fever and symptoms of COVID-19 in order to immediately isolate symptomatic residents and implement transmission-based precautions. Note: This is consistent with April 2 and March 13 guidance from the Centers for Medicare & Medicaid Services (CMS) and should be done in conjunction with similar recommendations for screening staff, as well as all visitors to the facility, to ensure comprehensive surveillance.

     

    If presumptive or confirmed COVID-19 residents are identified in the facility, the CDC recommends that providers monitor symptomatic residents “(including documentation of temperature and oxygen saturation) at least 3 times daily to … identify and quickly manage serious infection” and also to “consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new symptoms.” Note: This guidance is partially in Key Strategies to Prepare for COVID-19 in Long-term Care Facilities and partially in the Interim Additional Guidance.

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