Category: CMS

New Quality in Focus Videos Available

The Centers for Medicare and Medicaid Services (CMS) recently added four new Quality in Focus (QIF) videos to its Quality, Safety & Education Portal (QSEP). The video modules address commonly cited deficiencies in long term care related to food safety requirements, infection prevention and control, and developing a plan of Correction. These videos are available on demand, 24/7.
To access the videos, log into QSEP, then select the ‘Quality in Focus’ tab to access the newest videos and others in the series. For all technical issues and those requiring an urgent response, such as accessing the training, email helpdesk@qsep.org. For all content-related questions, email QSOG_GeneralInquiries@cms.hhs.gov​.  ​

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CMS Posts Updated Draft MDS 3.0 Item Sets

The Centers for Medicare and Medicaid Services (CMS) recently posted an updated version of the draft Minimum Data Set (MDS) 3.0 Item Sets v1.20.1v3 and draft Item Matrix v1.20.1v3. These are located in the Downloads section on CMS’ Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Of note, CMS removed Section R from these documents.
This version of the MDS item sets does not include items R0310. Living Situation, R0320. Food, R0330. Utilities. It also replaces item R0340. Transportation with item A1255. Transportation.
The final MDS item sets v1.20.1 will be posted in late summer, depending on the decisions finalized in rulemaking. The SNF PPS Proposed Rule is available here​.

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CMS Posts Updated Five-Star Quality Rating Program Technical User’s Guide

​The updated Nursing Home Care Compare Technical Users’ Guide has been posted on the Centers for Medicare and Medicaid Services’ (CMS’) Five Star Quality Rating System Page.  

Effective with the January 2025 refresh (expected on January 29th), CMS will unfreeze four quality measures (QMs) that were frozen beginning with the April 2024 refresh. These measures were updated to accommodate recent changes to the Minimum Data Set (MDS). Please refer to the CMS Memorandum QSO-25-01-NH for more information about these updates. 

Survey Tip: Transfer and Discharge Pt. 2

A new survey tip has been posted to the AHCA Survey Regulatory page​ for your review. In the Survey Tip section, on the Survey Regulatory page, you will find tips related to recently noted survey trends. In the latest survey tip​, you will find information about regulations for transfer and discharge of residents. The tip sheet provides tips regarding F625- Notice of bed-hold policy and return.

For more tips related to transfer and discharge, please visit the Discharges- Making the Safest Transition for Your Residents webinar on ahcancalED. Email any questions regarding survey prep to regulatory@ahca.org.

Survey Tip – Transfer and Discharge

A new survey tip has been posted to the AHCA Survey Regulatory page for your review. In the Survey Tip section on the Survey Regulatory page, you will find tips related to recently noted survey trends. In the latest survey tip, you will find information about regulations for the transfer and discharge of residents. The tip sheet provides tips regarding F623, Notice Before Transfer.
For more tips related to transfer and discharge, please visit the “Discharges – Making the Safest Transition for Your Residents” webinar on ahcancalED​. Email any questions regarding survey prep to regulatory@ahca.org.

Don’t Let Popcorn Affect Your Next Life Safety Survey

The only thing better than eating fresh popcorn is enjoying the mesmerizing entertainment it provides during the explosive transformation of the kernels.  How that transformation occurs, however, can have an impact on life safety compliance and subsequently your survey results.

Find the full article at https://www.ahcancal.org/News-and-Communications/Blog/Pages/Don%E2%80%99t-Let-Popcorn-Affect-Your-Next-Life-Safety-Survey.aspx

CMS Releases Revised Guidance for the LTC Facility Assessment

Today, the Centers for Medicare and Medicaid Services (CMS) released the revised guidance for the Long-term Care Facility Assessment regulation (QSO-24-13-NH), as part of the federal staffing mandate finalized last month.

The revised regulatory requirements have been moved from 42 CFR 483.70 to 42 CFR 483.71.  Existing regulations at 42 CFR 483.70(f) through (q) have been redesignated as paragraphs (e) through (p), respectively. The revised guidance notes that surveyors should determine whether a facility assessment contains the required components under the regulation; they should not evaluate the quality of the assessment.
The revision to the facility assessment regulation at F838 takes effect and must be implemented by August 8, 2024.
Areas added to the guidance to determine compliance include but are not limited to the following:
  • The facility assessment includes an evaluation of the resident population, and its needs (e.g., acuity) based on evidence-based, data driven methods.
  • The facility assessment reflects the population.
  • The facility assessment addresses the facility’s resident capacity.
  • The facility assessment includes information on the staffing level(s) needed for specific shifts, such as day, evening, and night and adjusted as necessary based on changes to resident population.
  • The facility assessment addresses what skills and competencies are required by those providing care.
  • The facility assessment is conducted with input from the individuals stated in the regulation (483.71(b))
  • The facility assessment indicates what resources, including but not limited to, equipment, supplies, services, personnel, health information technology, and physical environment are required to meet all resident needs.
  • The facility has a plan for maximizing recruitment and retention of direct care staff.
  • The facility assessment includes a contingency plan that is informed by the facility assessment.
AHCA is reviewing the guidance and will share helpful resources soon. Please reach out to regulatory@ahca.org​ with any questions.

Cybersecurity Safety is Patient Safety!

Post-acute care facilities play a unique and critical role in the health care ecosystem. However, with this specialized focus comes distinct challenges in the realm of cybersecurity. Additionally, the recent staffing mandates announced by the Centers for Medicare & Medicaid Services (CMS) as of April 22, 2024, pose further hurdles, potentially straining resources and complicating cybersecurity efforts.

Find out more by going to https://www.providermagazine.com/Articles/Pages/Cybersecurity-Safety-Is-Patient-Safety.aspx

Survey Tip: Documenting Protection on Abuse Reporting

A new survey tip has been posted to the AHCA Survey Regulatory page for your review. In the new Survey Tip section, on the Survey Regulatory page, you will find tips related to recently noted survey trends. In the latest survey tip, you will find tips to ensure you are protecting resident(s) from further abuse, and sufficiently documenting the protection you have provided/are providing residents on both your initial abuse reporting and your 5-day working report to the State Survey Agency.
For additional information about abuse, neglect, and misappropriation of resident property, please review the webinar series on ahcancalED. The series also provides individual tip sheets for each F-tag associated with abuse. If you have any topics or suggestions for future survey tips, or survey/regulatory questions, please send them to regulatory@ahca.org​.

Navigating “Safety” in Long Term Care Centers: Separating the Roles of OSHA and the CMS requirements for Emergency Preparedness

Continuation: 

In this third article regarding the connection between the Occupational Safety and Health Administration (OSHA) and the Centers for Medicare & Medicaid Services (CMS) Life Safety and Emergency Preparedness (EP) Requirements, the focus will be on how OSHA’s regulations overlap with CMS’ EP requirements, found in 42 CFR 483.73 (Appendix Z).
It’s important to note that CMS’ EP requirements do NOT apply to assisted living, however any OSHA requirements do apply.