Generated by All in One SEO Pro v4.9.10, this is an llms.txt file, used by LLMs to index the site. # CMS Compliance Group Defining Quality in Healthcare ## Sitemaps - [XML Sitemap](https://cmscompliancegroup.com/sitemap.xml): Contains all public & indexable URLs for this website. ## Posts - [CMS Makes It Official: Risk-Based Surveys Are Going Nationwide September 8](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-makes-it-official-risk-based-surveys-are-going-nationwide-september-8/) - CMS just confirmed risk-based nursing home surveys launch nationwide September 8, 2026. Only 12% of facilities qualify — here's what determines eligibility. - [New York Provider Alert: Criminal History Reference Checks](https://cmscompliancegroup.com/state-specific-updates/new-york-provider-alert-criminal-history-reference-checks/) - On July 7, 2026, The Office of the Inspector General (OIG) published a report which emphasized gaps in the New York State Department of Health’s (DOH) monitoring of nursing homes’ compliance with pre-employment background checks. The OIG has been conducting audits of different states to determine if information identified on background checks should have disqualified - [CMS Updated the Long-Term Care Survey Process Procedure Guide](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-updated-the-long-term-care-survey-process-procedure-guide/) - Effective June 23, 2026, CMS has released an updated LTCSP Procedure Guide. Per the Centers for Medicare & Medicaid Services Revision History document, revisions were made to the Survey Resources folder and Initial Surveys file on June 23, 2026. The updated Procedure Guide contains minor tweaks for survey teams related to iQIES when initiating a - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-3/) - Learn how small issues contribute to F689 accident hazards and what surveyors look for when assessing your facility’s accident‑prevention practices. - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 4)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-4/) - Explore common device‑related hazards under F689 and how misuse, poor maintenance, and system failures can lead to serious injuries and major citations. - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 5)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-5/) - Explore how high‑risk events under F689 reveal system failures in assessment, care planning, supervision, and communication — and why they’re never “one‑offs.” - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 6)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-6/) - Explore how elopement‑related IJ events occur under F689, why staff protocol failures are so dangerous, and what facilities must do to strengthen prevention systems. - [What Surveyors Actually Do — And What It Takes to Be Ready](https://cmscompliancegroup.com/resources/what-surveyors-actually-do-and-what-it-takes-to-be-ready/) - A CMS survey starts long before a chart is opened. CMSCG breaks down what surveyors actually do — from the initial tour to resident interviews to the medical record review — and what genuine readiness requires. - [New OIG Report Highlights Important PBJ Data Errors](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/new-oig-report-highlights-important-pbj-data-errors/) - The Office of the Inspector General (OIG) released a new report on June 18, 2026, “CMS’s Processes Were Not Effective in Ensuring the Accuracy of Staffing Information Reported in the Payroll-Based Journal.” The report reviewed Registered Nurse (RN) staffing hours submitted by nursing homes to the Payroll-Based Journal (PBJ) system in March 2024. While the - [NYSDOH DAL re Telehealth in Adult Care Facilities and Adult Day Programs](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-telehealth-in-adult-care-facilities-and-adult-day-programs/) - NYSDOH issues updated telehealth rules for Adult Care Facilities and Adult Day Programs, detailing permitted uses, restrictions, and provider compliance duties. - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 7)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-7/) - Final F689 series post: why strong fall and elopement prevention systems matter and how weak protocols can lead to F689, F610, and F609 citations. - [Updated LTCSP Survey Resources (April 30, 2026)](https://cmscompliancegroup.com/resources/updated-ltcsp-survey-resources-april-30-2026/) - Updated LTCSP Survey Resources became effective April 30, 2026. View Critical Element Pathways, current Ftag List and more. - [Are You Using the Current LTCSP Critical Element Pathways? (February 2026 Edition) - RETIRED](https://cmscompliancegroup.com/resources/ltcsp-critical-element-pathways-april-2026-edition/) - Ensure you’re using the current LTCSP CE Pathways. Our April 2026 resource list helps providers access the most up‑to‑date CMS LTCSP survey documents. - [Are You Using the Current LTCSP Critical Element Pathways? (April 30, 2026 Edition)](https://cmscompliancegroup.com/resources/ltcsp-critical-element-pathways-april-30-2026-edition/) - Are You Using the Current LTCSP Critical Element Pathways? (April 2026 Edition) CMS issued revised survey resources documents for April 30, 2026. - [Ftag of the Week – F628 Transfer and Discharge Process (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f628-transfer-and-discharge-process-pt-3/) - F628 Part 3 covers discharge summary requirements and key reminders about compliant transfer and discharge processes and surveyor expectations. - [Ftag of the Week – F628 Transfer and Discharge Process (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f628-transfer-and-discharge-process-pt-2/) - F628 Part 2 covers additional transfer/discharge requirements moved to F628, including bed‑hold policy notice and resident readmission rights. - [Ftag of the Week – F628 Transfer and Discharge Process (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f628-transfer-and-discharge-process-pt-1/) - F628 Part 1 covers transfer and discharge process requirements, including relocated F‑tags and notice requirements before a resident is moved or discharged. - [Ftag of the Week – F627 Inappropriate Transfers (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f627-inappropriate-transfers-pt-3/) - F627 Part 3 covers orientation for transfer/discharge, return rights, discharge summary requirements, and surveyor expectations for appropriate discharges. - [Ftag of the Week – F627 Inappropriate Transfers (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f627-inappropriate-transfers-pt-2/) - F627 Part 2 reviews CMS discharge planning requirements, facility responsibilities, and documentation expectations for determining appropriate and compliant discharges. - [Ftag of the Week – F627 Inappropriate Transfers (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f627-inappropriate-transfers-pt-1/) - F627 Part 1 covers inappropriate transfers and discharges, appeal‑pending rules, revised intent, and documentation requirements for compliant discharge decisions. - [Ftag of the Week - F620 Admissions Policy](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f620-admissions-policy/) - F620 details CMS rules for admissions policies, prohibited requirements, Medicaid‑pending issues, disclosures, and resident rights protections. - [Ftag of the Week – F621 Equal Practices Regardless of Payment Source](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f621-equal-practices-regardless-of-payment-source/) - F621 requires equal access to services and nondiscriminatory practices regardless of payment source, including notice requirements and surveyor focus areas. - [April 2026 Five-Star Technical Users’ Guide](https://cmscompliancegroup.com/resources/april-2026-five-star-technical-users-guide/) - CMS updates the April 2026 Five‑Star Technical Users’ Guide, revising antipsychotic QM calculations, exclusions, and scoring cut points for nursing homes. - [Ftag of the Week – F606 Not Employ/Engage Staff with Adverse Actions](https://cmscompliancegroup.com/blog/ftag-of-the-week-f606/) - F606 outlines facility responsibilities for screening staff for abuse‑related adverse actions, required checks, reporting duties, and links to F607 compliance. - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 4)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-4/) - F605 Part 4 reviews when GDRs are clinically contraindicated, required documentation, monitoring expectations, and common survey citation examples. - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-3-2/) - F605 Part 3 reviews CMS guidance on psychotropic medication dose, duration, and GDR, including definitions, timeframes, and documentation expectations. - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-2-2/) - F605 Part 2 covers CMS rules for psychotropic medication use, including GDR requirements, documentation, informed consent, and common survey citation issues. - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-1-2/) - F605 Part 1 outlines CMS requirements for protecting residents from chemical restraints, including definitions, regulatory intent, and resident rights. - [Ftag of the Week – F604 Right to be Free from Physical Restraints (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f604-right-to-be-free-from-physical-restraints-pt-3/) - Pt 3: Resident Requests, Bed Rails, Position‑Change Alarms, and Survey Considerations - [Ftag of the Week – F604 Right to be Free from Physical Restraints (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f604-right-to-be-free-from-physical-restraints-pt-2/) - F604 Part 2 explains CMS guidance on physical restraints used for convenience or discipline, including definitions, examples, and required assessment and care planning steps. - [Ftag of the Week – F604 Right to be Free from Physical Restraints (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f604-right-to-be-free-from-physical-restraints-pt1/) - F604 Part 1 explains CMS requirements for protecting residents from physical restraints, including definitions, permissible use, and facility responsibilities. - [Ftag of the Week – F603 Free from Involuntary Seclusion](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f603-free-from-involuntary-seclusion/) - Overview of F603, including CMS definitions of involuntary seclusion, key distinctions from allowable separation, and facility responsibilities for preventing improper isolation. - [Ftag of the Week – F602 Free from Misappropriation/ Exploitation](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f602-free-from-misappropriation-exploitation/) - Overview of F602, including CMS definitions of misappropriation and exploitation, facility responsibilities, and key expectations for preventing and addressing these incidents. - [Ftag of the Week – F600 Free from Abuse & Neglect (Part 4)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f600-free-from-abuse-neglect-pt4/) - F600 Part 4 examines CMS guidance on neglect, including indicators, facility responsibilities, and expectations for preventing harm under the abuse and neglect regulations. - [Ftag of the Week - F600 Free from Abuse and Neglect (Part 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f600-free-from-abuse-and-neglect-pt3/) - F600 Part 3 reviews CMS guidance on sexual abuse, consent, indicators, and facility response expectations under the updated Requirements of Participation. - [Ftag of the Week - F600 Free from Abuse and Neglect (Part 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f600-free-from-abuse-neglect-part-2/) - F600 Part 2 reviews staff, visitor, and resident‑to‑resident abuse situations and outlines key CMS expectations for identifying and addressing these incidents. - [Ftag of the Week - F600 Free from Abuse and Neglect (Part 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f600-free-from-abuse-and-neglect-part1/) - Overview of F600 Part 1, including definitions of abuse, facility risk factors, and key CMS expectations for protecting residents from harm. - [January 2026 Nursing Home Compare Users’ Guide Available](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/january-2026-nursing-home-compare-users-guide-available-antipsychotics-qm/) - Discover key updates to CMS's Five-Star Quality Measures for nursing homes, including new antipsychotic medication metrics effective January 2026. - [Ftag of the Week – F586 Resident Contact with External Entities](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f586-resident-contact-with-external-entities/) - F586: CMS requirements ensuring residents can freely contact surveyors, ombudsmen, and external agencies without interference or communication barriers - [Ftag of the Week – F585 Grievances](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f585-grievances/) - F585: CMS requirements for grievance policies, investigation procedures, the role of the Grievance Official, and protecting residents’ rights to voice concerns. - [Ftag of the Week – F584 Safe/ Clean/ Comfortable/ Homelike Environment](https://cmscompliancegroup.com/ftag-of-the-week/f584-safe-environment/) - F584: CMS requirements for a safe, clean, comfortable, homelike environment, including housekeeping, lighting, temperature, sound levels, and resident property protections. - [Ftag of the Week – F583 Personal Privacy/ Confidentiality of Records](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f583-personal-privacy-confidentiality-of-records/) - F583: CMS requirements for resident privacy, confidentiality of records, consent for photos, protection during care, and common survey citation issues. - [Ftag of the Week - F582 Medicaid/Medicare Coverage/Liability Notice (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f582-medicaid-medicare-coverage-liability-notice-pt2/) - F582 Pt 2: NOMNC, SNF ABN, ABN triggers, demand bills, and how surveyors review Medicare notice and billing compliance in skilled nursing facilities. - [Ftag of the Week - F582 Medicaid/Medicare Coverage/Liability Notice (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f582-medicaid-medicare-coverage-liability-notice-pt1/) - F582 Pt 1: Medicaid eligibility rules, covered vs. non‑covered services, refund requirements, and facility responsibilities under CMS regulations. - [Ftag of the Week – F580 Notify of Changes (Injury/ Decline/ Room, Etc.)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/ftag-of-the-week-f580-notify-of-changes-injury-decline-room/) - F580: CMS requirements for notifying residents, physicians, and representatives of injuries, condition changes, transfers, and common survey citation issues. - [Ftag of the Week – F579 Posting/Notice of Medicare/Medicaid on Admission](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f579-posting-notice-of-medicare-medicaid-on-admission/) - F579: CMS requirements for posting and providing Medicare/Medicaid information, refund processes, and common survey citation issues for missing notices. - [Ftag of the Week - F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f578-request-refuse-discontinue-treatment-formulate-advance-directives-pt-3/) - F578 Pt 3: CMS requirements for executed advance directives, facility responsibilities, required P&Ps, and common survey citation issues. - [Ftag of the Week – F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f578-request-refuse-discontinue-treatment-formulate-advance-directives-pt-2/) - F578 Pt 2: CMS requirements for advance care planning, nondiscrimination, conscientious objection, and facility policies on residents’ advance directives. - [Ftag of the Week – F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f578-request-refuse-discontinue-treatment-formulate-advance-directives-pt-1/) - F578 Pt 1: CMS rules protecting residents’ rights to request, refuse, or discontinue treatment and make informed decisions about their care. - [Ftag of the Week – F577 Right to Survey Results/Advocate Agency Info](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/ftag-of-the-week-f577-right-to-survey-results-advocate-agency-info/) - F577 Survey Results: CMS rules requiring facilities to make their most recent survey results easily accessible for residents to review. - [Ftag of the Week – F576 Right to Forms of Communication with Privacy](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f576-right-to-forms-of-communication-with-privacy/) - F576 Communication Privacy: CMS rules ensuring residents can communicate by phone, mail, email, or other methods with reasonable access and full privacy. - [Ftag of the Week – F575 Required Postings](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f575-required-postings/) - F575 Required Postings: CMS rules requiring facilities to prominently display residents’ rights, agency contacts, survey results, and other mandated notices. - [Ftag of the Week - F574 Required Notices and Communication](https://cmscompliancegroup.com/ftag-of-the-week/f574-required-notices-comm/) - F574 Required Notices: CMS rules requiring facilities to give residents timely written notice of changes in services, charges, or policies in an understandable format. - [Ftag of the Week – F573 Right to Access/ Purchase Copies of Records](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f573-records/) - F573 Records Access: CMS rules requiring facilities to provide residents timely access to inspect and obtain copies of their medical records. - [Ftag of the Week – F572 Notice of Rights and Rules](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f572-notice-of-rights-and-rules/) - F572 Notice of Rights: CMS rules requiring facilities to inform residents of their rights and facility rules in a language and format they can understand. - [Ftag of the Week – F571 Limitations on Charges to Personal Funds](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f571-limitations-on-charges-to-personal-funds/) - F571 Personal Funds Charges: CMS rules limiting what facilities can bill to residents’ personal funds and clarifying which services must be provided without charge. - [Ftag of the Week – F570 Surety Bond – Security of Personal Funds](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f570-surety-bond-security-of-personal-funds/) - F570 Surety Bond: CMS rules requiring facilities to secure residents’ personal funds with a surety bond to prevent loss, misuse, or mismanagement. - [Ftag of the Week – F569 Notice and Conveyance of Personal Funds](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f569-notice-and-conveyance-of-personal-funds/) - F569 Personal Funds Notice: CMS rules for notifying residents about fund management, providing statements, and properly conveying remaining balances. - [Ftag of the Week – F568 Accounting and Records of Personal Funds](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f568-accounting-and-records-of-personal-funds/) - F568 Personal Funds Records: CMS rules for accurate accounting, documentation, and safeguarding of residents’ personal funds in long‑term care. - [Ftag of the Week – F567 Protection/Management of Personal Funds](https://cmscompliancegroup.com/blog/ftag-of-the-week-f567-protect-mgmt/) - F567 Personal Funds: CMS rules for protecting resident funds, ensuring proper management, preventing misuse, and maintaining accurate financial records. - [Ftag of the Week – F566 Right to Perform Facility Services or Refuse](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f566-right-to-perform-facility-services-or-refuse/) - F566 Facility Services: CMS rules allowing residents to perform voluntary facility tasks with proper safeguards and protecting their right to refuse such services. - [Ftag of the Week – F565 Resident/Family Group and Response](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f565-groups/) - F565 Resident Groups: CMS rules requiring facilities to support resident groups, provide meeting space, and respond to group concerns or recommendations. - [Ftag of the Week – F564 Inform of Visitation Rights/ Equal Visitation Privilege](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f564-inform-of-visitation-rights-equal-visitation-privilege/) - F564 Visitation Rights: CMS rules requiring facilities to inform residents of visitation rights and ensure equal, non‑discriminatory access for all visitors. - [Ftag of the Week - F563 Right to Receive/Deny Visitors](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f563-visitors/) - F563 Visitation Rights: CMS rules ensuring residents can receive visitors of their choice, with only reasonable and safety‑based restrictions allowed. - [Ftag of the Week – F562 Immediate Access to Resident](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/ftag-of-the-week-f562-immediate-access-to-resident/) - F562 Immediate Access: CMS rules requiring facilities to provide authorized individuals immediate access to residents, records, and care areas when permitted. - [Ftag of the Week – F561 Self-Determination](https://cmscompliancegroup.com/ftag-of-the-week/f561-self-determination/) - F561 Self‑Determination: CMS requirements supporting resident choice in daily routines, activities, schedules, and participation in care decisions. - [Ftag of the Week – F560 Right to Refuse Certain Transfers](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f560-right-to-refuse-certain-transfers/) - F560 Right to Refuse Transfers: CMS rules allowing residents to refuse certain non‑emergency transfers and protections against inappropriate relocation. - [Ftag of the Week - F559 Choose/ Be Notified of Room/ Roommate Change](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f559-room/) - F559 Room/Roommate Change: CMS requirements for notice, honoring resident preferences, and reducing disruption during room or roommate changes in long‑term care - [Ftag of the Week – F558 Reasonable Accommodation of Needs/Preferences](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f558/) - F558 Reasonable Accommodation of Needs: CMS requirements for honoring resident needs and preferences, making reasonable adjustments, and supporting individualized care in long‑term care. - [Ftag of the Week - F557 Respect, Dignity/ Right to have Personal Property](https://cmscompliancegroup.com/ftag-of-the-week/ftag-f557-personal-property/) - F557 Respect and Protection of Personal Property: CMS requirements for safeguarding resident belongings, preventing loss or theft, and maintaining facility policies for personal items. - [Ftag of the Week – F555 Right to Choose/ Be Informed of Attending Physician](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f555-right-to-choose-be-informed-of-attending-physician/) - F555 Right to Choose and Be Informed of Attending Physician: CMS requirements for physician choice, notification, changes in providers, and resident decision‑making in long‑term care. - [Ftag of the Week – F554 Resident Self-Administer Meds – Clinically Appropriate](https://cmscompliancegroup.com/ftag-of-the-week/f554-resident-self-administer-med/) - F554 Right to Self‑Administer Medications: CMS requirements for assessing a resident’s ability to self‑administer medications safely, documentation, and survey expectations. - [Ftag of the Week – F553 Right to Participate in Planning Care](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f553/) - F553 Right to Participate in Planning Care: CMS requirements for resident involvement in care planning, goals, preferences, and interdisciplinary team expectations. - [Ftag of the Week - F552 Right to be Informed/ Make Treatment Decisions](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/f552-right-to-be-informed/) - F552 Right to Be Informed: CMS requirements for informing residents of rights, services, charges, care changes, and surveyor expectations in long‑term care. - [Ftag of the Week – F551 Rights Exercised by Representative](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f551-rights-exercised-by-representative/) - F551 Rights Exercised by Representative: CMS requirements for resident representatives, decision‑making authority, documentation, and surveyor expectations in long‑term care. - [Ftag of the Week – F550 Resident Rights/Exercise of Rights](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f550-resident-rights/) - F550 Resident Rights: Key CMS requirements, dignity standards, surveyor focus areas, and compliance guidance for supporting resident autonomy in long‑term care. - [Key Updates to SOM Chapter 5 Complaint Procedures](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/key-updates-to-som-chapter-5-complaint-procedures/) - In February 2026, and then again in April 2026, the Centers for Medicare & Medicaid Services (CMS) issued revisions to two chapters of the State Operations Manual, Chapter 5 and Chapter 7. These updates can be found in a QSO Memo with the same name. We’ll review some important information from Chapter 5 in this - [Key Updates to Chapter 7 Survey & Enforcement for Nursing Homes](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/key-updates-to-chapter-7-survey-enforcement-for-nursing-homes/) - In recently released updates to State Operations Manual Chapter 5 (Complaint Procedures) and Chapter 7 (Survey & Enforcement for Nursing Homes), multiple revisions to Chapter 7 were announced in two QSO Memos, one in February and another in April. Per the QSO Memo, “Revisions to the State Operations Manual (SOM) Chapters 5 and 7,” updated - [Do You Have the Current LTCSP Critical Element Pathways? - Retired](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/do-you-have-the-current-ltcsp-critical-element-pathways/) - To ensure you're up to date, use this link on the CMSCG Blog to ensure you have the current documents - including the April 28, 2025 Critical Element Pathways. Current Critical Element Pathways SNF Beneficiary Notification Review 10/2022 (CMS-20052 Beneficiary Notice) Dining Observation 10/2022 (CMS-20053 Dining) Infection Prevention, Control & Immunizations 8/2024 (CMS-20054 Infection Prevention - [LTCSP Critical Element Pathways (7/30/2025 Edition) - Retired](https://cmscompliancegroup.com/resources/ltcsp-critical-element-pathways-7-30-2025-edition/) - Preparing for survey? It’s important to ensure you’ve got the most current LTCSP Critical Element Pathways, as there have been revisions made throughout 2025. Here are the survey resources current in use: Abuse Critical Element Pathway 10/2022 (CMS-20059 Abuse) Accidents Critical Element Pathway 4/2025 (CMS-20127 Accidents) Activities Critical Element Pathway 10/2023 (CMS-20065 Activities) Activities of - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-2/) - F689 remains a top citation. Learn key accident‑prevention expectations, surveyor focus areas, and steps to strengthen resident safety and compliance. - [Ftag of the Week – F689 Free of Accident Hazards/Supervision/Devices (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f689-free-of-accident-hazards-supervision-devices-pt-1/) - Late last year, our “The State of IJs” series on the CMSCG Blog revealed a clear pattern across the Immediate Jeopardy citations we analyzed: many of the most serious survey findings were rooted in breakdowns within core accident‑prevention and supervision systems. Whether the issue involved lapses in resident monitoring, unaddressed environmental hazards, or failures to - [Ftag of the Week - F802 Sufficient Dietary Support Personnel](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f802-sufficient-dietary-support-personnel/) - Our next “Ftag of the Week, written by CMSCG Dietary Consultant Danielle Nichtern, MA, RD, CDN, is F802 Sufficient Dietary Support Personnel, which is part of the Food and Nutrition Services regulatory group. Similar to F801, this regulation focuses on staffing requirements. F802 focuses specifically on having sufficient support personnel to “safely carry out the - [Lithium-ion Battery Safety Reminders](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/lithium-ion-battery-safety-reminders-ltc-facilities/) - On February 19, 2026, the New York State Department of Health (NYSDOH) issued a Dear Administrator Letter (DAL) which discusses state-specific requirements related to the storage and maintenance of certain batteries. The DAL also addresses powered micromobility devices. Guidelines for All Providers The Letter also includes helpful safety guidelines which all providers could benefit from - [CMS QSAAM Alert re  Sprinkler System Requirements](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-qsaam-alert-re-lsc-sprinkler-system-requirements/) - On March 9, 2026, the Centers for Medicare and Medicaid Services (CMS) issued a Quality & Safety Special Alert. The alert, “Reminder: Upcoming Deadlines for Sprinkler System Requirement for Existing Health Care Occupancies in High-Rise Buildings,” indicates that there are no new or additional requirements. Instead, the document is a reminder for facilities that are - [CMS Updated LTCSP Survey Resources Folder (CE Pathways and more)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-updated-ltcsp-survey-resources-folder-ce-pathways-and-more/) - CMS updates LTCSP Survey Resources with new CE Pathways, staffing guidance & expanded survey procedures. Key 2026 changes impact compliance and survey readiness. - [Ftag of the Week – F656 Develop/Implement Comprehensive Care Plans (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f656-develop-implement-comprehensive-care-plans-pt-2/) - In Part 1 of our Ftag of the Week for F656, we reviewed the regulatory requirements for developing and implementing comprehensive care plans. We reviewed some examples of specific vs. non-specific goals, and in this post, we’ll review some more care planning considerations (and requirements). Assessment and Care Planning Considerations Per the Interpretive Guidance (IG) - [Ftag of the Week – F656 Develop/Implement Comprehensive Care Plans (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f656-develop-implement-comprehensive-care-plans-pt-1/) - Regulatory expectations never stop evolving, and neither should the way we prepare for them. That’s why our CMSCG Ftag of the Week series is back with a renewed focus on practical insights that help skilled nursing providers stay survey‑ready every day. Each week, we break down a specific F‑Tag, highlight what surveyors are looking for, - [EXPIRED - When’s Your Next Survey? The January 2026 Shutdown Means Some S&C Activity is Paused.](https://cmscompliancegroup.com/news/whens-your-next-survey-the-shutdown-means-some-sc-activity-is-paused-january-2026/) - -- Retired Information -- Due to the shutdown ending this week on February 3, the government is not shut down. Survey & Certification activity has resumed as usual. The following post remains available for past reference only. Here we go again . . . on February 2, 2026, the Centers for Medicare & Medicaid Services - [Life Safety Code & Emergency Preparedness: Your January Compliance Checklist](https://cmscompliancegroup.com/blog/life-safety-code-emergency-preparedness-your-january-compliance-checklist/) - Review Life Safety Code and emergency preparedness requirements. Key January tasks to reduce risk and improve survey outcomes. CMSCG can help. - [Abuse Prevention Systems: Reviewing Policies, Training & Reporting Workflows](https://cmscompliancegroup.com/blog/abuse-prevention-systems-reviewing-policies-training-reporting-workflows/) - Reinforce abuse prevention systems with policy reviews, training updates, and reporting workflow checks. - [Documentation Integrity: Ensuring Records Accurately Reflect Resident Care](https://cmscompliancegroup.com/blog/documentation-integrity-ensuring-records-accurately-reflect-resident-care/) - Improve documentation integrity by ensuring records accurately reflect resident care. Tips for audits, consistency, and compliance. - [Less Predictable Surveys – Coming to a Facility Near You?](https://cmscompliancegroup.com/blog/less-predictable-surveys-coming-to-a-facility-near-you/) - In several recent communications, the Centers for Medicare & Medicaid Services (CMS) has emphasized its focus on less predictable survey cycles to keep providers on their toes. Some of this guidance is new, and some of it isn’t, but it can be confusing to get through. Let’s review some of the key guidance issued in - [Your 2026 Compliance Roadmap: 12 Steps to a Stronger Year](https://cmscompliancegroup.com/blog/your-2026-compliance-roadmap-12-steps-to-a-stronger-year/) - Use this 12‑step compliance roadmap to guide your post-acute organization through a stronger, survey‑ready year. - [CMS issues Revisions to SOM Chapter 5 and SOM Chapter 7](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-issues-revisions-to-som-chapter-5-and-som-chapter-7/) - Hot off the presses -- In a new QSO Memo dated February 2, 2026 (despite today being January 30, 2026), the Centers for Medicare & Medicaid Services (CMS) issued updated guidance. The Memo, “Revisions to State Operations Manual (SOM) Chapters 5 and 7” addresses guidance for Chapter 5 related to Immediate Jeopardy and Chapter 7 - [CMS Releases FY26 State Survey Agency Performance Standards](https://cmscompliancegroup.com/blog/cms-releases-fy26-state-survey-agency-performance-standards/) - On January 13, 2026, the Centers for Medicare and Medicaid Services (CMS) issued its annual guidance related to State Performance Standards, the assessment by which State Survey Agency (SA) performance is measured. The FY26 guidance has been updated to account for the Federal government shutdown. State Survey Agencies are scored as “met,” partially met,” “not - [CMS iQIES Transition: What Nursing Homes Need to Know About the Latest Data Shake-Up](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-iqies-transition-what-nursing-homes-need-to-know-about-the-latest-data-shake-up-qssam-alert/) - CMS iQIES transition: Learn why complaint numbers changed, how data issues are being fixed, and what providers can do to ensure accurate facility data. - [Ftag of the Week - F925 Maintains Effective Pest Control Program](https://cmscompliancegroup.com/blog/ftag-of-the-week-f925-maintains-effective-pest-control-program/) - The official start of summer is here, and that usually mean that we put the “Ftag of the Week” on pause, however, based on demand, we will keep this series on compliance with the Requirements of Participation going throughout the summer. We are going to review the Ftags that are part of the Physical Environment, - [RETIRED Ftags of the Week – F884 and F885 COVID-19 Tags](https://cmscompliancegroup.com/blog/ftags-of-the-week-f884-f885-covid-19-ftags/) - Note: These regulatory requirements are no longer in effect. The content remains below for reference but should not be relied on as current guidance. In March, CMS Compliance Group put its “Ftag of the Week” Blog series on pause until providers were being less inundated with COVID-19 and infection Control-related information. However, in a May - [Ftag of the Week – F868 QAA Committee](https://cmscompliancegroup.com/blog/ftag-of-the-week-f868-qaa-committee/) - This week’s Ftag of the Week is F868 QAA Committee. This regulation has some new additions effective Phase 3 (November 28, 2019) and a good deal of Interpretive Guidance added when the RoPs were updated, so let’s take a look at what is required from providers. Each nursing home must have a Quality Assessment and - [Start the Year Survey Ready: Your 2026 Compliance Mindset Reset](https://cmscompliancegroup.com/blog/start-the-year-survey-ready-your-2026-compliance-mindset-reset/) - Day 1 – Compliance Mindset Reset Start 2026 survey‑ready with a strong compliance mindset. Practical steps to reset expectations, strengthen systems, and improve readiness. - [Resident Rights & Grievances: Strengthening Your 2026 Compliance Foundation](https://cmscompliancegroup.com/blog/resident-rights-grievances-strengthening-your-2026-compliance-foundation/) - Strengthen your grievance process and resident rights systems. Learn how to improve documentation, follow‑up, and compliance. - [Survey‑Ready All Year: January Tasks That Set the Tone](https://cmscompliancegroup.com/blog/survey-ready-all-year-january-tasks-that-set-the-tone/) - Stay survey‑ready all year. January tasks that help facilities maintain compliance, strengthen documentation, and prepare staff. Book your mock survey now. - [Behavioral Health & Trauma-Informed Care: Your Annual Competency Reset](https://cmscompliancegroup.com/blog/behavioral-health-trauma-informed-care-your-annual-competency-reset/) - Review behavioral health and trauma‑informed care competencies. Strengthen staff confidence and ensure individualized, compliant care. - [Care Plan Accuracy in the New Year: Aligning IDT Workflows for Success](https://cmscompliancegroup.com/blog/care-plan-accuracy-in-the-new-year-aligning-idt-workflows-for-success/) - Day 5 – Care Plan Accuracy Ensure care plans reflect current resident needs. Tips for improving IDT communication, documentation, and survey readiness. - [CMS Compliance Group’s “12 Days of Compliance”](https://cmscompliancegroup.com/blog/introducing-cms-compliance-groups-12-days-of-compliance-series/) - Use this 12‑step compliance roadmap from the team at CMS Compliance Group, Inc. to guide your post-acute organization through a stronger, survey‑ready year. - [Staff Competency in 2026: Validating Skills and Strengthening Compliance Systems](https://cmscompliancegroup.com/blog/staff-competency-in-2026-validating-skills-and-strengthening-compliance-systems/) - Day 4 – Staff Competency Validation Strengthen compliance by validating staff competencies. Learn how to assess skills, document performance, and align training with resident needs. - [QAPI in January: How to Refresh Your PIPs and Set Strong Goals](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/qapi-in-january-how-to-refresh-your-pips-and-set-strong-goals/) - Day 2 – QAPI Refresh Refresh your QAPI program for the new year. Learn how to update PIPs, review data trends, and strengthen IDT engagement. - [Annual Infection Control Tune-Up: What Every Facility Should Review in January](https://cmscompliancegroup.com/blog/annual-infection-control-tune-up-what-every-facility-should-review-in-january/) - Day 3 – Infection Control Tune‑Up Kick off the year with an infection control review. Key areas to assess to ensure your IPCP remains compliant and effective. - [Ftag of the Week – F826 Rehab Services- Physician Order/Qualified Person](https://cmscompliancegroup.com/blog/ftag-of-the-week-f826-rehab-services-physician-order-qualified-person/) - Next up in CMS Compliance Group’s “Ftag of the Week” series on the CMSCG Blog is F826 Rehab Services – Physician Order/ Qualified Person. F826 is the companion tag to F825 Provide/Obtain Specialized Rehab Services. F826 requires that specialized rehabilitative services must have a written physician order* and be provided by qualified personnel. Providers are - [Ftag of the Week – F807 Drinks Avail to Meet Needs/ Preferences/ Hydration](https://cmscompliancegroup.com/blog/ftag-of-the-week-f807-drinks-avail-to-meet-needs-preferences-hydration/) - This week’s Ftag of the Week on the CMSCG Blog is F807 Drinks Available to Meet Needs/Preferences/Hydration, which is part of the Food and Nutrition Services regulatory group. This regulation requires facilities to ensure that residents are provided with and receive drinks that are consistent with their needs and preferences and are provided in sufficient - [Revised Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f757-drug-regimen-is-free-from-unnecessary-drugs-pt-2/) - Last week in Part 1 of our Ftag of the Week post, we reviewed some of the key definitions and intent associated with F757 Free from Unnecessary Drugs, an Ftag which was revised earlier this year. In this post, we’ll review the newly added guidance related to the comprehensive assessment and determining the need to - [Revised Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f757-drug-regimen-is-free-from-unnecessary-drugs-pt-3/) - We are wrapping up our CMSCG “Ftag of the Week” series for F757 with this post. We would be remiss if we didn’t discuss the need for monitoring for adverse outcomes/ consequences related to medication use. It’s a significant section of the Interpretive Guidance (IG) which was included in the revised SOM Appendix PP effective - [Revised Ftag of the Week - F727 RN 8 Hrs/7 days/Wk, Full Time DON](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f727-rn-8hrs-7days-wk-full-time-don/) - Welcome back to the Ftag of the Week on the CMSCG Blog, your go-to spotlight for decoding the regulatory landscape of skilled nursing and long-term care. Each week (or sometimes more) we break down a specific Ftag from the CMS State Operations Manual, offering practical insights, survey trends, and actionable guidance to help providers stay - [Ftag of the Week – F699 Trauma-Informed Care (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f699-trauma-informed-care-pt-2/) - In Part 1 of our F699 Trauma-Informed Care deep dive, we unpacked the foundational elements of trauma-informed care and why it’s more than just a buzzword in today’s regulatory landscape. Now, let’s take it a step further. Part 2 shifts our focus to cultural competency—an essential, and often underemphasized, component of trauma-informed care. The Centers - [Ftag of the Week – F699 Trauma-Informed Care (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f699-trauma-informed-care-pt-3/) - This week, we’re ready to take the next step. Part 3 of this “Ftag of the Week” CMSCG Blog series will focus on practical approaches for integrating trauma-informed care into daily practice. We’ll discuss actionable strategies for care planning, ways to identify and address triggers, and how to create an environment that supports healing for - [Ftag of the Week – F699 Trauma-Informed Care (Pt. 4)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f699-trauma-informed-care-pt-4/) - In this week’s post, we’ll wrap up our review of F699 Trauma-Informed Care, an area that many nursing staff have a hard time wrapping their heads around. In Part 1, we discussed the regulatory requirements for this Ftag along with some key definitions. Next, we reviewed cultural competence, including its link to the Facility Assessment, - [Revised Ftag of the Week – F641 Accuracy of Assessments (Pt. 2)](https://cmscompliancegroup.com/blog/revised-ftag-of-the-week-f641-accuracy-of-assessments-pt-2/) - In Part 1 of our CMSCG Ftag of the Week series for F641 Accuracy of Assessments, we reviewed the regulatory requirements and guidance from the soon-to-be-obsolete F642 which are being relocated to F641. Those requirements are related to coordination and certification of assessments. The revised guidance to surveyors includes new investigative procedures which highlight how - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Illinois](https://cmscompliancegroup.com/blog/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-illinois/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Illinois These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in North Carolina](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-north-carolina/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across North Carolina These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in New Mexico](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-new-mexico/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New Mexico. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these IJ citations can help providers proactively address vulnerabilities and improve care outcomes. Top - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in West Virginia](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-west-virginia/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across West Virginia. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Connecticut](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-connecticut/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Connecticut. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Tennessee](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-tennessee/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Tennessee. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Key Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Minnesota](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-minnesota/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Minnesota in 2025. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Virginia](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-virginia/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Virginia. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Key Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in California](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-california/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across California. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in South Dakota](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-south-dakota/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across South Dakota. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Ohio](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-ohio/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Ohio. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Mississippi](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-mississippi/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Mississippi. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Pennsylvania](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-pennsylvania/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Pennsylvania. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Areas of Noncompliance - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in North Dakota](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-north-dakota/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across North Dakota. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Wyoming](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-wyoming/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Wyoming. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Alabama](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-alabama/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Alabama. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. We’re reaching the - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Florida](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-florida/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Florida. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Louisiana](https://cmscompliancegroup.com/blog/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-louisiana/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Louisiana. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Colorado](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-colorado/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Colorado. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Oregon](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-oregon/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Oregon. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Massachusetts](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-massachusetts/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Massachusetts. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Utah](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-utah/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Utah. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Kentucky](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-kentucky/) - Kentucky’s 2025 Immediate Jeopardy (IJ) citation data paints a sobering picture of regulatory scrutiny—and the stakes for noncompliance have never been higher. With 41 IJ citations issued across 30 facilities, the message is clear: surveyors are laser-focused on systemic failures that compromise resident safety. The top-cited F-tag, F689 (Free of Accidents), continues to dominate, underscoring the critical need for proactive fall prevention and risk mitigation strategies. But what’s equally telling is the uptick in citations tied to abuse and neglect—F600 and F607—signaling a renewed emphasis on resident rights and protections. Providers must recognize that IJ-level deficiencies are not just about isolated incidents—they reflect broader breakdowns in systems, training, and oversight. As we’ve seen in our compliance reviews, facilities that lack robust QA processes and fail to act on known risks are increasingly vulnerable to enforcement. Now is the time to reassess your incident management protocols, reinforce staff competencies, and ensure leadership is actively engaged in driving a culture of safety. Because when it comes to Immediate Jeopardy, prevention isn’t just best practice—it’s your strongest defense. - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Nebraska](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-nebraska/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Nebraska. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. IJ Noncompliance There - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in New York](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-new-york/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New York, our home base. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care - [Survey & Certification Q&A Released in a New CMS QSO Memo](https://cmscompliancegroup.com/blog/survey-certification-qa-released-in-a-new-cms-qso-memo/) - The Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo on November 24, 2025 for all provider types, “Questions + Answers for State Recovery after the Federal Government Shutdown.” The document includes answers to the questions CMS received from providers and State Agencies regarding survey & certification activities during the shutdown. Key - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Montana](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-montana/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Montana. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. There are approximately - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in South Carolina](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-south-carolina/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across South Carolina. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Maryland](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-maryland/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes Maryland. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Maryland’s State Agency has - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Texas](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-texas/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Texas. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in New Jersey](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-new-jersey/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New Jersey. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. The State - [Updated: When’s Your Next Survey? The Shutdown Means Some S&C Activity is Paused (10/31/2025)](https://cmscompliancegroup.com/news/whens-your-next-survey-the-shutdown-means-some-sc-activity-is-paused-october-31-update/) - 10/31/2025: This post is an update from our 10/21/2025 post regarding survey activities permitted and not permitted during the government shutdown. The Centers for Medicare and Medicaid Services issued an revised QSO Memo on October 31, 2025 regarding its contingency plans and clarifications to the plans. ** Clarifications from this memo will be indicated in - [Ftag of the Week – F699 Trauma-Informed Care (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f699-trauma-informed-care-pt-1/) - Next up on the CMSCG Blog, we’re going to dive deep into the heart of person-centered care by reviewing F699 Trauma-Informed Care. Trauma-Informed Care isn’t just about checking boxes on a care plan – it’s about understanding the lived experiences of our residents and how these experiences have shaped the way they respond to care, - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Iowa](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-iowa/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Iowa. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Area of - [When’s Your Next Survey? The Shutdown Means Some S&C Activity is Paused.](https://cmscompliancegroup.com/news/whens-your-next-survey-the-shutdown-means-some-sc-activity-is-paused/) - NOTE: An update to this post with more current information as of October 21, 2025 can be viewed here. On October 1, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo, “Contingency Plans – State Survey & Certification Activities in the Event of a Federal Government Shutdown.” The Memo covers three - [Updated: When’s Your Next Survey? The Shutdown Means Some S&C Activity is Paused (10/21/2025)](https://cmscompliancegroup.com/news/whens-your-next-survey-the-shutdown-means-some-sc-activity-is-paused-october-21-update/) - This post is an update of our post from earlier in October regarding the October 1, 2025 CMS QSO Memo about contingency plans related to the Federal government shutdown. *Updates from the revised QSO Memo will be indicated in italics and with an asterisk. On October 21, 2025, CMS issued a revised QSO Memo to - [The State of IJs: Midway Recap & Lessons Learned](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-midway-recap-lessons-learned/) - As we reach the midpoint of our “The State of IJs” blog series, the CMS Compliance Group team is reflecting on the trends and insights uncovered so far in 2025. Our goal remains clear: to keep nursing home providers informed and prepared by highlighting Immediate Jeopardy (IJ) citations across the country. While some states have - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Rhode Island](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-rhode-island/) - n this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Rhode Island. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Nevada](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-nevada/) - In this edition of The State of IJs, we’re spotlighting two Immediate Jeopardy (IJ) citations issued to Nevada nursing homes. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Delaware](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-delaware/) - In this edition of The State of IJs, we’re digging into an Immediate Jeopardy (IJ) citation issued to a nursing home in Delaware. Remember, IJ citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Missouri](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-missouri/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Missouri. IJ citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Maine](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-maine/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Maine. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Oklahoma](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-oklahoma/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Oklahoma. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Surveyors in this - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Washington](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-washington/) - In this edition of The State of IJs, we’re spotlighting certain Immediate Jeopardy (IJ) citations issued to nursing homes in Washington but could be cited anywhere in the US. These citations represent the most serious level of noncompliance with health and safety regulations, whereby a resident’s is at immediate risk for serious injury, harm, impairment - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Georgia](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-georgia/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes in Georgia in 2025. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Kansas](https://cmscompliancegroup.com/blog/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-kansas/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes in Kansas. IJ citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the pattern of findings associated with any citation, which is usually spelled out in the Statement of Deficiencies, - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Wisconsin](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-wisconsin/) - In this edition of The State of IJs on the CMSCG Blog, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Wisconsin. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care - [Nursing Home Compare Updates – Sort of – Paused](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/nursing-home-compare-updates-sort-of-paused/) - On August 15, 2025 the Centers for Medicare and Medicaid Services (CMS) announced in a Quality & Safety Special Alert Memo that Nursing Home Compare updates would be temporarily paused due to the July iQIES transition. The pause was to allow for a review of data integrity. Now, CMS has announced in a revision to - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Michigan](https://cmscompliancegroup.com/blog/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-michigan/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Michigan. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Arkansas](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-arkansas/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Arkansas. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. It doesn’t matter - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Indiana](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-indiana/) - In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Indiana. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. Top Areas of - [NYSHFA | NYSCAL 2025 Survey Trends & Tips Webinar (12/3/2025)](https://cmscompliancegroup.com/education/2025-survey-trends-tips-webinar-december-3/) - Join CMS Compliance Group’s interdisciplinary team - including Linda Elizaitis, Brandie Elizaitis, Jim Houle and more - for a high-impact session designed to help your organization stay ahead of the curve in 2026. This webinar will provide a comprehensive recap of recent survey activity across New York State in 2025, with a focused analysis of - [The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Hawaii](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/the-state-of-ijs-2025-nursing-home-immediate-jeopardy-citations-in-hawaii/) - In this edition of The State of IJs, we’re spotlighting the lone Immediate Jeopardy (IJ) citation issued to a nursing home in Hawaii in 2025. Remember, IJ citations represent the most serious level of noncompliance, where resident safety is at immediate risk. The citation we’re going to discuss is one that could happen in any - [QSO Memo: Civil Money Penalty Reinvestment Program Updates](https://cmscompliancegroup.com/blog/qso-memo-civil-money-penalty-reinvestment-program-updates/) - The Centers for Medicare & Medicaid Services (CMS) recently issued a new QSO Memo dated September 26, 2025. The Memo, "Civil Money Penalty Reinvestment Program (CMPRP) Updates" provides updates about the program, including: Streamlined Application Form Increases to per-project funding limited Additions to areas where applications are being accepted, such as Mental and Behavioral Health - [Special Focus Facilities 101: A 3-Part Series](https://cmscompliancegroup.com/blog/01-special-focus-facilities/) - In April, the Centers for Medicare & Medicaid Services (CMS) adjusted the number of required slots and candidates for the Special Focus Facilities program. CMS created a list of SFF slots available for each state, and States have until July 31, 2014 to designate facilities in their area, but many have already started selecting facilities. - [Antipsychotic drug use in nursing homes continues to decline](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/18-antipsychotic-nursinghomes/) - The latest update from the National Partnership to Improve Dementia Care in Nursing Homes shows that nursing homes have continued to decrease the percentage of long-stay nursing home residents who are on antipsychotic drugs. The Partnership, which started in 2011, has found that there has been a decrease of 21.7% since the program was started, - [Breaking Down a Nursing Home's Immediate Jeopardy: Pt. 4](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/07-category-3-remedies/) - In Part 3 of our series on Immediate Jeopardy situations in nursing homes, we discussed the less severe remedies that can be imposed by the CMS or the State. In the final part of our series, we will take a look at Category 3 remedies, which include: Civil monetary penalties (both Category 2 and 3) - [Nutritional Directors Leadership Workshop (11/20/2025)](https://cmscompliancegroup.com/education/nutritional-directors-leadership-workshop-nov-20/) - CMS Compliance Group’s Kelly Hellberg, MS, RD, CDN presents a comprehensive leadership development workshop tailored for Nutrition Directors and dietary professionals in post-acute and long-term care settings. This multi-module program is designed to enhance regulatory understanding, promote ethical practices, and reinforce the critical role of nutrition services in resident-centered care. Participants will engage with key - [Final MDS 3.0 Item Sets and Users' Manual Posted](https://cmscompliancegroup.com/resources/final-mds-3-0-item-sets-and-users-manual-posted/) - On September 23, 2025, the Centers for Medicare & Medicaid Services (CMS) posted the updated Final MDS 3.0 Item Sets version 1.20.1v4 which goes into effect October 1, 2025. CMS also posted an updated Final MDS 3.0 RAI User’s Manual version 1.20.1 on September 2025. This is also effective October 1, 2025. The final versions - [NYSCAL Assisted Living IDT Series - Dining & Nutrition (10/30/2025)](https://cmscompliancegroup.com/education/nyscal-assisted-living-interdisciplinary-team-series-2/) - NYSCAL's Assisted Living Interdisciplinary Team Series is back for 2025! CMSCG's Kelly Hellberg, Dietary Consultant, will be presenting on October 30, 2025 on Dining & Nutrition in Assisted Living. View the brochure for full details. Registration is available now on the NYSHFA | NYSCAL website. You can register for one session, two - or them - [The State of IJs: Turning Deficiencies into Opportunities for Improvement](https://cmscompliancegroup.com/state-specific-updates/the-state-of-ijs-turning-deficiencies-into-opportunities-for-improvement/) - While Nursing Home Compare updates may be temporarily paused to ensure survey data is validated (and likely to help surveyors catch up), there’s no shortage of data available—especially when it comes to Immediate Jeopardy (IJ) citations in nursing homes across the U.S. in 2025. We’re sharing state-by-state IJ trends and insights on the CMSCG Blog - [Join CMSCG at the NYSHFA | NYSCAL Nurse Leadership Conference](https://cmscompliancegroup.com/education/join-cmscg-at-the-nyshfa-nyscal-nurse-leadership-conference/) - Join CMS Compliance Group's Linda Elizaitis and Brandie Elizaitis for the NYSHFA | NYSCAL Nurse Leadership Conference on October 10, 2025. CMSCG will be discussing "Applying QA Principles to Problematic Areas" for Assisted Living attendees. Dry topic? Maybe. Critical for your organization's success and for your next survey? Absolutely. This session delivers the kind of - [Ftag of the Week – F694 Parenteral/IV Fluids (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f694-parenteral-iv-fluids-pt-1/) - Next up on the CMSCG Blog “Ftag of the Week,” we will be looking at F694 Parenteral/IV Fluids. CMS Compliance Group Clinical Consultant Mary Quinn is lending some additional clinical expertise to this regulation. F694 – What’s Required According to the regulation in Appendix PP of the State Operations Manual (SOM), parenteral fluids must be - [Ftag of the Week – F693 Tube Feeding Management/Restore Eating Skills (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f693-tube-feeding-management-restore-eating-skills-pt-1/) - Next up on the CMSCG Blog “Ftag of the Week" series, we will be looking at F693 Tube Feeding Management/ Restore Eating Skills. F693 addresses assisted nutrition and hydration and enteral nutrition – tube feeding. F693 – Regulatory Requirements The regulation under F693 includes assisted nutrition and hydration, specifically: Naso-gastric tubes Gastrostomy tubes Percutaneous endoscopic - [Ftag of the Week – F688 Increase/Prevent Decrease in ROM/Mobility (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f688-increase-prevent-decrease-in-rom-mobility-pt-1/) - Our next CMSCG “Ftag of the Week” is part of the Quality of Care regulatory group, F688 Increase/Prevent Decrease in ROM/Mobility. There are three parts to this regulation, along with a significant amount of documentation and care planning expectations. Let’s start with the regulatory requirements and then, of course, we will review the definitions provided - [Ftag of the Week – F742 Treatment/Svc for Mental/Psychosocial Concerns](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f742-treatment-svc-for-mental-psychosocial-concerns/) - Next up on the CMSCG Blog “Ftag of the Week,” we are reviewing one of the Behavioral Health regulatory group tags, F742 Treatment/ Svc for Mental/ Psychosocial Concerns. The focus of this regulation is to ensure that a resident who, on admission, was assessed and displayed or was diagnosed with a mental or psychosocial adjustment - [Revised Ftag of the Week – F658 Services Provided Meet Professional Standards (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f658-services-provided-meet-professional-standards-pt-2/) - In Part 1 of our revised Ftag of the Week for F658, we reviewed the significant guidance addition to the tag related to documentation requirements to support mental health diagnoses. The revised Interpretive Guidance in Appendix PP includes long lists of examples of what would be considered insufficient documentation to support a new or existing - [Nursing Home Compare Updates Temporarily Paused](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/nursing-home-compare-updates-temporarily-paused/) - In a new Quality & Safety Special Alert Memo dated August 15, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a temporary pause in Nursing Home Compare updates. This announcement follows the July 14, 2025 transition of nursing home survey & certification data infrastructure from QIES to iQIES and multiple changes to Nursing - [Final MDS 3.0 RAI User’s Manual version 1.20.1](https://cmscompliancegroup.com/resources/final-mds-3-0-rai-users-manual-version-1-20-1/) - The Centers for Post-Acute Quality Reporting Programs issued a notice today, August 25, 2025, that the final MDS User's Manual version 1.20.1 is available to download from this CMS webpage. This manual is effective October 1, 2025. Per this update, there are several "refinements" which have been made to the following sections: Section A Section - [NYSCAL Assisted Living Interdisciplinary Team Series](https://cmscompliancegroup.com/assisted-living/nyscal-assisted-living-interdisciplinary-team-series/) - NYSCAL's Assisted Living Interdisciplinary Team Series is back for 2025! CMSCG's Kelly Hellberg, Dietary Consultant, will be presenting on October 30, 2025 on Dining & Nutrition in Assisted Living. View the brochure for full details. Registration is available now on the NYSHFA | NYSCAL website. You can register for one session, two - or them - [Current LTCSP Critical Element Pathways (4/28/2025 Edition) - Retired](https://cmscompliancegroup.com/blog/do-you-have-the-current-ltcsp-critical-element-pathways-4-28-2025-edition/) - Looking for the current Critical Element Pathways? CMSCG has got you covered- check out our August 11, 2025 post for the most recent CE Pathways. Critical Element Pathways that have not changed SNF Beneficiary Notification Review 10/2022 (CMS-20052 Beneficiary Notice) Dining Observation 10/2022 (CMS-20053 Dining) Infection Prevention, Control & Immunizations 8/2024 (CMS-20054 Infection Prevention Control - [Changes to the LTCSP are Here](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/changes-to-the-ltcsp-are-here/) - As part of its overhaul of survey & certification-related items, including revisions to the Five-Star Quality Rating's Health Inspection methodology, the Centers for Medicare & Medicaid Services (CMS) released a revised QSO Memo related to the COVID-19 PHE. The Memo, originally released on May 1, 2023, (QSO-23-13-ALL), "Guidance for the Expiration of the COVID-19 Public - [July 2025 Five Star Users' Guide](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/july-2025-five-star-users-guide/) - If you're looking for the Nursing Home Five-Star Quality Rating System Technical Users' Guide that includes the changes coming with the July 30, 2025 refresh to Care Compare, then look no further. Per the guide: July 2025 RevisionsEffective with the July 2025 refresh: CMS is implementing a change to the methodology for calculating the health - [SNF Revalidation Deadline Delayed](https://cmscompliancegroup.com/blog/snf-revalidation-deadline-delayed/) - Per MLNConnects: Skilled Nursing Facilities: Revalidation Deadline Extended to January 1 Enrolled skilled nursing facilities should collect data on ownership, managerial, and related party information and submit their revalidation. CMS extended the deadline to January 1, 2026. More Information is available in the most recent guidance attachment (5/9/2025) and can be viewed on the CMS - [Payroll-Based Journal Policy Manual - June 2025](https://cmscompliancegroup.com/resources/payroll-based-journal-policy-manual-june-2025/) - The June 2025 revisions to the Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual were released and can be downloaded from the CMS.gov website here. There is an associated Frequently Asked Questions (FAQ) document dated June 30, 2025 which can be downloaded here. - [Survey Readiness – Trends & Regulatory Changes Webinar](https://cmscompliancegroup.com/blog/survey-readiness-trends-regulatory-changes-webinar/) - Join CMS Compliance Group for a Pharmscript webinar on July 24, 2025 from 2PM-3PM. Big changes are on their way to Nursing Home Compare shortly – how will this impact your next survey and your Five-Star Quality Rating? During this webinar, the presenters will discuss the most frequently cited F-tags on survey in 2025, along - [CMS Announces Changes to Statement of Deficiency Availability](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-announces-changes-to-statement-of-deficiency-availability/) - On June 18, 2025, the Centers for Medicare and Medicaid Services (CMS) released a QSO Memo, “Release of CMS-2567: Statement of Deficiencies and Plan of Correction.” The Memo notes that the official Form CMS-2567 Statement of Deficiencies and Plan of Correction will be publicly releasable within 14 days after receipt by the provider. Prior CMS - [Significant Updates to Nursing Home Compare Announced](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/significant-updates-to-nursing-home-compare-announced/) - On June 18, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo, “Updates to Nursing Home Compare.” The Memo includes important updates for providers to be aware of. Key changes include: Third-Cycle Standard Surveys are being removed from the Health Inspection Rating. Performance Data for nursing home chains will be - [NYSDOH DAL re: Entrapment Risk and Siderails](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-re-entrapment-risk-and-siderails/) - We’ve been waiting for this reminder to arrive from the New York State Department of Health (NYSDOH) because there have been several high-level citations related to negative outcomes from the use of side rails in New York nursing homes recently. During CMSCG mock surveys and on-site visits to clients, this is one of the areas - [Revised Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f757-drug-regimen-is-free-from-unnecessary-drugs-pt-1/) - We initially reviewed F757 Drug Regimen is Free from Unnecessary Drugs back in 2021, when the Ftag only included regulatory requirements without any real guidance. F757 was revised to only address unnecessary drugs/medications which are not psychotropics, since the psychotropic-specific guidance was incorporated into F605 Free from Chemical Restraints. The remaining requirements have not changed, - [NYSDOH DAL re: Emergency Preparedness](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/nysdoh-dal-re-emergency-preparedness/) - June 2025 has been full of DALs from the New York State Department of Health (NYSDOH). The latest, issued June 11, 2025, "Emergency Preparedness Reminder," (DACF 25-21 / DNH 25-13) is for New York nursing home and adult care facility administrators and includes the following: Reminder that both nursing homes and adult facilities are required - [NYSDOH DAL Nurse Aide Training & Competency Evaluation Program](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-nurse-aide-training-and-competency-evaluation-program/) - The New York State Department of Health (NYSDOH) issued a DAL on June 4, 2025, “Nurse Aide Training and Competency Evaluation Program Waiver and Appeal Requirements.” The DAL was issued to clarify information regarding the Nurse Aide Training Program. Highlights/ reminders include that a skilled nursing facility may not have a CNA training program when - [NYSDOH DAL Further Revisions to MOLST (Revision to May 2025 DAL)](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-further-revisions-to-molst-revision-to-may-2025-dal/) - On May 1, 2025, the New York State Department of Health (NYSDOH) issued a DAL notifying providers that the MOLST form was updated. On June 2, 2025, a second DAL regarding this topic was issued, “Further Revisions to Medical Orders for Life Sustaining Treatment (MOLST).” We didn’t post the initial DAL on the CMSCG Blog - [Multiple QSO Memos are Now Expired](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/multiple-qso-memos-are-now-expired/) - The Centers for Medicare and Medicaid Services published several QSO Memos on June 5, 2025, which indicate the expiration of other guidance. QSO-23-01-NH – Expired Effective October 4, 2024 - Updates to Nursing Home Care Compare Staffing and Quality Measures. The timeline was revised in QSO-25-01-NH. QSO-20-29-NH – Expired Effective December 31, 2024 - Interim - [Updated Draft MDS 3.0 Item Sets Available (5/23/2025)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/updated-draft-mds-3-0-item-sets-available-section-r-removed/) - Per a Centers for Medicare & Medicaid Services (CMS) Post-Acute Quality Programs update, updates to the draft MDS item sets effective October 1, 2025 are now available for download. Per the update, Section R related to Health-Related Social Needs has been removed. UPDATED: Draft MDS 3.0 Item Sets version 1.20.1v3-Section_R_removed The draft Minimum Data Set - [SOM Appendix PP (4/25/2025)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/som-appendix-pp-4-25-2025/) - The "official" version of Appendix PP that was recently released lacks several sections, so we've been waiting for the version to be updated to reflect the full set of regulatory requirements before posting. We've finally got it - download below. Compliance concern? We've got a solution. Not sure your nursing home is where it needs - [CMSCG Client Alert: Recent NY/CT Nursing Home Fires](https://cmscompliancegroup.com/subscriptions/cmscg-subscriber-provider/cmscg-client-alert-recent-ny-ct-nursing-home-fires/) - CMSCG Life Safety Consultant Jim Houle requested that we alert New York and Connecticut-based nursing facilities about several recent nursing home fires. Thankfully, staff were able to swiftly address all fire and smoke events quickly, but these types of events could occur in any facility. Recent concerning events include: Cell phone fire (lithium battery) in - [NYALTCA Online Seminar 6/6/2025 (CEUs available)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/nyaltca-online-seminar-6-6-2025-ceus-available/) - Join members of the CMSCG interdisciplinary consulting team for a NYALTCA online seminar on June 6, 2025. We're providing 6 hours of education (CEUs available!) on the following topics and hope you can join us: Regulatory changes and how the revised surveyor guidance can impact your next survey results F-tag citation trends - including everything - [Revised List of Ftags (effective 4/28/2025)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-list-of-ftags-effective-4-28-2025/) - The revised guidance to surveyors which became effective April 28, 2025 included several changes to the list of Ftags. You can view the revised list here or view and download the current LTSCP Survey Resources folder here (.zip). We'll have more information on the CMSCG Blog on all the revised documents in the coming days, - [Top 10 Most Frequently Cited Ftags](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/top-10-most-frequently-cited-ftags/) - What are surveyors citing so far in 2025 on recertification surveys? According to CASPER data current as of April 27, 2025, here are the top ten most frequently cited Ftags in the United States: F880 Infection Prevention & Control F812 Food Procurement, Store/ Prepare/ Serve Sanitary F761 Label/Store Drugs and Biologicals F689 Free of Accident - [Flu no longer prevalent in New York](https://cmscompliancegroup.com/state-specific-updates/flu-no-longer-prevalent-in-new-york/) - New York State issued a press release on April 28, 2025 indicating that flu is no longer prevalent. Health care workers who are not vaccinated against the flu no longer have to follow the masking requirement. View the April 29, 2025 press release on the NYS website. Track weekly flu activity on the CDC website - [SNF Revalidation Extended to 8/1/2025](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/snf-revalidation-extended-to-8-1-2025/) - The Centers for Medicare & Medicaid Services (CMS) announced (via MLN Connects) that the deadline for skilled nursing facilities to submit their revalidation information has been extended to August 1, 2025. For more details, view this McKnight's Long-Term Care News article (updated 4/17/2025). - [How to Make Your Assisted Living QA Program Effective](https://cmscompliancegroup.com/education/how-to-make-your-assisted-living-qa-program-effective/) - Join CMS Compliance Group, Inc. President Linda Elizaitis, RN, BS, RAC-CT, CDS for a NYSCAL webinar, "How to Make Your Assisted Living QA Program Effective." Date/Time: May 15, 2025 10AM-11:30AM Program Overview: Does your staff truly understand what Quality Assurance (QA) is all about? It’s more than just audits and reports—it’s a powerful tool for - [FY 2026 SNF PPS Proposed Rule Issued](https://cmscompliancegroup.com/blog/fy-2026-snf-pps-proposed-rule-issued/) - On April 11, 2025, the Centers for Medicare & Medicaid Services released the FY 2026 SNF PPS proposed rule. The associated Fact Sheet addresses some of the key areas proposed, including: Proposed updates to SNF payment rates (2.8%) Proposed changes to PDPM ICD-10 Code mappings (for consistency with current coding guidance) Proposed changes to the - [Revised Ftag of the Week – F658 Services Provided Meet Professional Standards (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f658-services-provided-meet-professional-standards-pt-1/) - Another week, another opportunity for us to review the upcoming regulatory guidance changes in State Operations Manual Appendix PP – now coming your way on April 28, 2025. We reviewed F658 as part of our CMSCG “Ftag of the Week” blog series in June 2018, but we’re back at it to help nursing homes understand - [Ftag of the Week – F688 Increase/Prevent Decrease in ROM/Mobility (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f688-increase-prevent-decrease-in-rom-mobility-pt-3/) - In Part 3 of our CMSCG “Ftag of the Week” blog series for F688 ROM/Mobility, we’ll close out our review of these regulatory requirements by looking at a key area – care planning. Then, CMSCG President Linda Elizaitis and CMSCG Clinical Consultant Mary Quinn will share some important compliance tips and reminders for F688. Care - [NYSDOH DAL re: HERDS Reporting](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-re-herds-reporting-changes-april-2/) - On March 31, 2025, the New York State Department of Health (NYSDOH) distributed a new DAL (DACF 25-17 / NH 25-08) which will likely be music to the ears of every nursing home and adult care facility administrator. Changes are being made to the required daily HERDS COVID-19 reporting requirements. Here's what to know: Daily - [Revised Ftag of the Week – F641 Accuracy of Assessments (Pt. 1)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f641-accuracy-of-assessments-pt-1/) - When we originally reviewed F641 Accuracy of Assessments on the CMSCG Blog back in November 2018, we were towards the start of surveyors getting their hands around the LTCSP, but F641 was in the National Top 10 at that time. Per CASPER data for 2024 (current as of March 16, 2025), F641 landed in the - [Ftag of the Week – F641 Accuracy of Assessments](https://cmscompliancegroup.com/blog/ftag-of-the-week-f641-mds-accuracy/) - This week’s “Ftag of the Week” is F641 Accuracy of Assessments, which is currently the ninth most frequently cited deficiency on standard surveys across the United States (2018). This regulation, as its name suggests, requires that the MDS assessment accurately reflects the resident’s status at the time of assessment. The Interpretive Guidance (IG) specifically states - [Revised Surveyor Guidance Delayed - Again](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-surveyor-guidance-delayed/) - In a revised QSO Memo dated March 10, 2025, further delayed the implementation of the revised surveyor guidance in State Operations Manual Appendix PP expected at the end of this month. - [Survey Trends & Tips - May 7, 2025](https://cmscompliancegroup.com/education/survey-trends-tips-may-7-2025/) - Join CMS Compliance Group at the NYSHFA | NYSCAL Annual Conference and Expo from May 6-8, 2025 at the Sagamore Resort in Bolton Landing, NY. We're taking our annual NYSHFA | NYSCAL webinar on the road this year to provide an update on everything you need to know about survey activity in New York for - [Ftag of the Week – F622 Transfer and Discharge Requirements (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f622-transfer-and-discharge-requirements-pt1/) - Next up in our “Ftag of the Week” series on the CMSCG Blog is F622 Transfer and Discharge Requirements, which is part of the Admission, Transfer, and Discharge regulatory group. The purpose of this regulation is to limit the circumstances under which a nursing home can initiate a transfer or discharge of a resident. It - [CMS Postpones iQIES Nursing Home Launch](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-postpones-iqies-nursing-home-launch/) - The Centers for Medicare and Medicaid Services (CMS) announced revisions to its August 6, 2024 Memo (Admin Info: 24-21-NH) in a new Administrative Memo. The Memo states that CMS is postponing the iQIES Survey & Certification (S&C) Nursing Home (NH) release scheduled for February 2025. Since May 2021, State Survey Agencies and CMS locations have - [Ftag of the Week – F742 Treatment/Svc for Mental/Psychosocial Concerns (Pt 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f742-treatment-svc-for-mental-psychosocial-concerns-pt-2/) - In Part 1 of our CMSCG “Ftag of the Week” for F742 Treatment/Svc for Mental/ Psychosocial Concerns, we reviewed information related to pertinent diagnoses and the regulatory requirements under F742. In this post, Part 2, we want to highlight the Investigative Protocol for this tag, because it’s an activity that facilities could use internally to - [Ftag of the Week – F742 Treatment/Svc for Mental/Psychosocial Concerns (Pt 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f742-treatment-svc-for-mental-psychosocial-concerns-pt-3/) - In Part 3 of our CMSCG “Ftag of the Week” blog series for F742 we will finish reviewing the Investigative Protocol outlined in SOM Appendix PP for this regulation and provide some citation examples to help you better understand how issues can be identified during a survey. On CMSCG mock surveys, we often find during - [Revised Ftag of the Week – F725 Sufficient Nurse Staffing (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f725-sufficient-nurse-staffing-pt-2/) - In Part 1 of CMSCG’s revised Ftag of the Week for F725 Sufficient Nurse Staffing, we reviewed some of the basic revisions in the newly revised Appendix PP State Operations Manual (SOM) which will be effective March 25, 2025. We’ll continue reviewing the Investigative Procedure because there are several concerns which could be identified by - [Revised Ftag of the Week – F841 Responsibilities of the Medical Director](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f841-responsibilities-of-the-medical-director/) - This week’s “Ftag of the Week” on the CMSCG Blog is a review of F841 Responsibilities of the Medical Director. F841 is one of the tags with revised/ clarified guidance to surveyors that will be effective at the end of March 2025. It’s clear from the draft Interpretive Guidance (IG) that the Centers for Medicare - [Food Safety & Clinical Outcomes Webinar](https://cmscompliancegroup.com/blog/2025-food-safety-clinical-outcomes-webinar/) - Join CMS Compliance Group's Kelly Hellberg, MS, RD, CDN on April 1, 2025 for a NYSHFA | NYSCAL webinar. This widely-attended program has become an annual update - don't miss out. 2025 Update: Food Safety & Its Impact on Clinical Outcomes in the LTC Setting Date/Time: April 1, 2025 10AM-12PM Program Overview: Food safety in - [Recent NYSDOH DALs for Adult Care Facilities](https://cmscompliancegroup.com/state-specific-updates/recent-nysdoh-dals-for-adult-care-facilities/) - The New York State Department of Health (NYSDOH) issued two adult care facility Dear Administrator notices recently, which you can view below in case you missed them: DAL 25-14 Communicable Disease Reporting Requirements (1/29/2025) DACF 25-15 Mitigating Risks of Water Damage and Mold Growth (2/7/2025) CMSCG shares information notices from New York, which is our - [Ftag of the Week - F730 - Revisited](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f730-revisited/) - am sure that you are asking yourself, “why go back to this unimportant tag?” It is not so unimportant if you take a few minutes to re-read Brandie’s original Ftag of the Week from January 19, 2018. A revisit is warranted in my mind as nursing homes appear to have gotten lost in the weeds as to the importance of inservice training and how this education ties into a Nurse Aide’s annual Performance Evaluation. - [McKnights LTC News Article re: Surveyor Guidance Delays](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/mcknights-ltc-news-article-re-surveyor-guidance-delays/) - CMS Compliance Group, Inc. discussed the delayed relayed of the revised guidance to surveyors with McKnights Long-Term Care News in a January 24, 2025 article. View "‘Armed and ready’: Delayed guidance updates strategies for nursing home surveyors" on the McKnights website for more details. CMSCG will continue to post updates on the blog to help - [Revised QSO Memo & Implementation Date for LTCSP Surveyor Guidance Updates](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-qso-memo-implementation-date-for-ltcsp-surveyor-guidance-updates/) - On January 15, 2025, the Centers for Medicare and Medicaid Services (CMS) revised the November 18, 2024 Memo, QSO-25-25-07-NH, “Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process.” The revised Memo has a new reference number: QSO-25-12-NH. - [Join CMSCG at the NASVH Winter Conference!](https://cmscompliancegroup.com/education/join-cmscg-at-the-nasvh-winter-conference/) - Linda Elizaitis, President of CMS Compliance Group and Brandie Elizaitis, Director of Operations, will be presenting at the National Association of State Veterans Homes (NASVH) Winter Conference. Join CMSCG on February 13, 2025 for "CMS Survey Trends and 2025 Revised Regulatory Guidance for SNFs." This presentation will address current survey issues to be aware of - [NYSDOH DAL on Cultural Competency Training for Aides](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-on-cultural-competency-training-for-aides/) - On January 17, 2025, the New York State Department of Health (NYSDOH) released a new DAL, “Cultural Competency Requirements for Home Health Aide, Personal Care Aide, and Certified Nurse Aide Training Programs” (DRS #25-02). This DAL is essentially a follow-up to two other DALs, the March 18, 2024 DAL, “Long-Term Care Facility Residents’ Bill of - [Revised Ftag of the Week – F725 Sufficient Nurse Staffing (Pt. 1)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-ftag-of-the-week-f725-sufficient-nurse-staffing-pt-1/) - In case you missed this post on the CMSCG Blog, on January 15, 2025, the Centers for Medicare and Medicaid Services (CMS) revised its November 18, 2024 QSO Memo which addressed the “significant revisions” to the LTC survey process. The revised QSO Memo includes revisions to several tags, including F725 Sufficient Nurse Staffing. - [Ftag of the Week – F725 Sufficient Nursing Staff](https://cmscompliancegroup.com/blog/ftag-of-the-week-725-sufficient-nursing-staff/) - This week on the CMSCG Blog, we are reviewing F725 Sufficient Nursing Staff for our "Ftag of the Week." We held off on reviewing this tag over the past few years in anticipation that it could be expanded once the revisions to the State Operations Manual were released, but thankfully it’s not chock-full of surprise - [Revised Ftag of the Week – F678 CPR](https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f678-cpr/) - Happy New Year! We first posted an "Ftag of the Week" for F678 Cardio-Pulmonary Resuscitation (CPR) back in 2017. Now it’s time for a little update to reflect the CMS QSO Memo from November 2024 which includes revised guidance for surveyors effective February 24, 2025 effective March 25, 2025 per the updated QSO Memo from - [MDS 3.0 QM User's Manual v17.0](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/mds-qm-users-manual-v17-01012025/) - In case you missed it due to the recent holiday rush, the current Quality Measures User's Manual (v 17.0) was posted on December 23, 2024 and is effective as of January 1, 2025. Per the CMS Quality Measures webpage: December 23, 2024 MDS 3.0 Quality Measures User's Manual v17.0 and Accompanying Risk Adjustment Appendix File - [NYSDOH DAL Transfer or Discharge Notice Expectations](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-transfer-or-discharge-notice-expectations/) - On January 7, 2025, the New York State Department of Health (NYSDOH) issued DAL NH-25-01 “Transfer or Discharge Notice Expectations.” The DAL, like its title indicates, outlines expectations for permitting residents to return a facility after they have been transferred to acute care. The DAL includes a Q&A guide and addresses the requirements for transferring - [Ftag of the Week – F678 Cardio-Pulmonary Resuscitation (CPR)](https://cmscompliancegroup.com/blog/f678-cpr-nursing-facility/) - Welcome back to CMS Compliance Group’s “Ftag of the Week” blog series. This week’s tag is under the regulatory group Quality of Life. It’s F678, which under the existing Ftags can be found under F155 Right to Refuse; Formulate Advance Directives. In 2013, CMS issued a S&C memo mandating that nursing facilities may not establish - [New QSO Memo for Nursing Homes – Respiratory Illness Reporting](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/new-qso-memo-for-nursing-homes-respiratory-illness-reporting-12312024/) - Happy New Year! On December 31, 2024, the Centers for Medicare and Medicaid Services (CMS) released a new QSO Memo, “Long-Term Care (LTC) Facility Acute Respiratory Illness Reporting Requirements” (QSO-25-11-NH). Here’s what you need to know: The COVID-19 requirements for reporting expired on 12/31/2024, except for reporting COVID-19 vaccination status for LTC facility residents and - [New York - Required Posting Effective 12/26/2024](https://cmscompliancegroup.com/state-specific-updates/new-york-required-posting-effective-12-26-2024/) - Effective December 26, 2024, New York nursing homes are required to post the following information in accordance with NYS Public Health law: Website Postings: Overall CMS rating on the homepage of any website maintained by the facility and on any website or webpage relating to the facility maintained by an entity which owns or operates - [Join the CMSCG Team on 12/11/24 for a Survey Trends Webinar!](https://cmscompliancegroup.com/education/nyshfa-survey-trends-cmscg/) - Register now for CMSCG's annual NYSHFA year-end webinar - 2024 Survey Trends & Tips! Date/Time: December 11, 2024 10AM-12PM Presenters: Linda Elizaitis, RN, BS, RAC-CT, CDS, President Brandie Elizaitis, MS, LNHA, CDP, QCP, Director of Operations Kelly Hellberg, MS, RD, CDN, Dietary Consultant Jim Houle, Life Safety Consultant Session Overview: Join CMSCG's interdisciplinary team for - [New LTCSP Guidance and Appendix PP Updates Effective in 2025](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/new-ltcsp-guidance-and-appendix-pp-updates-effective-in-2025/) - On November 18, 2024 the Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo, "Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process." The 902-page document includes revised surveyor guidance related to multiple areas, including, but not limited to: Admission, Transfer & Discharge - [Reminder: Revised Facility Assessment Requirements Effective 8/8/2024!](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/reminder-revised-facility-assessment-requirements-effective-8-8-2024/) - Just a reminder to nursing home providers - the revised requirements for the Facility Assessment are effective in just two weeks, August 8, 2024. You can see what's required in this recent CMSCG Blog post - a revised Ftag of the Week. Need another set of eyes to assist with your review? Contact CMS Compliance - [CMS Announces Some Quality Measures to Remain Frozen](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-announces-some-quality-measures-to-remain-frozen/) - The Centers for Medicare and Medicaid Services (CMS) issued a new QSO Memo on October 4, 2024. This Memo, “Revised: Updates to Nursing Home Care Compare Staffing and Quality Measures” (QSO-25-01-NH) includes revisions to QSO-23-21-NH (9/20/2023). Specifically, the timeline for adjusting the quality measures affected by the MDS G-GG transition has been revised to allow - [State Agencies Complaining about Complaint Investigation Backlog](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/state-agencies-complaining-about-complaint-investigation-backlog/) - In an Administrative Memo dated October 9, 2024, “ACTS Bulk Intake Import Functionality,” the Centers for Medicare and Medicaid Services (CMS) provided information to State Agencies intended to help them with management of their complaint backlog. CMS indicates in the Memo that during “Pending Overdue Workload Quarterly Reviews,” State Agencies are still reporting issues with - [2024 Survey Trends & Tips Webinar](https://cmscompliancegroup.com/education/2024-survey-trends-and-tips-webinar/) - Join CMS Compliance Group, Inc. for our annual NYSHFA | NYSCAL year-end survey trends webinar! Date & Time: December 11, 2024 10AM-12PM Presenters: Linda Elizaitis, RN, BS, RAC-CT, CDS, President Brandie Elizaitis, MS, LNHA, CDP, QCP, Director of Operations Kelly Hellberg, MS, RD, CDN, Dietary Consultant Jame Houle, Life Safety Consultant Session Overview: Join CMSCG’s - [NYSDOH DALs - October 9, 2024](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dals-october-9-2024/) - The New York State Department of Health (NYSDOH) issued two new Dear Administrator Letters (DALs) on October 9, 2024: Conservation Strategies Following Closure of Baxter Plant (DAL NH 24-19, DAL HCBS 24-05) Cybersecurity Incident Reporting (DAL NH 24-18, DAL ACF 24-30, DAL HCBS 24-07) - [Draft MDS 3.0 Item Sets v 1.20.1 available](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/draft-mds-3-0-item-sets-available-october-2025/) - Just an FYI - Per a Centers for Medicare & Medicaid Services (CMS) Post-Acute Quality Reporting Programs update, draft MDS information for October 2025 is now available for download: The draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.20.1 and Item Matrix are now available in the Downloads section on the page. The MDS - [NYSDOH DAL - Cultural Competency Training for Direct Caregivers](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-cultural-competency-training-for-direct-caregivers/) - The New York State Department of Health (NYSDOH) issued a new DAL on October 2, 2024, "Affirming Care for Older LGBTQIA+ Individuals Online Training Module for Direct Support Caregivers." This DAL is directed to nursing homes, adult care facilities, hospice providers and home care providers. The additional requirements in this memo are related to NYS - [Reminder - Ensure You Uphold Your Residents Right to Vote](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/reminder-ensure-you-uphold-your-residents-right-to-vote/) - On September 26, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a QSO Memo, “Compliance with Residents’ Rights requirement related to Nursing Home Residents’ Right to Vote.” The Memo reiterates the regulatory expectations that residents of nursing homes have the right to vote without any interference from the facility. The Memo also reminds - [NYSCAL Interdisciplinary Series - Dining & Nutrition](https://cmscompliancegroup.com/education/nyscal-interdisciplinary-series-dining-nutrition-10302024/) - Join CMS Compliance Group on October 30, 2024 for a presentation on Dining and Nutrition, part of the NYSCAL Assisted Living Interdisciplinary Team Series. Session: Dining and Nutrition Date: October 30, 2024 10:00AM-11:30AM Presenter: Kelly Hellberg, MS, RD, CDN During this presentation, the following will be reviewed: Role & Responsibilities Developing meal plans based on - [NYSDOH - DAL for COVID-19 Vaccine (9/18/2024)](https://cmscompliancegroup.com/state-specific-updates/nysdoh-dal-for-covid-19-vaccine-9-18-2024/) - New York Nursing Home, Adult Care and Home and Community-Based Service Providers, if you haven't seen it, check out the September 18, 2024 DAL related to the new COVID-19 vaccine for the 2024-2025 "season." Download the DAL here (DAL DACF 24-26, DAL NH 24-15 and DAL HCBS 24-02). - [Revised SNF ABN Available - Mandatory 10/31/2024](https://cmscompliancegroup.com/blog/revised-snf-abn-available-mandatory-10-31-2024/) - A new Skilled Nursing Advanced Beneficiary Notice Form (SNF ABN) is available and will be mandatory effective October 31, 2024. The revised form includes check boxes for the types of care versus needing to write it in. Per the SNF ABN webpage: The SNF ABN form and instructions are located in the download section and - [Join CMSCG for a Plan of Correction Workshop](https://cmscompliancegroup.com/assisted-living/join-cmscg-for-a-plan-of-correction-workshop/) - Planning to attend the NYSCAL Fall Education Forum for Assisted Living providers in Albany, NY in November? Join CMS Compliance Group, Inc. for an interactive workshop on November 20th from 11:15AM-12:15PM. Session: Plan of Correction (POC Workshop: Hands-On Strategies for Success During this interactive session, attendees will gain a better understanding of what’s required for - [Revised Survey Resources Available – Effective 8/8/2024](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-survey-resources-available-effective-8-8-2024/) - CMS released updated survey resources for nursing homes effective August 8, 2024. - [Revised Survey Resources Available (8/20/2024)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/revised-survey-resources-available-8-20-2024/) - A couple weeks ago, CMSCG posted revisions to the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Survey Process (LTCSP) survey resources, including a revised Appendix PP. There have been additional changes since then, so please note: On 8/16/2024, another revision to State Operations Manual Appendix PP was issued. That revision included updates to - [Final MDS 3.0 RAI User’s Manual version 1.19.1 available](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/final-mds-3-0-rai-users-manual-version-1-19-1-available/) - The final MDS Manual v1.19.1 effective October 1, 2024 is now available for download on the CMS.gov website. - [July 2024 Five-Star Technical Users’ Guide Now Available](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/july-2024-five-star-technical-users-guide-now-available/) - The Centers for Medicare and Medicaid Services (CMS) released, as expected, the Nursing Home Five-Star Quality Rating System Technical Users’ Guide for July 2024. The updated guide is effective with the monthly data refresh which feeds Care Compare. Here’s a recap of what’s changed with the Five-Star Quality Rating System: Staffing case-mix methodology adjusted to - [Changes Coming to Nursing Home Compare This Summer](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/changes-coming-to-nursing-home-compare-this-summer/) - On July 1, 2024, The Centers for Medicare and Medicaid Services (CMS) released a new QSO Memo, “Nursing Home Data and Care Compare Updates” which outlines upcoming changes to publicly available data shared by CMS. Here’s what you need to know about what’s coming on July 31, 2024. Staffing Level Case-Mix Adjustment Methodology Implementation In - [Payroll-Based Journal FAQ Updated (July 2024)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/payroll-based-journal-faq-updated-july-2024/) - The Centers for Medicare and Medicaid Services (CMS) revised its Electronic Staffing Submission Payroll-Based Journal (PBJ) Frequently Asked Questions document for July 2024. View the updated FAQ here. - [Rejected POCs for High-Level Citations? More Onsite Visits Coming.](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/rejected-pocs-for-high-level-citations-more-onsite-visits-coming/) - In a June 6, 2024 CMS Admin Memo, The Centers for Medicare and Medicaid Services (CMS) announced revisions related to the review and approval process for Plans of Corrections for certain citations. CMS states in the Memo that while Plans of Correction (POCs) are one element of the compliance review for issues identified on a - [Ftag of the Week – F693 Tube Feeding Management/Restore Eating Skills (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f693-tube-feeding-management-restore-eating-skills-pt-3/) - In the final part of our “Ftag of the Week” series for F693 Tube Feeding Management/ Restore Eating Skills, we will review the key nutritional aspects and concerns related to tube feeding. Mary Quinn, RN, MA will be lending some clinical insight for this post. Physician’s Orders Physician’s orders typically include a significant amount of - [Ftag of the Week – F688 Increase/Prevent Decrease in ROM/Mobility (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f688-increase-prevent-decrease-in-rom-mobility-pt-2/) - In Part 1 of our “Ftag of the Week” series on the CMSCG Blog, we reviewed the regulatory requirements for F688, key definitions, and the list of policies that providers need to have in place for compliance. Now we’ll review assessments, a key part of this regulation. Assessments The regulation includes Interpretive Guidance for both - [Ftag of the Week – F777 Radiology/Diag. Svcs Orders/Notify Results](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f777-radiology-diag-svcs-orders-notify-results/) - The next CMSCG “Ftag of the Week” is our last post before our annual “summer break” for this blog series. This week, we’re looking at F777, which is part of the Laboratory, Radiology, and Other Diagnostic Services regulatory group. Like several of the tags we’ve covered recently on the CMSCG Blog, this regulation is not - [OIG to Review Nursing Home Special Focus Facility Program](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/oig-to-review-nursing-home-special-focus-facility-program/) - The Office of the Inspector General (OIG) added a new item to its Work Plan in June, “Assessment of the Special Focus Facility Program for Nursing Homes.” The report, which has an expected issue date of FY 2025, will evaluate the Centers for Medicare & Medicaid Services (CMS) and State Agencies’ implementation of the Special - [Ftag of the Week – F838 Facility Assessment (Revised – Effective 8/8/2024)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f838-facility-assessment-revised-effective-08082024/) - On June 18, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a new QSO Memo, “Revised Guidance for Long-Term Care Facility Assessment Requirements.” The QSO Memo sets out the new guidance for the Facility Assessment requirements – and an updated version of the State Operations Manual Appendix PP – effective August 8, 2024. - [Ftag of the Week – F838 Facility Assessment (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f838-facility-assessment-pt2/) - Welcome back to the CMSCG Blog and Part 2 of our Ftag of the Week regarding F838 Facility Assessment. Last week, in Part 1, we identified the basic components of the Facility Assessment and provided some gentle reminders that providers may indeed be due for a review of their Facility Assessment to ensure that it - [Ftag of the Week – F711 Physician Visits – Review Care/Notes/ Order](https://cmscompliancegroup.com/blog/ftag-of-the-week-f711-physician-visits-review-care-notes-order/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Physician Services regulatory group, F711 Physician Visits – Review Care/Notes/Order. The intent of this regulation is to ensure that physicians have an active role in the supervision of resident care and visits are not “superficial.” F711 addresses tasks that must be - [Ftag of the Week – F806 Resident Allergies, Preferences and Substitutes](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f806-resident-allergies-preferences-and-substitutes/) - Next up on the CMSCG Blog, we’re reviewing one of the regulations from the Food and Nutrition regulatory group, F806 Resident Allergies, Preferences and Substitutes. This regulation doesn’t include a lot of content, but it can easily pack a punch on survey with a widespread (S/S: F), harm or Immediate Jeopardy-level citation, so it’s important - [Top 10 Most Frequently Cited Ftags (National)](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/top-10-most-frequently-cited-ftags-national/) - New month, new list! Here are the top 10 most frequently cited Ftags on recertification surveys in 2024 (per CASPER 4/28/2024) so far: F812 Kitchen Sanitation F880 Infection Control F761 Storage of Drugs & Biologicals F689 Accidents/Supervision F656 Comprehensive Care Plans F684 Quality of Care F694 Respiratory/Trach Care F677 ADL Care F550 Resident Rights F641 - [Ftag of the Week – F693 Tube Feeding Management/Restore Eating Skills (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f693-tube-feeding-management-restore-eating-skills-pt-2/) - In Part one of our CMSCG “Ftag of the Week” for F693, we reviewed definitions included in the regulation and discussed some important considerations for use of a feeding tube. The Interpretive Guidance in Appendix PP provides a list of risks and benefits which we also reviewed in Part 1,including a reminder to providers to - [Time to Upgrade Your Facility Assessment](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/time-to-upgrade-your-facility-assessment/) - If you’re a CMS Compliance Group client, you probably know what we’re going to say in this post: “You’ll need to upgrade your Facility Assessment once the staffing rule comes out.” As expected, the Centers for Medicare and Medicaid Services (CMS) announced its Minimum Staffing Standards for Long-Term Care Facilities final rule on April 22, - [Nursing Home Staffing & Medicaid Home Care Rules Arrive (White House Media Release)](https://cmscompliancegroup.com/blog/nursing-home-staffing-medicaid-home-care-rules-arrive-white-house-media-release/) - On April 22, 2024, the White House issued a release, "Fact Sheet: Vice President Harris Announced Historic Advancements in Long-Term Care to Support the Care Economy," which announced the final Nursing Home Minimum Staffing Rule and Ensuring Access to Medicaid Services Rule. Nursing Home Minimum Staffing Rule The breakdown of required hours, per the release, - [Ftag of the Week – F586 Resident Contact with External Entities](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f586-resident-contact-with-external-entities-2/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Resident Rights regulatory group, F586 Resident Contact with External Entities. F586 is a short and sweet regulation, but not one to forget about. The regulation states that facilities cannot prohibit or otherwise discourage a resident from communicating with external entities. These - [CMS Provides Details on “Risk-Based Survey” Approach](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/cms-provides-details-on-risk-based-survey-approach/) - The Centers for Medicare and Medicaid Services (CMS) announced that it is currently testing its risk-based survey (RBS) approach. This testing is projected to occur over the next few months. The Agency had floated the idea of a modified survey approach, but there weren’t any details to go with it. CMS indicated some pretty telling - [Quality 101 - Why Quality Matters (ESAAL Conference) Register Now!](https://cmscompliancegroup.com/blog/quality-101-why-quality-matters-esaal-conference-2/) - Reminder -- Registration is open for ESAAL's 43rd Annual Conference. Join CMSCG President Linda Elizaitis, RN, BS, RAC-CT, CDS on Wednesday, April 17, 2023 from 11AM-12:30 for her session, "Quality 101 - Why Quality Matters." We hope to see you there! Session Overview: While SNFs have long been exposed to a mountain of regulatory expectations - [Survey & Oversight Changes in Nursing Homes – What to Know (Pt 2)](https://cmscompliancegroup.com/blog/survey-oversight-changes-in-nursing-homes-what-to-know-pt-2/) - On November 12, 2021, the Centers for Medicare & Medicaid (CMS) released a QSO Memo, “Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes” (QSO-22-02-ALL). The Memo provides information on changes that CMS is making to help State Survey Agencies (SAs) get caught up with a significant backlog of recertification and complaint surveys. - [Ftag of the Week – F759 Free of Medication Error Rates of 5% or More (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f759-free-of-medication-error-rates-of-5-or-more-pt2/) - In this week’s “Ftag of the Week” post on the CMSCG Blog, we are digging deeper into med errors. The first post for F759 provided an overview of what is considered a med error, how surveyors calculate med errors and a couple of areas where med errors can be identified during the Medication Administration task. - [Ftag of the Week – F759 Free of Medication Error Rates of 5% or More (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f759-free-of-medication-error-rates-of-5-percent-or-more-pt3/) - As noted in earlier posts, there is significant Interpretive Guidance (IG) in Appendix PP regarding F759 and what constitutes a med error and how it is calculated. In Part 3 of our Ftag of the Week for F759 Med Error Rates of 5% or More, we will wrap up this regulation by discussing a few - [Ftag of the Week – F760 Residents Are Free of Significant Med Errors (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f760-residents-are-free-of-significant-med-errors-pt-2/) - Last week on the CMSCG Blog, we reviewed the majority of the regulatory requirements and Interpretive Guidance (IG) for F760 regarding Significant Medication Errors. The IG also provides examples of what can contribute to the significance of a med error, as well as medication errors that would be considered “significant” errors regardless of the resident’s - [Ftag of the Week – F949 Behavioral Health Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f949-behavioral-health-training/) - Although we usually pause the CMSCG “Ftag of the Week” blog series for the summer, that’s not in the cards this year now that we have updated guidance for the Requirements of Participation effective October 24, 2022. The RoPs have greatly expanded requirements and guidance related to behavioral health, so this week we’re looking at - [Ftag of the Week – F944 QAPI Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f944-qapi-training/) - This week’s “Ftag of the Week” on the CMSCG Blog is another Phase 3 requirement, F944 QAPI Training. Just like with last week’s post regarding mandatory Infection Control Training, it’s likely that most providers already have training for their Quality Assurance and Performance Improvement (QAPI) Program in place, but now with the draft guidance in - [Ftag of the Week – F741 Sufficient/Competent Staff – Behav Health Needs (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f741-sufficient-competent-staff-behav-health-needs-pt-3/) - This week on the CMSCG Blog “Ftag of the Week,” we are wrapping up our series for F741 related to sufficient and competent staffing to meet your residents’ behavioral health needs. Key Skills The Interpretive Guidance (IG) states that all staff must have the ability to effectively interact with residents and implement person-centered approaches to - [CMS Revises Special Focus Facility Program (SFF)](https://cmscompliancegroup.com/blog/cms-revises-special-focus-facility-program-sff/) - In a media release dated October 21, 2022, changes to the CMS Special Focus Facility (SFF) Program were announced. Read the full release below or visit cms.gov/newsroom. Biden-Harris Administration Strengthens Oversight of Nation’s Poorest-Performing Nursing Homes Changes to CMS’ Special Focus Facilities program will increase scrutiny, hold facilities accountable for substandard safety and quality, and improve - [Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f686-treatment-svcs-to-prevent-heel-pressure-injuries-pt-3/) - Welcome back to the CMSCG “Ftag of the Week” for F686 Pressure Injuries. We hope you had a wonderful Thanksgiving! Let’s get back into what is required for treatment of pressure injuries and the importance of documentation. Treatment A resident has been admitted to your facility with a pressure injury or unfortunately has developed a - [Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f686-treatment-svcs-to-prevent-heal-pressure-injuries-pt-4/) - Welcome back to the CMSCG Blog and the final post in our “Ftag of the Week” for F686 Treatment/ Svcs to Prevent/Heal Pressure Injuries. In this post, Mary Quinn, CMS Compliance Group, Inc. Consultant, provides some helpful tips and reminders. Documentation Review all areas of documentation on a routine basis to ensure consistency. It’s amazing - [Ftag of the Week - F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f690-bowel-bladder-incontinence-catheter-uti-pt2/) - Last week, in Part 1 of our CMSCG “Ftag of the Week” for F690, we reviewed some key terms used in the regulation and looked at some important items that need to happen on admission. In this post, we will continue our review of this regulation as it relates to catheter use – a high-risk - [Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f695-respiratory-tracheostomy-care-and-suctioning-pt3/) - In Part 3 of our CMSCG “Ftag of the Week” for F695, we will review additional care and services that fall under this category, namely, C-pap and Bi-pap for obstructive sleep apnea (OSA) as well as tracheostomy care and suctioning. CPAP/BiPAP There are many types of treatments that can address OSA, which results in the - [COVID-19 PHE Ending – What Nursing Homes Need to Know re: Waivers & Regs](https://cmscompliancegroup.com/blog/covid-19-phe-ending-what-nursing-homes-need-to-know-re-waivers-regs/) - As noted on the CMSCG Blog in our post, “COVID-19 PHE Ending – Along with Waivers & Requirements for all Provider Types,” there are changes ahead for skilled nursing/long-term care providers due to the end of the COVID-19 Public Health Emergency (PHE). Skilled Nursing/ Long Term Care Providers – What to Know 3-Day Prior Hospitalization - [Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f695-respiratory-tracheostomy-care-and-suctioning-pt4/) - Sometimes our CMSCG “Ftag of the Week” for certain regulations is more like an “Ftag of the Month,” and F695 is one of those regs with a lot to cover. In this post, we will wrap up our CMSCG Blog series for F695 Respiratory/ Trach Care and Suctioning by looking at ventilators and some other - [2023 Top 10 Most Frequently Cited F-tags](https://cmscompliancegroup.com/blog/2023-top-10-most-frequently-cited-ftags-nov2023-national/) - Preparing for your upcoming survey? Here’s the top 10 most frequently cited Ftags on recertification surveys for 2023 in the United States, per CASPER data from 11/12/2023: F812 Food Procurement, Store/Prepare/Serve Sanitary F880 Infection Prevention and Control F689 Free of Accident Hazards/Supervision/Devices F656 Develop/Implement Comprehensive Care Plan F761 Storage of Drugs & Biologicals F684 Quality - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-2/) - In Part 1 of our “Ftag of the Week” for F605, we reviewed the regulation itself and outlined some key definitions. In this part of our review, we will review one more important definition – indication for use – and look at how it’s applied in this regulation. What’s Indication for Use? Indication for use, - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-3/) - In this week’s CMSCG “Ftag of the Week,” post, we will finish our review of F605 Right to Be Free from Chemical Restraints, a potentially high-risk area for providers. As you can tell from the actual citation examples we have provided in Part 1 and Part 2 of this blog series, residents can experience significant - [Ftag of the Week – F694 Parenteral/IV Fluids (Pt. 3)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f694-parenteral-iv-fluids-pt-3/) - In this week’s “Ftag of the Week” post on the CMSCG Blog, we’ll finish our review of F694 Parenteral/IV Fluids with some important reminders from CMSCG Clinical Consultant Mary Quinn. Maintenance and Discontinuation Don't forget about these: Arm circumference and catheter length should be monitored when a PICC line is in place. Documentation is often - [Ftag of the Week – F646 MD/ID Significant Change Notification (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f646-md-id-significant-change-notification-pt-2/) - In the first part of our “Ftag of the Week” for F646, we reviewed important definitions related to this regulation – PASARR and Significant Change. As discussed in the last post, nursing facilities are required to notify the appropriate state authority when a resident with MI/ID experiences a significant change in his/her physical or mental - [Ftag of the Week – F694 Parenteral/IV Fluids (Pt. 2)](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f694-parenteral-iv-fluids-pt-2/) - This week on the CMSCG Blog, CMSCG Consultant Mary Quinn continues our discussion about the regulatory requirements for F694 Parenteral/IV Fluids. If you missed Part 1, you can check that out here. Next, we’ll review what you need to think about regarding IV therapy, including best practices. Before we get started, here’s an actual survey - [LTCSP Materials Revised to Reflect Infection Control Changes (Effective 4/1/2024)](https://cmscompliancegroup.com/blog/ltcsp-materials-revised-to-reflect-infection-control-changes-effective-ebp-04012024/) - Hot off the presses! On April 1, 2024 the Centers for Medicare & Medicaid Services (CMS) released updated Critical Element Pathways to reflect the recent announcement requiring Enhanced Barrier Precautions in nursing homes. That requirement, effective April 1, 2024, impacts infection control requirements for high-contact resident care activities – such as those which may occur - [OIG to audit MDS accuracy related to a high-risk area in upcoming report](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/oig-to-audit-mds-accuracy-related-to-a-high-risk-area-in-upcoming-report/) - The Office of the Inspector General (OIG) added another nursing facility-focused item to its Work Plan in March 2024, “Assessing the Accuracy of Nursing Home Falls Reporting in MDS Assessments.” OIG will be reviewing Medicare claims data to identify hospitalizations related to a fall with major injury and then compare that data to MDS assessments - [OIG is Auditing Nursing Home Drug Overdoses](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/oig-is-auditing-nursing-home-drug-overdoses/) - The Office of the Inspector General (OIG) added a new item to its Work Plan, “Audit of Nursing Facility Drug Overdoses.” The report, with an expected issue date of FY 2025, will review if selected nursing facilities complied with quality-of-care regulatory requirements and reported and investigated drug overdoses appropriately. The audit will also determine if - [Ftag of the Week (Revised) – F880 – Guidance for Enhanced Barrier Precautions](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-revised-f880-guidance-for-enhanced-barrier-precautions/) - If it feels like there is a never-ending amount of infection control information and requirements to be aware of, you’re not alone. That’s why we’re back with more additions to our Ftag of the Week series for F880 Infection Prevention and Control. This time, we’re discussing the brand-new requirements for using Enhanced Barrier Precautions in - [CMS Mandates Use of Enhanced Barrier Precautions (EBP)](https://cmscompliancegroup.com/blog/cms-mandates-use-of-enhanced-barrier-precautions-ebp-nursing-homes/) - If you’ve been delaying the use of Enhanced Barrier Precautions (EBP) in your nursing home since the CDC introduced this PPE strategy in 2019, it’s time to take another look. In a March 20, 2024 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) announced that it will require nursing homes to implement use - [Are Our Investigations Really That Bad?](https://cmscompliancegroup.com/education/are-our-investigations-really-that-bad-nyshfa-nyscal-conference-2024-linda-elizaitis/) - Join CMS Compliance Group President Linda Elizaitis at the 75th annual NYSHFA | NYSCAL Conference on May 8, 2024 to find out! Topic: "Are Our Investigations Really That Bad?" Presenter: Linda Elizaitis, RN, BS, RAC-CT, CDS, President of CMS Compliance Group, Inc. Date/Time: May 8, 2024 10:15AM-11:45AM Session Overview: Although you may not want to - [NYSDOH Warm Weather Advisory (3/20/2024)](https://cmscompliancegroup.com/state-specific-updates/nysdoh-warm-weather-advisory-dal-2024/) - On March 20, 2024, the New York State Department of Health (NYSDOH) released its annual "Warm Weather Advisory" DAL (NH 24-07). View the guidance here. - [New York NH & ACF Provider Alert – Resident Rights](https://cmscompliancegroup.com/state-specific-updates/new-york-nh-acf-provider-alert-resident-rights/) - On March 18, 2024, the New York State Department of Health (NYSDOH) issued new DALs for nursing home and adult care facility providers, “Long-Term Care Facility Residents’ Bill of Rights Amendment.” Effective May 28, 2024, Public Health Law section 2803-c-2 establishes that it is unlawful for a nursing home or adult care facility to take/fail - [LTC Health FY24 Mandated Federal Monitoring Surveys Updated](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/ltc-health-fy24-mandated-federal-monitoring-surveys-updated/) - On March 13, 2024, the Centers for Medicare and Medicaid Services (CMS) revised Admin Memo 24-12-NH, “Guidance for Federal Monitoring Surveys (FMS).” The revisions to this Memo now reflect the number of statutorily mandated Federal Monitoring Surveys for Fiscal Year 2024. The required number of FMS for FY 2025 is not expected until the end - [LTC LSC FY24 Mandated Federal Monitoring Surveys Updated](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/ltc-lsc-fy24-mandated-federal-monitoring-surveys-updated/) - The Centers for Medicare and Medicaid Services (CMS) issued a revision to its November 20, 2023 Admin Memo, “Guidance for Federal Monitoring Surveys (FMS)” on March 13, 2024. The revised Memo now reflects the number of mandated Federal Monitoring Surveys for LTC LSC that must be completed in FY24. There have been a number of - [Ftag of the Week – F645 PASARR Screening for Mental Disorder/ Intellectual Disability](https://cmscompliancegroup.com/cmscg-updates/ftag-of-the-week-f645-pasarr/) - Ftag of the Week – F645 PASARR Screening for Mental Disorder/ Intellectual Disability This week’s “Ftag of the Week” is part of the Resident Assessments regulatory group, F645 PASARR Screening for Mental Disorder/Intellectual Disability. This Ftag outlines a nursing facility’s requirements for not admitting new residents with a mental disorder or intellectual disability except where - [Ftag of the Week – F640 Encoding/Transmitting Resident Assessment](https://cmscompliancegroup.com/blog/ftag-of-the-week-f640-encoding-transmitting-resident-assessment/) - This week’s “Ftag of the Week” on the CMSCG Blog is a tag that we’re unfortunately seeing an increasing number of citations under, F640 Encoding/Transmitting Resident Assessment. Consider this a friendly reminder from the CMSCG Team about getting your assessments in timely! During survey, if there is reason to suspect that assessments are not being - [Food Safety & Its Impact on Clinical Outcomes in the Long-Term Care Setting (Webinar)](https://cmscompliancegroup.com/education/food-safety-its-impact-on-clinical-outcomes-in-the-long-term-care-setting-webinar/) - Please join CMS Compliance Group Consultant Kelly Hellberg, MS, RD, CDN for a NYSHFA | NYSCAL webinar, "Food Safety & Its Impact on Clinical Outcomes in the Long-Term Care Setting" on April 2, 2024. Date & Time: April 2, 2024 10AM-12PM Session Overview: Food safety in long-term care settings presents a significant daily challenge for - [OIG to Update Nursing Facility Compliance Program Guidance in 2024](https://cmscompliancegroup.com/blog/oig-to-update-nursing-facility-compliance-program-guidance-in-2024-icpg/) - On February 21, 2024, the Office of the Inspector General (OIG) issued an update, "OIG Announces the Next Anticipated Compliance Program Guidance Documents." OIG had announced in 2023 that it planned to update existing compliance program guidance documents (CPGs) and would provide new guidance. In today's update, OIG states that it intends to publish specific - [Ftag of the Week – F805 Food in Form to Meet Individual Needs](https://cmscompliancegroup.com/ftag-of-the-week/ftag-of-the-week-f805-food-in-form-to-meet-individual-needs/) - Thought we might be done reviewing regulations on the CMSCG Blog? Nope, we’ve still got plenty to review! Our first 2024 “Ftag of the Week” on the CMSCG Blog is part of the Food & Nutrition regulatory group, F805 Food in Form to Meet Individual Needs. This regulation is light on content requirements, but if - [Quality 101 - Why Quality Matters (ESAAL Conference)](https://cmscompliancegroup.com/education/quality-101-why-quality-matters-esaal-conference/) - Registration is open for ESAAL's 43rd Annual Conference. Join CMSCG President Linda Elizaitis, RN, BS, RAC-CT, CDS on Wednesday, April 17, 2023 from 11AM-12:30 for her session, "Quality 101 - Why Quality Matters." Session Overview: While SNFs have long been exposed to a mountain of regulatory expectations around quality, assisted living providers have had less - [Q&A from NYSDOH re: Infection Inspection Audit & Checklist](https://cmscompliancegroup.com/blog/qa-from-nysdoh-re-infection-inspection-audit-checklist/) - The New York State Department of Health (NYSDOH) released a Questions & Answers document about the Infection Inspection Audit and Checklist on February 8, 2024. Several CMSCG clients have notified us that they have been contacted by DOH regarding this audit. Please take a moment to read through this document if it's your turn - - [Implementing a Successful Assisted Living QA Program (Webinar)](https://cmscompliancegroup.com/assisted-living/nyscal-implementing-a-successful-assisted-living-qa-program-webinar/) - Please join CMS Compliance Group President Linda Elizaitis on February 21, 2024 for a NYSCAL webinar, "Implementing a Successful Assisted Living QA Program." Session Overview: DOES YOUR STAFF GROAN EVERY TIME YOU MENTION MONITORING OR AUDITING? Your QA program doesn’t need to be an enemy of the staff. Understanding the basics of Quality Assurance will - [OIG to Look at CMS Oversight of Nursing Home Survey Contractors](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/oig-to-look-at-cms-oversight-of-nursing-home-survey-contractors/) - The Office of the Inspector General (OIG) added a new report to its Work Plan in January. The report, “Audit of CMS Oversight of States’ Use of Third-Party Contractors to Conduct Nursing Home Surveys,” will review the Center for Medicare & Medicaid Services’ (CMS) reliance of third-party contractors to conduct nursing home surveys. The report - [Are You Using the Right LTCSP Resources?](https://cmscompliancegroup.com/resources/are-you-using-the-right-ltcsp-resources-january-2024/) - New year, new LTCSP resources? Nope, not yet, despite the Centers for Medicare and Medicaid Services (CMS) stating late last year that it is looking to potentially revamp the survey process to be more efficient. So, in the meantime, if you’re looking for the current Long-Term Care Survey Process (LTCSP) Resources, here’s a list and - [CDC LTC "Quick Start Guide" - Respiratory Virus Season](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/resource-cdc-ltc-quick-start-guide-respiratory-virus-season/) - In case you missed it, the Centers for Disease Control and Prevention (CDC) has a webpage, "Long-Term Care Quick Start Guide: Preparing for Respiratory Virus Season" which includes links to CDC guidance related to respiratory illness in LTC facilities. The webpage includes helpful information, including guidance, recommendations, posters, information on treatment and more. View the - [Draft MDS Items Effective 10/2024 Posted](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/draft-mds-items-effective-10-2024-posted/) - Via a 1/12/2024 Centers for Medicare & Medicaid Services Post-Acute Care Quality Reporting Programs Email Update: NOW AVAILABLE: Draft MDS 3.0 Item Sets version 1.19.1 The draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.19.1 and Item Matrix are now available in the Downloads section on the page. The MDS Item Sets v1.19.1 will - [Implementing a Successful Assisted Living QA Program (Webinar)](https://cmscompliancegroup.com/blog/implementing-a-successful-assisted-living-qa-program-webinar/) - Join CMS Compliance Group President Linda Elizaitis on February 21, 2024 for a NYSCAL webinar. Program Title: Implementing a Successful Assisted Living QA Program Date & Time: February 21, 2024 10AM-12PM EST Program Description: Does your staff groan every time you mention monitoring or auditing? Your QA Program doesn’t need to be an enemy of - [The New CMSCG Website is Here](https://cmscompliancegroup.com/cmscg-updates/the-new-cmscg-website-is-here/) - Welcome to the all-new CMS Compliance Group website. We’re happy you’re here. In the coming weeks, you’ll see brand-new resources and insights from the CMSCG Team as a result of our new site. We’re excited to announce several new features coming soon: Five-Star Focus Podcast CMSCG Academy Complimentary subscriber-only resources for CMSCG clients and providers - [New York State OMIG 2024 Work Plan Released](https://cmscompliancegroup.com/blog/new-york-state-omig-2024-work-plan-released/) - On January 3, 2024, the NYS Office of the Medicaid Inspector General (OMIG) released its 2024 Work Plan. The Work Plan includes multiple program focus areas, some of which include: Nursing Home Minimum Data Set (MDS) Reviews Adult Day Health Care Audits Assisted Living Program Audits Home Health Episodic Payments Nursing Home Transition and Diversion - [Join CMSCG for a Michigan Focused Surveys Seminar](https://cmscompliancegroup.com/blog/11-michigan-focused-surveys/) - Join CMS Compliance Group President Linda Elizaitis for a full day education session in Detroit, Michigan on the CMS Focused Survey types. Learn about the MDS/Staffing Focused Survey, the Dementia Care Focused Survey and the Medication Accuracy/Adverse Drug Event Focused Survey. Date: Tuesday, March 8, 2016 Location: Embassy Suites (Livonia, MI) View more details and register - [Home Health Star Ratings now reflect patient feedback](https://cmscompliancegroup.com/news/01-home-health-patient-stars/) - With last week’s announcement that Home Health Compare now includes patient star ratings, CMS has shown that it intends to increase transparency into the care provided by home health agencies. In July 2015, CMS published the first Quality of Patient Care Star Ratings which is based on OASIS assessments and Medicare claims data. The newly - [Linda Elizaitis discusses CMS Focused Surveys in Illinois](https://cmscompliancegroup.com/blog/12-illinois-focused-surveys/) - Please join CMSCG President Linda Elizaitis if you are a nursing home administrator, director of nursing, or other management-level position in the Chicago-area on March 9, 2016 for an all-day seminar on the CMS Focused Surveys. CMS has continued to implement a more targeted survey approach, with three distinct Focused Surveys now underway. The MDS - [Massachusetts Nursing Homes CMS Focused Surveys Education](https://cmscompliancegroup.com/blog/15-mass-focused-surveys/) - Please join CMS Compliance Group's President, Linda Elizaitis, for a seminar on the CMS Focused Surveys in Marlborough, Massachusetts on March 23rd, 2016. Administrators, Directors of Nursing and other management are strongly encouraged to attend. This seminar will attempt to demystify the new Focused Survey process and provide best practices for compliance in each of the - [Connecticut Focused Surveys Education with Linda Elizaitis](https://cmscompliancegroup.com/blog/16-connecticut-focused-surveys/) - Connecticut nursing home administrators, DONs and management, we will be providing education on the CMS Focused Surveys in Cromwell, CT on March 24, 2016. CMS Compliance Group President Linda Elizaitis will be providing an all-day education session on the MDS/Staffing Focused Survey, the Dementia Care Focused Survey and the Med Error Focused Survey. Date: Wednesday, - [CMS Focused Surveys are a hot topic - join us in these cities!](https://cmscompliancegroup.com/blog/17-cms-focused-surveys/) - CMS Compliance Group President Linda Elizaitis will be presenting on the CMS Focused Survey types in March in several cities. We hope to see you there! What You Will Learn: Overview and update on all three Focused Surveys now underway: MDS/Staffing, Dementia Care, and Medication management CMS rationale and background for the Focused Survey initiative - [NYSDOH Nursing Home Surveillance Report Findings](https://cmscompliancegroup.com/news/02-nysdoh-nursing-home-survey/) - A new audit of the New York State Department of Health’s oversight of nursing homes notes that the Department should improve its enforcement of violations in nursing homes. According to the February 22, 2016 press release issued about the audit, NYSDOH inspects nursing homes at the expected frequency, and acts relatively quickly on serious complaints, - [CMS announces 6 new Quality Measures for Nursing Home Compare](https://cmscompliancegroup.com/news/03-cms-6-new-quality-measures/) - CMS announced the addition of six new Quality Measures that will be added to Nursing Home Compare in an Open Door Forum call today. The new Quality Measures will be publicly available on Nursing Home Compare beginning April 2016. In July 2016, CMS will begin the process of incorporating five of the six measures into - [CMS clarifies IMPACT ACT comment from SNF/LTC Open Door Forum (3/3)](https://cmscompliancegroup.com/news/09-cms-impact-act-snfodf/) - Via the CMS Daily Digest Bulletin for March 9, 2016: CMS would like to correct an announcement provided at the Skilled Nursing Facilities/Long Term Care Facilities Open Door Forum on 3/3/16. When providing the IMPACT Act updates CMS announced that we would be participating in a Pre-Summit session on June 26, 2016 at the upcoming - [Another facet of abuse prevention & maintaining resident dignity](https://cmscompliancegroup.com/news/14-snf-ltc-social-media-policy/) - Everyone reading this post probably cringed a little at the title, but what we are about to discuss requires a serious look internally before it becomes a potential problem at your facility. At CMSCG, we work with our clients to develop policies and procedures for systems across the gamut, whether it’s nursing, dietary or facilities - [OIG: Oregon nursing home surveyors verify all deficiency corrections](https://cmscompliancegroup.com/news/18-oig-oregon-nursing-homes/) - The Office of the Inspector General (OIG) released a March 2016 report, “Oregon Properly Verified Correction of Deficiencies Identified During Surveys of Nursing Homes Participating In Medicare And Medicaid” that gives the Oregon Department of Human Services a great review. The purpose of the audit was to verify if Oregon nursing home surveyors were verifying - [CMS S&C Letter: Payroll-Based Journal mandatory July 1, 2016](https://cmscompliancegroup.com/news/21-cms-payroll-based-journal/) - The Centers for Medicare & Medicaid Services (CMS) issued a reminder that long term care facilities better be getting ready for the Payroll-Based Journal (PBJ). The voluntary data submission period ends on June 30, 2016, at which point the mandatory data submission period begins on July 1, 2016. CMS has been recommending that LTC facilities - [Most cited nursing home health deficiencies 2005-2014](https://cmscompliancegroup.com/news/28-top-cited-deficiencies/) - The newly released Nursing Home Data Compendium 2015 provides the list of most highly cited health deficiencies in nursing homes for the period of 2005-2014. The list is full of “gotcha” tags that can be highly cited: F-371 Food Procurement, Store/Prepare/Serve – Sanitary (Average ranking 1.8) F-323 Free of Accident Hazards/Supervision/Devices (Average ranking 2.4) F-309 - [CMS revises State Operations Manual guidance at F-329](https://cmscompliancegroup.com/news/06-cms-som-f329-update/) - In a new S&C letter for nursing homes, CMS provides updated guidance to assist surveyors with identifying psychosocial harm related to the use of unnecessary medications. There have been no changes to the regulatory language itself, but revisions include: Revision to Appendix PP of the SOM at F-329 to make it easier for surveyors to - [New DOJ Elder Justice Task Forces to pursue nursing homes providing poor care](https://cmscompliancegroup.com/news/07-doj-elder-justice/) - The United States Department of Justice (DOJ) has announced the launch of 10 regional Elder Justice Tasks Forces to “coordinate and enhance efforts to pursue nursing homes that provide grossly substandard care to their residents.” The Acting Associate Attorney General Stuart F. Delery stated in the press release, “Millions of seniors count on nursing homes - [OIG prods CMS to increase focus on nursing home adverse events](https://cmscompliancegroup.com/blog/25-nursing-home-adverse-events/) - In the April 2016 OIG Compendium of Unimplemented Recommendations, the Office of the Inspector General (OIG) reminds the Centers for Medicare & Medicaid Services (CMS) that it provided recommendations in its reports that have not been fully addressed. As part of the March 2014 Compendium of Priority Recommendations, the OIG made recommendations to address resident - [CMS proposes new Quality Measure as part of IMPACT Act](https://cmscompliancegroup.com/blog/26-qm-drug-regimen-review/) - CMS issued a proposed rule for FY 2017 skilled nursing facility (SNF) payment rates and information on quality programs on April 21, 2016. Within the document, CMS provides information about the SNF Quality Reporting Program (QRP) that will require SNFs to report quality data to CMS beginning in FY 2018. The QRP is being implemented - [SNF Value-Based Purchasing Program begins FY 2019](https://cmscompliancegroup.com/blog/27-snf-vbp-2019/) - In the April 21, 2016 Federal Register, CMS outlines some of its proposed quality program initiatives, including details on the SNF Value-Based Purchasing Program (VBP). The SNF VBP is authorized under the Social Security Act and creates a system where value-based incentive payments are made to SNFs based on their performance. This reflects the emphasis - [OIG: CMS, you need to reform skilled nursing therapy payments](https://cmscompliancegroup.com/blog/29-oig-snf-therapy/) - In its April 2016 Compendium of Unimplemented Recommendations, the OIG reminds CMS of the findings of its September 2015 report on the Medicare Payment System for SNFs. The key to that report is that OIG’s statement that SNFs billed for ultra-high therapy, which is the highest level, considerably more in the years reviewed even though - [CMS clarifies requirements for “justice involved” nursing home residents](https://cmscompliancegroup.com/blog/10-justice-involved-residents/) - In its May 3, 2016 S&C letter, CMS clarifies the federal requirements for providing services to justice involved individuals to ensure that the quality of care provided protects patient rights and ensures the safety of all individuals within the facility. The letter outlines information related to skilled nursing providers’ ability to qualify for payment from - [Happy New Year from CMSCG!](https://cmscompliancegroup.com/blog/happy-new-year-from-cmscg/) - The Team at CMS Compliance Group, Inc. wishes you a very happy, healthy and successful 2024! We look forward to working together. - [CMS Guidance for Life Safety & Emergency Preparedness Federal Monitoring Surveys](https://cmscompliancegroup.com/blog/cms-guidance-for-life-safety-emergency-preparedness-federal-monitoring-surveys/) - On November 20, 2023, the Centers for Medicare & Medicaid Services (CMS) issued guidance for Federal Monitoring Surveys. Long Term Care Federal Monitoring Surveys (aka validation surveys) are conducted by Federal CMS locations during each Fiscal Year (FY). In a prior post on the CMSCG Blog, we reviewed everything you need to know for the - [NYSDOH DAL - Cold Weather Advisory](https://cmscompliancegroup.com/blog/nysdoh-dal-cold-weather-advisory/) - On November 29, 2023, The New York State Department of Health (NYSDOH) issued a Cold Weather Advisory DAL. Click here to view the document. - [NYSDOH DAL - Infection Inspection Audit & Checklist](https://cmscompliancegroup.com/blog/nysdoh-dal-infection-inspection-audit-checklist/) - The New York State Department of Health (NYSDOH) also issued DAL NH 23-16, "Infection Inspection Audit and Checklist" on November 28, 2023. The DAL advises New York nursing homes that DOH has implemented an annual audit checklist to evaluate the facilities' infection control competencies. Beginning January 24, 2024, all nursing homes are required to adhere - [CMS Compliance Group Long Term Care Industry News Recap (Week of 10/28/13)](https://cmscompliancegroup.com/blog/01-ltc-news-recap-110113/) - Can you believe it's already November? While you're snacking on leftover Halloween treats today, check out these long term care industry articles yo may have missed. 125 Nursing Home Residents Died Within Months of Sandy Evacuation | NY 1 | ow.ly/qkXO2 Is a wound-free facility possible? | Long Term Living | ow.ly/qbq6n Close, specific hospital-SNF - [59% of Adverse & Temporary Harm Events during SNF Stays Preventable, OIG Finds](https://cmscompliancegroup.com/blog/5-oig-adverse-events/) - In a February 2014 report, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries,” the Office of the Inspector General (OIG) details its study to estimate the incidence rate, preventability and cost of adverse events that occur at skilled nursing facilities. This report reviewed Federal oversight of nursing homes, including looking specifically at - [CMS releases updated Payroll Based Journal Manual](https://cmscompliancegroup.com/blog/27-updated-pbj-manual/) - On August 27, CMS released updated information on Payroll Based Journal (PBJ) Electronic Staffing Submission. Information on how to register for the voluntary submission period starting October 1, 2015 is provided. A draft policy manual, PBJ Policy Manual DRAFT (V1.1) 8-25-15 has been released, along with a FAQ list. View the CMS website for more - [The Quality Indicator Survey is coming. Is your facility prepared?](https://cmscompliancegroup.com/blog/homepage-side-2/) - Even if the QIS has not been implemented in your state, it’s best to start preparing now. CMSCG is seeing an increasing volume of clients asking for QIS mock surveys to help get their staffs up to speed. There is also a growing demand for our QIS Education, a program focusing on the critical points - [CMS S&C letter reminds LTC surveyors about exit conference procedures](https://cmscompliancegroup.com/blog/29-nursing-home-survey-exit/) - The Centers for Medicare & Medicaid Services (CMS) issued Advance Guidance to surveyors on the procedures for conducting Exit Conferences at long term care facilities as well as for non-LTC providers/suppliers. The Agency issued this letter to “ensure uniformity in the survey procedures” – mainly to ensure that States know they must follow the federal - [Breaking Down a Nursing Home's Immediate Jeopardy: Pt. 1](https://cmscompliancegroup.com/blog/02-what-is-immediate-jeopardy/) - As we posted last week, CMS Compliance Group will be defining an Immediate Jeopardy situation for our readers in Part 1 of our series on nursing homes and these potentially costly situations. Read last week's post here. Part 1: What is an Immediate Jeopardy? The purpose of a survey of your nursing home is to - [Breaking Down a Nursing Home's Immediate Jeopardy: Pt 2](https://cmscompliancegroup.com/blog/1-immediate-jeopardy-process/) - In a recent update, we discussed Immediate Jeopardy and some other key terms you need to know, and now in we will review the Immediate Jeopardy process in nursing homes and how you need to respond to it. Part 2: The Process CMS requires that all nursing home surveys are unannounced, so after the surveyors - [Breaking Down a Nursing Home's Immediate Jeopardy: Pt. 3](https://cmscompliancegroup.com/blog/03-ij-remedies/) - The State and CMS can impose multiple remedies once an Immediate Jeopardy situation is identified. These include a Directed Plan of Correction and Directed InService, which may occur before your facility receives monetary penalties. While you are surely familiar with nursing home Plans of Correction and InService training for your staff, the way the State - [CMSCG Immediate Jeopardy Series Recap](https://cmscompliancegroup.com/cmscg-updates/13-cmscg-ij/) - CMS Compliance Group took a look at nursing home Immediate Jeopardy situations over the past few blog entries. If you missed any of this important information for your facility, you can review all our posts by following the links below: Introduction to Breaking Down a Nursing Home’s Immediate Jeopardy: View this blog post Part 1: - [Ftag of the Week – F745 Provision of Medically Related Social Services](https://cmscompliancegroup.com/blog/ftag-of-the-week-f745-medical-ss/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Behavioral Health Services regulatory group that was added to the regulations under the updated Requirements of Participation. The emphasis on behavioral health and involvement of the interdisciplinary team in ensuring nursing facility residents have their needs met has been significantly expanded - [Ftag of the Week - F610 Investigate/Prevent/Correct Alleged Violation](https://cmscompliancegroup.com/blog/ftag-of-the-week-f610-investigate/) - This week’s “Ftag of the Week” is F610 Investigate / Prevent/ Correct Alleged Violations, which is part of the Freedom from Abuse, Neglect, and Exploitation regulatory group. While the regulation itself was not changed when the Requirements of Participation (RoPs) were updated, the Interpretive Guidance (IG) has been significantly expanded to state what providers are - [Ftag of the Week – F659 Qualified Persons](https://cmscompliancegroup.com/blog/ftag-of-the-week-f659-qualified/) - This week’s “Ftag of the Week” on the CMSCG Blog is F659 Qualified Persons, which is part of the Comprehensive Resident Centered Care Plans regulatory group. This requirement is part of the care planning group because it requires that the services that have been set out in the comprehensive care plan (CCP) to be provided - [Ftag of the Week – F880 Infection Prevention & Control (Part 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f880-pt3/) - This week on the CMSCG Blog, we are continuing to delve into the Infection Prevention and Control regulations that are part of the Requirements of Participation. In our last two posts, we provided an overview of the other requirements under F880, and this week we will specifically look at linens. The Interpretive Guidance (IG) provides - [Ftag of the Week – F880 Infection Prevention & Control (Part 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f880-ipcp-pt2/) - Infection Prevention and Control is a regulatory hot button currently, since as we mentioned in our last post, F880 is the most frequently cited deficiency across the country. This is no surprise, since this regulation encompasses a massive set of expectations. Let’s take a deeper dive into some of the some of the information we - [Ftag of the Week – F926 Smoking Policies](https://cmscompliancegroup.com/blog/ftag-of-the-week-f926-smoking-policies/) - This week’s “Ftag of the Week” on the CMSCG Blog is F926 Smoking Policies. This is part of the Physical Environment regulatory group. This regulation requires that nursing homes establish policies for smoking, tobacco cessation, smoking areas, and smoking safety (for both smokers and non-smokers) that are compliant with Federal, State and local laws and - [Ftag of the Week – F812 Food Procurement, Store/Prepare/Serve – Sanitary (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f812-food-procurement-store-prepare-serve-sanitary-pt2/) - This week’s Ftag of the Week on the CMSCG Blog is Part 2 of our review of F812 Food Procurement, Store/Prepare/Serve – Sanitary. If you missed Part 1, you can view it here. F812 requires that nursing homes have policies, procedures, training and monitoring systems in place to prevent the spread of foodborne illness and - [Ftag of the Week – F812 Food Procurement, Store/Prepare/Serve – Sanitary (Pt 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f812-food-procurement-store-prepare-serve-sanitary-pt-3/) - If you ever wondered why F812 is always one of the most frequently cited deficiencies, reading CMSCG’s Ftag of the Week posts that review the extensive guidance for this regulation should give you a pretty good idea about exactly how many different areas are being looked at under this Ftag. In Part 1, we reviewed - [Ftag of the Week – F812 Food Procurement, Store/Prepare/Serve – Sanitary (Pt 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f812-food-procurement-store-prepare-serve-sanitary-pt-4/) - This week’s Ftag of the Week post on the CMSCG Blog is the final part of our review of F812 Food Procurement, Store/Prepare/Serve – Sanitary. We will look at food service and distribution, as well as provide some infection control reminders. Food Service and Distribution Now that we have discussed food safety from the procurement, - [Ftag of the Week - F697 Pain Management (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f697-pain-management-pt-3/) - In this week’s Ftag of the Week post on the CMSCG Blog, we will continue to look at pain management. The regulation at F697 is thorough, and the associated CE Pathway provides additional insight into how surveyors will look at what a facility is doing to address a resident’s pain. Let’s look at what is - [Ftag of the Week – F697 Pain Management (Pt 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f697-pain-management-pt-4/) - This week’s Ftag of the Week is Part 4 of CMSCG's blog series for F697 Pain Management. Now that we have looked at recognizing pain and gathering all the necessary information to conduct a pain assessment, let’s look at pain management and pain management interventions. Pain Management Once all of the above-mentioned information has been - [Ftag of the Week – F755 Pharmacy Svcs/Procedures/Pharmacist/Records (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f755-pharmacy-svcs-procedures-pharmacist-records-pt-2/) - Welcome back to CMS Compliance Group’s “Ftag of the Week” series on the CMSCG Blog. This week, we continue to look at the regulation for F755 Pharmacy Services. In our first post, we provide an overview of the regulatory requirements and looked at the some of the procedures required for pharmaceutical services related to acquisition - [Ftag of the Week – F755 Pharmacy Svcs/ Procedures/ Pharmacist/ Records (Pt 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f755-pharmacy-svcs-procedures-pharmacist-records-pt-4/) - Pharmacy Services are such an important element of care for nursing home residents, and understandably, the regulatory requirements are comprehensive. In our final part of CMSCG's Ftag of the Week series for F755 Pharmacy Services, we will review the regulatory guidance related to controlled medications and discuss the facility’s responsibility for obtaining the services of - [Ftag of the Week – F622 Transfer and Discharge Requirements (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f622-transfer-and-discharge-requirements-pt-2/) - Per Part 1 of our review of F622, there is a heavy emphasis on documentation throughout the regulatory requirements. A facility must be able to demonstrate that one of the situations discussed in the previous post is applicable for it to initiate a transfer or discharge, including having the required physician documentation in place. As - [Ftag of the Week – F700 Bedrails (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f700-bedrails-pt-2/) - Last week, we published Part 1 of our “Ftag of the Week” for F700 Bed Rails. Bed rails have been making news headlines again recently, and oftentimes, when we see issues in the news, we see those same areas get more attention on survey. In our previous post, we laid out the provider’s responsibilities for - [Ftag of the Week – F700 Bed Rails (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f700-bed-rails-pt3/) - This week, we are rounding out our “Ftag of the Week” for F700 Bed Rails on the CMSCG Blog. Once you have completed the necessary assessments and received informed consent for the use of bed rails, then the facility can start thinking about installation. The facility is expected to check with the manufacturer(s) of the - [Ftag of the Week – F740 Behavioral Health Services (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f740-behavioral-health-services-pt2/) - In Part 2 of our Ftag of the Week for F740 Behavioral Health Services, we’ll look at how providers are expected to determine the behavioral health needs of their residents. Last week, we discussed different types of behavioral health conditions that nursing homes may encounter in their resident population. The Centers for Medicare & Medicaid - [Ftag of the Week – F740 Behavioral Health Services (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f740-behavioral-health-services-pt3/) - We hope you’re not tired of hearing the term “Behavioral Health” yet, because we’re back with another post on the CMSCG Blog “Ftag of the Week” series for F740 Behavioral Health Services. This week we are wrapping up our series on a key regulatory requirement that will be getting extra attention come October 24, 2022 - [Ftag of the Week – F741 Sufficient/Competent Staff – Behav Health Needs (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f741-sufficient-competent-staff-behav-health-needs-pt-2/) - In our Part 2 of our “Ftag of the Week” regarding sufficient and competent staffing for behavioral health needs, we are going to look at the competency-related requirements in more details. In our first part of the post for F741, we reviewed sufficiency and reminded providers about the importance of the Facility Assessment. In the - [Ftag of the Week – F623 Notice Requirements Before Transfer/Discharge (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f623-notice-requirements-before-transfer-discharge-pt1/) - This week’s “Ftag of the Week” on the CMSCG Blog is F623 Notice Requirements Before Transfer/ Discharge. This tag covers everything a nursing home needs to do prior to transferring or discharging a resident to help ensure a safe discharge/transfer. The regulatory requirements for F623 addresses facility-initiated discharges, which is something regulatory agencies will be - [Ftag of the Week – F623 Notice Requirements Before Transfer/Discharge (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f623-notice-requirements-before-transfer-discharge-pt-2/) - This week on the CMSCG Blog “Ftag of the Week” series, we will be reviewing additional information about F623 Notice Requirements Before Transfer or Discharge. In Part 1, we looked at some key definitions and reviewed what constitutes a resident-initiated discharge. Now, we will look at what the Centers for Medicare & Medicaid Services (CMS) - [Ftag of the Week – F698 Dialysis (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f698-dialysis-pt-3/) - This week on the CMSCG Blog “Ftag of the Week,” CMS Compliance Group Clinical Consultant Mary Quinn continues with a review of F698 Dialysis and the associated regulatory requirements in Appendix PP. Let’s start with some areas where issues are prone to be identified – physician orders and medication orders. These sound like they should - [Ftag of the Week – F698 Dialysis (Pt. 4)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f698-dialysis-pt4/) - This week on the CMSCG Blog, we are wrapping up our review of F698 Dialysis. We will close out this “Ftag of the Week” with Mary Quinn, CMSCG Clinical Consultant, sharing some helpful information you need to know to provide compliant care and services related to dialysis. First, let’s look at communication. There are many - [Ftag of the Week - F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f690-bowel-bladder-incontinence-catheter-uti-pt3/) - This week on the CMSCG Blog “Ftag of the Week” series, we will wrap up our review of F690 Bowel/Bladder Incontinence, Catheter, UTI. First, we will look at the requirements related to Urinary Tract Infections (UTIs) and fecal incontinence. Urinary Tract Infection (UTI) Let’s discuss one of the biggest issues related to UTIs – antibiotic - [Ftag of the Week – F644 Coordination of PASARR and Assessments](https://cmscompliancegroup.com/blog/ftag-of-the-week-f644-coordination-of-pasarr-and-assessments/) - Summer’s over, so the CMSCG Team is back at its “Ftag of the Week” Blog series. While many people joke that the nursing home industry is more regulated than nuclear power, proof that this industry is highly regulated is the fact that CMSCG has been publishing our Ftag of the Week since 2017 – and - [Ftag of the Week – F836 License/Comply w/ Fed/State/Local Law/Prof Std](https://cmscompliancegroup.com/blog/ftag-of-the-week-license-comply-with-fed-state-local-law-prof-std/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Administration regulatory group, F836 License/Comply with Fed/State/Local Law/Prof Std. Per Appendix PP of the State Operations Manual (SOM), there are three regulatory requirements under the rule, one of which is typically used as the basis for citations more than others. State - [Ftag of the Week – Revised F886 COVID-19 Testing-Residents & Staff](https://cmscompliancegroup.com/blog/ftag-of-the-week-revised-f886-covid-19-testing-residents-staff/) - This week’s Ftag of the Week on the CMSCG Blog covers important revisions to F886 COVID-19 Testing – Residents & Staff, which we previously reviewed in our “Ftag of the Week” series around this same time last year. (You can view the original regulatory requirements in Part 1 and Part 2 of our Ftag of - [Ftag of the Week – F691 Colostomy, Urostomy, or Ileostomy Care](https://cmscompliancegroup.com/blog/ftag-of-the-week-f691-colostomy-urostomy-or-ileostomy-care/) - This week’s “Ftag of the Week” on the CMSCG Blog is F691 Colostomy, Urostomy, or Ileostomy Care, which is part of the Quality of Care regulatory group. The regulation requires nursing home providers to ensure that resident who require colostomy, urostomy or ileostomy services receive care that is consistent with the resident’s goals/preferences, the resident’s - [Ftag of the Week - F888 COVID-19 Vaccination of Facility Staff](https://cmscompliancegroup.com/blog/ftag-of-the-week-f888-covid-19-vaccination-of-facility-staff/) - Just when we thought that we may finally have seen an end to new infection control-related Federal regulations, the Centers for Medicare and Medicaid Services (CMS) left providers with a holiday gift for the new year. In a December 28, 2021 QSO Memo, “Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus - [Ftag of the Week – F888 COVID-19 Vaccination of Facility Staff (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f888-covid-19-vaccination-of-facility-staff-pt-2/) - Welcome back to the CMSCG Blog. In this post, we will continue our “Ftag of the Week” for F888 COVID-19 Vaccination of Facility Staff. In Part 1 of this series, we outlined the requirements for the newest Infection Control Ftag, including all the required elements of the COVID-19 vaccination policy and procedures that nursing homes - [Ftag of the Week – F808 Therapeutic Diet Prescribed by a Physician](https://cmscompliancegroup.com/blog/ftag-of-the-week-f808-therapeutic-diet-prescribed-by-a-physician/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Food and Nutrition Services regulatory group, F808 Therapeutic Diet Prescribed by a Physician. This regulation is meant to ensure that nursing home residents receive and consume foods that are in the appropriate form and/or have the appropriate nutrient content to support - [Ftag of the Week – F635 Admission Physician Orders for Immediate Care](https://cmscompliancegroup.com/blog/ftag-of-the-week-f635-admission-physician-orders-for-immediate-care/) - This week’s CMSCG Blog “Ftag of the Week” is F635 Admission Physician Orders for Immediate Care, which is part of the Resident Assessments regulatory group. While this Ftag has been infrequently cited in 2019, it has been cited at about a 50/50 split between recertification and complaint surveys, so it is not just an issue - [Ftag of the Week – F842 Resident Records – Identifiable Information](https://cmscompliancegroup.com/blog/ftag-of-the-week-f842-resident-records-identifiable-information/) - This week’s Ftag of the Week on the CMSCG Blog is F842 Resident Records – Identifiable Information, which is part of the Administration regulatory group. There are multiple requirements under this regulation, of which the following are included: Requirements for the release of resident-identifiable information – Facilities are prohibited from releasing information to the public - [Ftag of the Week - F713 Physician for for Emergency Care, Available 24 Hours](https://cmscompliancegroup.com/blog/ftag-of-the-week-f713-physician-for-for-emergency-care-available-24-hours/) - This week’s Ftag of the Week on the CMSCG Blog is F713 Physician for Emergency Care, Available 24 Hours, which is part of the Physician Services regulatory group. As the name of the Ftag suggests, this regulation requires that nursing facilities provide or arrange for physician services 24 hours a day/ 7 days a week - [Ftag of the Week – F886 re COVID-19 Testing (Part 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f886-re-covid-19-testing-part-1/) - In an August 26, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) provided several policy and regulatory revisions related to COVID-19 and long-term care facility testing requirements. This is the third Ftag that CMS has added to the Infection Control regulatory group since the beginning of the COVID-19 Public Health Emergency (PHE). - [Ftag of the Week – F886 COVID-19 Testing – Residents & Staff (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f886-covid-19-testing-residents-staff-pt-2/) - In this week’s Ftag of the Week on the CMSCG Blog, we will continue to review the newly implemented F886 COVID-19 Testing – Residents & Staff. First, let’s continue to discuss testing. Here are some key points: Staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be retested for - [Ftag of the Week – F676 Activities of Daily Living (ADLs)/ Maintain Abilities](https://cmscompliancegroup.com/blog/ftag-of-the-week-f676-activities-of-daily-living-maintain-abilities/) - This week’s Ftag of the Week on the CMSCG Blog is F676 Activities of Daily Living (ADLs)/ Maintain Abilities, which is part of the Quality of Life regulatory group. F676 spells out the facility’s responsibility for the provision of care and services to ensure that a resident’s activities of daily living do not diminish unless - [Ftag of the Week – F919 Resident Call System](https://cmscompliancegroup.com/blog/ftag-of-the-week-f919-resident-call-system/) - This week’s Ftag of the Week on the CMSCG Blog is F919 Resident Call System which is part of the Physical Environment regulatory group. F919 was effective in Phase 1, but there is a Phase 3 requirement that will become effective in November. F919 requires that nursing homes have adequately equipped communications systems to allow - [Ftag of the Week – F907 Space and Equipment](https://cmscompliancegroup.com/blog/ftag-of-the-week-f907-space-and-equipment/) - This week’s Ftag of the Week on the CMSCG Blog is F907 Space and Equipment, which is part of the Physical Environment regulatory group. F907 focuses on ensuring that nursing home dining, health services, recreation and activities and other programs are conducted in spaces of sufficient size to allow staff to meet residents’ needs as - [Ftag of the Week – F910 Resident Room](https://cmscompliancegroup.com/blog/ftag-of-the-week-f910-resident-room/) - This week’s Ftag of the Week on the CMSCG Blog is F910 Resident Rooms. This is a short, self-explanatory regulation, but there are several conditions under which it has been cited that providers should be aware of. In prior posts (you can access them at the end of this post) reviewing the Ftags in the - [Ftag of the Week - F920 Requirements for Dining and Activity Rooms](https://cmscompliancegroup.com/blog/ftag-of-the-week-f920-requirements-for-dining-and-activity-rooms/) - This week’s Ftag of the Week is part of the Physical Environment regulatory group, F920 Requirements for Dining and Activity Rooms. This regulation requires that facilities provide one or more rooms that are designated for resident dining and resident activities. The rooms must: Be well-lit – By definition, illuminated sufficiently to allow residents to perform - [Ftag of the Week – F922 Procedures to Ensure Water Availability](https://cmscompliancegroup.com/blog/ftag-of-the-week-f922-procedures-to-ensure-water-availability/) - This week’s “Ftag of the Week” on the CMSCG Blog is F922 Procedures to Ensure Water Availability, which is part of the Physical Environment regulatory group. September is National Preparedness Month, and with hurricane season underway and the opportunity for other severe inclement weather events to occur, this is an important requirement for providers to - [Ftag of the Week – F909 Resident Bed](https://cmscompliancegroup.com/blog/ftag-of-the-week-f909-resident-bed/) - This week’s Ftag of the Week on the CMSCG Blog is F909 Resident Bed, which is part of the Physical Environment regulatory group. The regulation at F909 requires nursing facilities to conduct regular inspections of all bed frames, bed rails and mattresses as part of their routine maintenance programs to identify possible areas of entrapment. - [Ftag of the Week – F921 Safe/Functional/Sanitary/Comfortable Environment](https://cmscompliancegroup.com/blog/ftag-of-the-week-f921-safe-functional-sanitary-comfortable-environment/) - This week’s Ftag of the Week on the CMSCG Blog is the final Ftag that is part of the Physical Environment Regulatory group, F921 Safe/Functional/Sanitary/Comfortable Environment. The Centers for Medicare & Medicaid Services (CMS) must have felt that the title of the Ftag was sufficient to explain the regulatory requirement to providers, as the regulation - [Ftag of the Week - F810 Assistive Devices – Eating Equipment/Utensils](https://cmscompliancegroup.com/blog/ftag-of-the-week-f810-assistive-devices-eating-equipment-utensils/) - This week’s Ftag of the Week is F810 Assistive Devices – Eating Equipment/Utensils, which is part of the Food and Nutrition Services regulatory group. F810 requires nursing facilities to provide any special eating equipment and utensils that a resident needs to maintain their current abilities related to eating and drinking or, if possible, to improve - [Ftag of the Week – F812 Food Procurement, Store/Prepare/Serve – Sanitary (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f812-food-procurement-store-prepare-serve-sanitary-pt1/) - Up next on the CMSCG Blog “Ftag of the Week” series is the third most frequently cited deficiency on survey in the United States, F812, Food Procurement, Store/Prepare/Serve – Sanitary. This regulation is part of the Food and Nutrition Services regulatory group and is routinely one of the most frequently cited regulations, so most facilities - [Ftag of the Week – F687 Foot Care](https://cmscompliancegroup.com/blog/ftag-of-the-week-f687-foot-care/) - This week’s “Ftag of the Week” on the CMSCG Blog is F687 Foot Care. This regulation was effective November 28, 2017, so by now you should have a sound system in place to ensure that proper treatment and care is being provided to residents to maintain their mobility as well as optimal foot health. Care - [Ftag of the Week – F947 Required In-Service Training for Nurse Aides](https://cmscompliancegroup.com/blog/ftag-of-the-week-f947-inservice/) - This week’s Ftag of the Week is F947 Required In-Service Training for Nurse Aides, which is part of the Training Requirements regulatory group. The Federal regulation requires that nurse aides receive at least 12 hours of in-service training annually, but states have varying requirements for education that exceed this minimum requirement may be needed based - [Ftag of the Week – F880 Infection Prevention & Control (Part 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f880-ipcp/) - This week’s “Ftag of the Week” is F880 Infection Prevention & Control, which we will be looking at over the course of the next couple of posts on the CMSCG Blog since this is such an important regulation to understand. Why? Infection Prevention and Control is the most frequently cited deficient practice in the country - [Ftag of the Week - F883 Influenza and Pneumococcal Vaccinations](https://cmscompliancegroup.com/blog/ftag-of-the-week-f883-vaccinations/) - This week’s “Ftag of the Week” is F883 Influenza and Pneumococcal Vaccinations, which is part of the Infection Prevention and Control regulatory group that we are reviewing in full on the CMSCG Blog. F883 is a relatively straight-forward regulation, but where facilities are vulnerable is in not having a strong system around thorough documentation. During - [Ftag of the Week - F882 Infection Preventionist Qualifications/Role](https://cmscompliancegroup.com/blog/ftag-of-the-week-f882-infection-preventionist/) - This week’s Ftag of the Week on the CMSCG Blog, F882 Infection Preventionist Qualifications/Role, rounds out our look at the Infection Control regulatory group of the Requirements of Participation (RoPs). This regulation becomes effective in Phase 3, which is November 28, 2019, and includes the following requirements for this role. Nursing facilities will be required - [Ftag of the Week – F801 Qualified Dietary Staff](https://cmscompliancegroup.com/blog/ftag-of-the-week-f801-qualified-dietary-staff/) - This week’s Ftag of the Week on the CMSCG Blog is F801 Qualified Dietary Staff, which is part of the Food and Nutrition Services Regulatory Group. This regulation has been in effect since Phase 1 (November 28, 2016) with some of the education requirements waived until 5 years from that date. The Requirements of Participation - [Ftag of the Week – F770 Laboratory Services](https://cmscompliancegroup.com/blog/ftag-of-the-week-f770-laboratory-services/) - This week’s Ftag of the Week on the CMSCG Blog is F770 Laboratory Services, which is part of the Laboratory, Radiology, and Other Diagnostic Services regulatory group. This regulation has been in effect since November 28, 2017. The regulation states that the facility must provide or obtain laboratory services to meet the needs of its - [Ftag of the Week – F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (Part 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f865-qapi-program-plan-part1/) - This week’s “Ftag of the Week” on the CMSCG Blog begins our look at the Quality Assurance and Performance Improvement regulatory group, which is comprised of 4 Ftags. F865 QAPI Program/Plan, Disclosure/ Good Faith Attempt is a large regulation that was partially effective in Phase 2, but will be fully implemented in Phase 3 – - [Ftag of the Week – F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (Part 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f865-qapi-program-pt2/) - This week on the CMSCG Blog we are continuing our “Ftag of the Week” series on QAPI with Part 2 of F865 QAPI Program/Plan, Disclosure/Good Faith Attempt. In last week’s post, we reviewed the scope and design of a QAPI Program, the regulatory expectation that QAPI is continuous and ongoing, and also reviewed what will - [Ftag of the Week - F866 QAPI/QAA Data Collection and Monitoring](https://cmscompliancegroup.com/blog/ftag-of-the-week-f866-qapi-qaa-data-collection-and-monitoring/) - This week’s “Ftag of the Week” on the CMSCG Blog is F866 QAPI/QAA Program Feedback, Data Collection and Monitoring, which is part of the Quality Assurance and Performance Improvement Regulatory Group. This Ftag becomes effective in Phase 3 (November 28, 2019). F866 outlines a provider’s responsibilities for developing and implementing policies and procedures related to - [Ftag of the Week – F867 QAPI/QAA Improvement Activities](https://cmscompliancegroup.com/blog/ftag-of-the-week-f867-qapi-qaa-improvement-activities/) - This week’s “Ftag of the Week” is F867 QAPI/QAA Improvement Activities, which is the third Ftag in the Quality Assurance and Performance Improvement regulatory group. This regulation was partially effective in Phase 1 as it relates to the QAA , and then has two major components which become effective this November with Phase 3. Quality - [Ftag of the Week – F841 Responsibilities of Medical Director](https://cmscompliancegroup.com/blog/ftag-of-the-week-f841-responsibilities-of-medical-director/) - This week’s “Ftag of the Week” on the CMSCG Blog is F841 Responsibilities of Medical Director, which is part of the Administration regulatory group. The regulation requires that each nursing facility has designates a physician who will act as the Medical Director. The Medical Director is responsible for implementation of resident care policies and coordination - [Ftag of the Week – F727 RN 8 Hrs/7 days/Wk, Full Time DON](https://cmscompliancegroup.com/blog/ftag-of-the-week-f727-rn-don/) - This week’s CMSCG Blog Series “Ftag of the Week” is F727 RN 8 hours a day / 7 days a week, Full Time DON, which is part of the Nursing Services Regulatory Group. This regulation is one that all providers are aware of, but it warrants a reminder thanks to a QSO memo released late - [Ftag of the Week - F777 Radiology/Diag. Svcs Ordered/Notify Results](https://cmscompliancegroup.com/blog/ftag-of-the-week-f777-radiology/) - This week’s “Ftag of the Week” is part of the Laboratory, Radiology and Other Diagnostic Services regulatory group, F777 Radiology/Diagnostic Services Ordered/Notify Results. As the tag name suggests, this regulation outlines a facility’s requirements to provide/obtain radiology and other diagnostic services and promptly notify the practitioner of results, including: These services may only be ordered - [Ftag of the Week – F943 Abuse, Neglect, and Exploitation Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f943-training/) - This week’s “Ftag of the Week” is part of the Training Requirements regulatory group. While most of this group of regulations is not effective until Phase 3, F943 Abuse, Neglect and Exploitation Training became effective with Phase 1 of the RoPs. This regulation outlines the requirements related to staff training on abuse, neglect, exploitation and - [Ftag of the Week – F800 Provided Diet Meets Needs of Each Resident](https://cmscompliancegroup.com/blog/ftag-of-the-week-f800-diet-needs/) - This week’s Ftag of the Week is part of the Food and Nutrition Services regulatory group, F800 Provided Diet Meets Needs of Each Resident. This regulation requires that facilities provide “each resident with a nourishing, palatable, well-balanced diet” that meets the resident’s daily nutritional needs, special dietary needs, and in alignment with the person-centered focus - [Ftag of the Week – F675 Quality of Life](https://cmscompliancegroup.com/blog/ftag-of-the-week-f675-qol/) - This week’s “Ftag of the Week” is F675 – Quality of Life. This regulation, which is part of the similarly named Quality of Life regulatory group, is a concept that is familiar to all providers, but there’s an important nuance to how and when this Ftag can be cited under the updated Requirements of Participation - [Ftag of the Week – F658 Services Provided Meet Professional Standards](https://cmscompliancegroup.com/blog/ftag-of-the-week-f658-standards/) - This week’s “Ftag of the Week” is F658 Services Provided Meet Professional Standards, which is part of the Comprehensive Resident Centered Care Plans regulatory group under the updated Requirements of Participation (RoPs). F658 requires that the care and services provided by the facility are provided according to accepted standards of clinical practice. The regulation requires - [Ftag of the Week – F684 Quality of Care (Part 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f684-quality/) - This week’s “Ftag of the Week” on the CMSCG Blog is F684 Quality of Care, which is part of the Quality of Care regulatory group. This requirement is almost all new regulatory language, so we will be addressing it in two parts. Next week we will be reviewing End of Life and Hospice Care as - [Ftag of the Week – F684 Quality of Care (Part 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f684-eol/) - This week’s “Ftag of the Week” on the CMSCG Blog is, as promised, Part 2 of our overview of F684 Quality of Care, which is part of the Quality of Care regulatory group. Just a reminder - quality of care is a fundamental principle that applies to all care and treatment provided to a facility’s - [Ftag of the Week – F743 No Pattern of Behavioral Difficulties Unless Unavoidable](https://cmscompliancegroup.com/blog/ftag-of-the-week-f743-behavioral/) - This week’s “Ftag of the Week” on the CMSCG Blog, F743 No Pattern of Behavioral Difficulties Unless Avoidable, is part of the Behavioral Health Services Regulatory Group. In Phase 3 (effective November 28, 2019), there is a strong emphasis on Behavioral Health, so providers need to ensure that they are familiar with the requirements of - [Ftag of the Week - F948 Training for Feeding Assistants](https://cmscompliancegroup.com/blog/ftag-of-the-week-f948-feeding/) - This week’s “Ftag of the Week” is F948, Training for Feeding Assistants, which is part of the Training Requirements regulatory group. This Ftag is one of only a handful of training-related Ftags that went into effect in Phase 1, since the bulk of the training requirements for nursing homes are part of Phase 3, effective - [Ftag of the Week – F811 Feeding Asst – Training/Supervision/Resident](https://cmscompliancegroup.com/blog/ftag-of-the-week-f811-feeding-asst/) - This week’s “Ftag of the Week” on the CMSCG Blog is F811 Feeding Assistant training, supervision and resident suitability to be assisted with eating by a paid feeding assistant. Our last Ftag of the Week was F948 Training for Feeding Assistants, so this week we will look more in-depth at this associated Ftag. F811 is - [Ftag of the Week – F825 Provide/ Obtain Specialized Rehab Services](https://cmscompliancegroup.com/blog/f825-specialized-rehab/) - This week’s “Ftag of the Week” in our blog series is F825 Provide/ Obtain Specialized Rehab Services. Specialized Rehab services are those that are required as part of the resident’s comprehensive care plan, including: Physical Therapy Speech-Language Pathology Occupational Therapy Respiratory Therapy Rehabilitative Services for mental illness and intellectual disability You may remember that in - [Ftag of the Week – F881 Antibiotic Stewardship Program](https://cmscompliancegroup.com/blog/f881-antibiotic-stewardship/) - This week’s “Ftag of the Week” is F811 Antibiotic Stewardship Program because it’s also the Center for Disease Control’s (CDC) US Antibiotic Awareness Week. The number of people dying each year from antibiotic-resistant bacterial infections in our country is more than 23,000. Healthcare providers, including nursing facilities, play an important role in appropriate prescribing of - [Ftag of the Week – F803 Menus Meet Resident Needs/ Prepared in Advance/ Followed](https://cmscompliancegroup.com/blog/ftag-of-the-week-f803-menus/) - What better week to talk about menus to meet resident needs than the week where we are ready to cook for hours and feast with family and friends – Thanksgiving week! This week’s Ftag of the Week is F803 Menus Meet Resident Needs/ Prepared in Advance/ Followed, which is the current F363. Just like those - [Ftag of the Week – F624 Orientation for Transfer or Discharge](https://cmscompliancegroup.com/blog/ftag-of-the-week-f624-orientation/) - This week’s Ftag of the Week is F624 Orientation for Transfer or Discharge. Being transferred to a different setting, whether it is the Emergency Room or to a lower level of care can create anxiety for a resident, so nursing facilities are charged with minimizing this stress in the new RoPs. The regulation for F624 - [Ftag of the Week – F835 Administration](https://cmscompliancegroup.com/blog/f835-administration/) - Happy New Year and welcome to the first “Ftag of the Week” of 2018. This week we’ll look at F835 Administration, which was previously Ftag 490 with the same description. While the content of the tag is straight-forward – “A facility must be administered in a manner that enables it to use its resources effectively - [Ftag of the Week – F639 Maintain 15 Months of Resident Assessments](https://cmscompliancegroup.com/blog/f639-maintain-resident-assessments/) - This week’s CMSCG Blog “Ftag of the Week” series is F639 Maintain 15 Months of Resident Assessments, which is the former F286. The regulatory language at F639 states the obvious, which is that “a facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record.” However, the updated Appendix - [Ftag of the Week – F730 Nurse Aide Performance Review – 12Hr/Yr In-Service](https://cmscompliancegroup.com/blog/f730-cna-performance-review/) - This week’s “Ftag of the Week” is F730 Nurse Aide Performance Review – 12 Hr/Year In-Service. This regulation outlines the performance review and in-service education components that are required for nurse aides. Nurse aides must receive a minimum of 12 hours of in-service education per year; record reviews will show surveyors if a performance review - [Ftag of the Week – F696 Prostheses](https://cmscompliancegroup.com/blog/ftag-of-the-week-f696-prostheses/) - This week’s Ftag of the Week is F696 Prostheses. The regulation at F696 requires nursing facilities to ensure that residents who have prostheses are provided with care and assistance to wear and use the prosthetic device. The care/ assistance given must be in accordance with the person-centered care plan, the resident’s goals and preferences, and - [Ftag of the Week - F809 Frequency of Meals/ Snacks at Bedtime](https://cmscompliancegroup.com/blog/f809-freq-meals-snacks-bedtime/) - This week’s “Ftag of the Week” on the CMSCG Blog is F809 Frequency of Meals/ Snacks at Bedtime, which is part of the Food and Nutrition Services regulatory group. The basic requirements of this regulation have stayed the same, but emphasis on resident choice has been added. First, the regulation states that residents must receive, - [Ftag of the Week – F685 Treatment/Devices to Maintain Hearing/Vision](https://cmscompliancegroup.com/blog/f685-maintain-hearing-vision/) - Welcome back to CMS Compliance Group’s “Ftag of the Week” Blog series. This week’s Ftag up for review is F685 Treatment/Devices to Maintain Hearing/Vision. This regulatory requirement mandates that providers ensure all residents receive the proper treatment and assistive devices required to maintain their hearing and vision. It also requires that the facility assists residents - [Ftag of the Week - F761 Label/Store Drugs & Biologicals](https://cmscompliancegroup.com/blog/ftag-of-the-week-f761-label-store/) - This week’s Ftag of the Week is F761 Label/Store Drugs & Biologicals. F761 is currently the 7th most frequently cited deficiency on standard surveys under the new LTCSP for the entire country, so it’s one to pay extra attention to. The regulation states: Labeling of Drugs and Biologicals - Drugs and biologicals used in the - [Ftag of the Week – F908 Essential Equipment, Safe Operating Condition](https://cmscompliancegroup.com/blog/ftag-of-the-week-f908-equipment/) - This week’s Ftag of the Week is part of the Physical Environment regulatory group, F908 Essential Equipment, Safe Operating Condition. The regulation requires that facilities maintain all mechanical, electrical and patient care equipment in safe operating condition. The inclusion of “all” types of equipment includes everything from unit refrigerators, kitchen equipment to laundry machines. The - [Ftag of the Week – F710 Resident’s Care Supervised by a Physician](https://cmscompliancegroup.com/blog/ftag-of-the-week-f710-physician/) - This week’s Ftag of the Week is part of the Physician Services regulatory group. The regulation requires that a physician must personally approve in writing a recommendation that a person be admitted to a facility. A non-physician practitioner (Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant) is not allowed to provide this written recommendation. This - [CMS Issues Additional Nursing Home Staff Vaccination Guidance for Some States](https://cmscompliancegroup.com/blog/cms-issues-additional-nursing-home-staff-vaccination-guidance-for-some-states/) - After the nursing home staff vaccination mandate was upheld by the United States Supreme Court on January 13, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo, “Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination” (Ref: QSO-22-09-ALL). CMS had previously published - [CMS Includes Texas in New Vaccine Mandate Guidance](https://cmscompliancegroup.com/blog/cms-includes-texas-in-new-vaccine-mandate-guidance-qso/) - Rather than waiting to issue the COVID-19 staff vaccination mandate information all in one QSO Memo, the Centers for Medicare & Medicaid Services (CMS) has issued multiple sets of guidance for different states. On December 28, 2021, part of the nation’s states were alerted that their facilities’ staff would need to make quick strides to - [Ftag of the Week – F851 Payroll Based Journal](https://cmscompliancegroup.com/blog/f851-payroll-based-journal/) - CMSCG continues its “Ftag of the Week” blog series with F851 Payroll Based Journal, which is part of the Administration regulatory group under the renumbered Ftags. Each facility is responsible for ensuring that complete and accurate direct care staffing data that is entered into the Payroll-Based Journal system is auditable and, as the name implies, - [Ftag of the Week – F758 Free from Unnecessary Psychotropic Meds / PRN Use](https://cmscompliancegroup.com/blog/f758-unnecess-psychotropic-prn/) - This week’s Ftag of the week is F758 Free from Unnecessary Psychotropic Meds / PRN use, which is the existing F329 Unnecessary Drugs . . . but expanded upon. Since F329 Unnecessary Drugs is always one of the most frequently cited deficiencies across the country, it’s important to understand the nuances of this requirement for - [Ftags of the Week – F915, F916, F917 and F918 (Resident Room-Related)](https://cmscompliancegroup.com/blog/ftags-of-the-week-f915-f916-f917-f918-resident-room/) - This week on the CMSCG Blog, we are looking at some additional Ftags that comprise the Physical Environment regulatory group. While these Ftags may not be frequently cited, there are a significant number of regulations related to the resident’s room including F915 Resident Room Window, F916 Resident Room Floor Above Grade, F917 Resident Room Bed/Furniture/Closet - [Ftags of the Week – F911, F912, F913 and F914 (Resident Room-related)](https://cmscompliancegroup.com/blog/ftags-of-the-week-f911-f912-f913-f914-resident-room-related/) - This week on the CMSCG Blog, we will review four Ftags that are part of the Physical Environment regulatory group, including F911 Bedroom Number of Residents, F912 Bedrooms Measure at Least 80 Sq Ft/Resident, F913 Bedrooms have Direct Access to Corridor and F914 Bedrooms Assure Full Visual Privacy. F911 Bedroom Number of Residents F911 requires - [Ftags of the Week – F790 & F791 Routine/Emergency Dental Services in SNFs/NFs](https://cmscompliancegroup.com/blog/ftags-of-the-week-f790-f791-dental/) - This week, we’re looking at two Ftags with similar content, F790 Routine/Emergency Dental Services in SNFs (Medicare) and F791 Routine/Emergency Dental Services in NFs (Medicaid). These are the only tags that comprise the 483.55 Dental Services regulatory group. What’s Required for Both SNFs and NFs Facilities must: Assist residents in obtaining both routine and 24-hour - [2023 Survey Trends & Tips (NYSHFA Webinar)](https://cmscompliancegroup.com/blog/2023-survey-trends-tips-nyshfa-webinar/) - Join CMS Compliance Group, Inc. on December 19, 2023 for our annual NYSHFA | NYSCAL Survey Trends discussion. 2023 Survey Trends & Tips Program Description: Survey activity is getting back to normal after the PHE, and surveys have been increasingly tougher and more thorough. During this webinar, the presenter will discuss the most frequently cited - [SNF in Trouble After Prohibiting Individuals with OUDs to be Admitted](https://cmscompliancegroup.com/blog/snf-in-trouble-after-prohibiting-individuals-with-ouds-to-be-admitted/) - The Office of Civil Rights (OCR) announced on November 13, 2023, that it had reached an agreement with a Massachusetts-based skilled nursing facility. The facility was reported for violating the ADA, Section 504 of the Rehabilitation Act of 1973 and Section 1557 of the Patient Protection and Affordable Care Act after the facility denied admission - [New OIG Report Finds Issues with Pennsylvania Nursing Home Compliance](https://cmscompliancegroup.com/blog/new-oig-report-finds-issues-with-pennsylvania-nursing-home-compliance/) - Last month, we posted on the CMSCG Blog about the Office of the Inspector General’s unannounced visits to nursing homes in multiple states to assess their compliance with federal requirements for Life Safety, Emergency Preparedness and Infection control. Similar to the report findings about New Jersey, OIG found deficits in its sample of facilities in - [Register Today! 2023 Survey Trends & Tips (12/19/2023)](https://cmscompliancegroup.com/blog/register-today-2023-survey-trends-tips-12-19-2023/) - Join CMS Compliance Group, Inc. on December 19, 2023 for our annual NYSHFA | NYSCAL Survey Trends discussion. 2023 Survey Trends & Tips Program Description: Survey activity is getting back to normal after the PHE, and surveys have been increasingly tougher and more thorough. During this webinar, the presenter will discuss the most frequently cited - [CMS Issues Guidance for Federal Monitoring Surveys](https://cmscompliancegroup.com/blog/cms-issues-guidance-for-federal-monitoring-surveys/) - It’s that time of the year where the Centers for Medicare and Medicaid Services (CMS) issues an Admin Memo regarding Long Term Care (LTC) Federal Monitoring Surveys (FMS). Federal Monitoring Surveys are required for CMS locations to validate health, Life Safety Code and Emergency Preparedness survey processes. In this post, we’ll look at what’s required - [Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f605-right-to-be-free-from-chemical-restraints-pt-1/) - Next up on the CMSCG Blog, we will be reviewing F605 Right to be Free from Chemical Restraints, a regulation that is part of the Freedom from Abuse, Neglect, and Exploitation regulatory group. F605, like most of the other regulations in this group, are lengthy, so this “Ftag of the Week” will be part of - [CMS Announces Additional Ownership Disclosure Requirements for SNF/NF (Media Release)](https://cmscompliancegroup.com/blog/cms-announces-additional-ownership-disclosure-requirements-for-snf-nf-media-release/) - Via the CMS.gov/newsroom November 15, 2023 Biden-Harris Administration Continues Unprecedented Efforts to Increase Transparency of Nursing Home Ownership Final rule will require disclosure of new information to shine a light on private equity ownership The Biden-Harris Administration is taking additional action to empower nursing home residents and their families to make informed decisions about care - [Ftag of the Week - F712 Physician Visits–Frequency/Timeliness/Alternate NPPs](https://cmscompliancegroup.com/blog/ftag-of-the-week-f712-physician-visits-frequency-timeliness-alternate-npps/) - Next up on the CMSCG Blog “Ftag of the Week,” we’re reviewing F712 Physician Visits – Frequency/ Timeliness/ Alternate NPPs. F712 is part of the Physician Services regulatory group, and this regulation specifies the requirements for physician visits to residents. Visit timing is based on a resident’s admission date. Physician Visits Requirements – Skilled Nursing - [CY 2024 Home Health PPS Final Rule - Fact Sheet](https://cmscompliancegroup.com/blog/cy-2024-home-health-pps-final-rule-fact-sheet/) - Per the CMS.gov Newsroom: "On November 1, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2024 Home Health Prospective Payment System (HH PPS) Rate Update final rule, which updates Medicare payment policies and rates for Home Health Agencies (HHAs). This rule includes routine updates to the Medicare Home Health - [New Long-Term Care Survey Process Resources Available (10/2023)](https://cmscompliancegroup.com/blog/new-long-term-care-survey-process-resources-available-10232023/) - The Centers for Medicare and Medicaid Services (CMS) updated documents related to the Long-Term Care Survey Process (LTCSP) on October 23, 2023. Per the revision history (10/26/2023), multiple LTCSP documents have been revised, including: Pathways updated with “extensive” changes Updated Entrance Conference Form Mapping Document has been revised (predominantly around staffing) Offsite Prep Worksheet revised - [Ftag of the Week – F680 Qualifications of Activity Professional](https://cmscompliancegroup.com/blog/ftag-of-the-week-f680-qualifications-of-activity-professional/) - This week’s CMSCG Blog “Ftag of the Week” is F680 Qualifications of Activity Professional. F680 is a regulation that hasn’t traditionally been widely cited, but there are multiple citations throughout the country and given the industry’s staffing shortages, it’s important to be aware of the requirements for the individual responsible for your activities program. It - [How Would Your Facility Fare on an Unannounced OIG Compliance Inspection?](https://cmscompliancegroup.com/blog/how-would-your-facility-fare-on-an-unannounced-oig-compliance-inspection/) - If you’re reading this post and wondering what on earth is CMSCG talking about, you may not be aware that almost two dozen New Jersey nursing homes were the target of unannounced inspections by the Office of the Inspector General (OIG) in 2022. OIG issued a report in July 2022 which assessed nursing homes’ compliance - [MDS 3.0 Quality Measures Users' Manual (v16.0)](https://cmscompliancegroup.com/blog/mds-3-0-quality-measures-users-manual-v16-0/) - The Centers for Medicare & Medicaid Services (CMS) has released the MDS 3.0 Quality Measures Users' Manual (v16.0), effective October 1, 2023 -- tomorrow!. The QM Manual can be found here. You can also check out CMSCG's guide to helpful MDS 3.0 resources for the 10/1/2023 MDS changes. - [Five-Star Technical Users Manual Guide (9/2023)](https://cmscompliancegroup.com/blog/five-star-technical-users-manual-guide/) - The Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide has been updated for September 2023. The updated guide reflects recent announcements CMS made related to Staffing and Quality Measures calculations on Nursing Home Compare. Download the September 2023 Guide here. - [CMS Announces Updates to NHC Staffing & Quality Measures](https://cmscompliancegroup.com/blog/cms-announces-updates-to-nhc-staffing-amp-quality-measures-qso/) - In a new QSO Memo dated September 20, 2023, the Centers for Medicare and Medicaid Services (CMS) announced updates coming to the Nursing Home Compare Staffing and Quality Measures. These changes are coming in tandem with changes to the MDS which are effective October 1, 2023. A couple important items to note: Changes are coming - ["Ftag of the Week" Summer Break](https://cmscompliancegroup.com/blog/ftag-of-the-week-summer-break/) - Please note that our CMSCG “Ftag of the Week” blog is on pause for the summer. The CMS Compliance Group team will continue to important news you need to know about, so keep an eye out for updates from the CMSCG Blog – and stay tuned for the all new CMSCG website coming this fall. - [CMS Posts New Nursing Home Ownership Data](https://cmscompliancegroup.com/blog/cms-posts-new-nursing-home-ownership-data/) - Per a Centers for Medicare & Medicaid Services (CMS) announcement on June 28, 2023: Today, the Centers for Medicare &Medicaid Services (CMS) is making additional ownership data including names of affiliated owners for the first time on . Aggregate data on the safety, staffing, and quality for groups of nursing homes sharing ownership/operatorship is also - [Resources for MDS 3.0 Changes Effective October 1, 2023 (Updated 10/26)](https://cmscompliancegroup.com/blog/resources-for-mds-3-0-changes-effective-october-1-2023/) - October 1, 2023 is around the corner, and with it comes a significant set of changes to the MDS 3.0. The Centers for Medicare & Medicaid Services (CMS) has provided helpful information in a variety of places over the last few months. We’ve compiled a list below to help you keep everything in one place. - [Linda Elizaitis discusses proposed staffing rule with McKnight's LTC News](https://cmscompliancegroup.com/blog/linda-elizaitis-discusses-proposed-staffing-rule-with-mcknights-ltc-news/) - CMS Compliance Group, Inc. President, Linda Elizaitis, discussed the proposed changes to the Facility Assessment requirements included in the new proposed staffing rule with McKnight's Long-Term Care News. Read the September 19, 2023 article, "Don't underestimate first compliance challenge of proposed staffing rule: experts" on the McKnight's website. - [CDC NHSN Webinar "Up to Date Vaccination Status" 9/18/2023](https://cmscompliancegroup.com/blog/cdc-nhsn-webinar-up-to-date-vaccination-status-09182023/) - CDC is hosting a webinar on September 18, 2023 related to Weekly HCP and Resident COVID-19 Vaccination. The webinar, "Up to Date Vaccination Status: Surveillance Definition Change for Long Term Care Facilities (Initial)," will be held at 2PM EST. Register here. - [CMS Issues Proposed Minimum Staffing Standards for Nursing Homes](https://cmscompliancegroup.com/blog/cms-issues-proposed-minimum-staffing-standards-for-nursing-homes/) - HHS Media Release (9/1/2023): HHS Proposes Minimum Staffing Standards to Enhance Safety and Quality in Nursing Homes Builds on President Biden’s Historic Commitment to Create a Long-Term Care System Where People Can Live with Dignity Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued - [Staff Vaccination QSO Memos Consolidated and "Expired"](https://cmscompliancegroup.com/blog/staff-vaccination-qso-memos-consolidated-and-expired/) - On July 25, 2023, The Centers for Medicare & Medicaid Services (CMS) released QSO-23-02-ALL, "Revised Guidance for Staff Vaccination Requirements" which consolidates all previous QSO Memos related to this topic. Those include: QSO 22-07-ALL Revised, and QSO 22-09-ALL Revised, and QSO 22-11-ALL. QSO-23-02-ALL has been set to "expired" as of June 5, 2023. - [CMS Announces New Dementia Care Model](https://cmscompliancegroup.com/blog/cms-announces-new-dementia-care-model/) - Via a CMS.gov July 31, 2023 Press Release: Biden-Harris Administration Announces Medicare Dementia Care Model The Biden-Harris Administration is taking further action on its commitment to promote care and support for people with Medicare living with dementia and their unpaid caregivers. Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare - [CMS Final Rule to Address Certain COVID-19 Related Requirements](https://cmscompliancegroup.com/blog/cms-final-rule-to-address-certain-covid-19-related-requirements-06052023/) - In the June 5, 2023 Federal Register, the Centers for Medicare & Medicaid Services (CMS) final rule, “Medicare and Medicaid Programs; Policy and Regulatory Changes to the Omnibus COVID-19 Health Care Staff Vaccination Requirements; Additional Policy and Regulatory Changes to the Requirements for Long-Term Care (LTC) Facilities and Intermediate Care Facilities for Individuals with Intellectual - [Ftag of the Week – F776 Radiology/Other Diagnostic Services](https://cmscompliancegroup.com/blog/ftag-of-the-week-f776-radiology-other-diagnostic-services/) - This week’s “Ftag of the Week” on the CMSCG Blog is F776 Radiology/ Other Diagnostic Services. F776, like the name of the tag implies, sets out the requirements for radiology and other diagnostic services for nursing home residents. Facilities that provide their own services are required to meet additional requirements under the CoPs for Hospitals - [COVID-19 Nursing Home Visitation Restrictions – Revised QSO Memo](https://cmscompliancegroup.com/blog/covid-19-nursing-home-visitation-restrictions-revised-qso-memo/) - In accordance with the end of the COVID-19 Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) revised QSO-20-39-NH, “Nursing Home Visitation – COVID-19.” The QSO Memo, initially published on September 17, 2020, provided guidance on visitation guidelines for nursing homes. Here’s what to know about the revisions. Two bullet points were - [CMS QSO Memo re COVID-19 Testing for Nursing Homes Expires May 11, 2023](https://cmscompliancegroup.com/blog/cms-qso-memo-re-covid-19-testing-for-nursing-homes-expires-may-11-2023/) - The Centers for Medicare and Medicaid Services (CMS) announced on May 8, 2023 that the August 26, 2023 QSO Memo, “Interim Final rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements” would expire on May 11, 2023. The expired QSO - [CDC Updates COVID-19 Infection Control Recommendations for HCP](https://cmscompliancegroup.com/blog/cdc-updates-covid-19-infection-control-recommendations-for-hcp/) - On May 8, 2023, the Centers for Disease Control (CDC) updated its webpage, “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic." The updated changes include new recommendations for universal source control and admission testing in nursing homes. An Appendix has been added to assist healthcare facilities with - [COVID-19 PHE Ending – Along with Waivers & Requirements for all Provider Types](https://cmscompliancegroup.com/blog/covid-19-phe-ending-along-with-waivers-requirements-for-all-provider-types/) - On May 1, 2023, the Centers for Medicare & Medicaid Services (CMS) released a new QSO Memo, “Guidance for the Expiration of the COVID-19 Public Health Emergency (PHE).” The PHE is ending on May 11, 2023, so that’s not a lot of time to ensure your organization is ready for return to post-PHE operations. Let’s - [Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f695-respiratory-tracheostomy-care-and-suctioning-pt2/) - In Part 2 of our CMSCG “Ftag of the Week” for F695 Respiratory/Trach Care, we will begin to review the importance of staff knowledge of what needs to be provided for different types of respiratory care and services. F695 requires that facilities assess and develop individualized plans of care that are based on professional standards - [Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f695-respiratory-tracheostomy-care-and-suctioning-pt1/) - Next up on the CMSCG Blog “Ftag of the Week” series, we will be reviewing F695 Respiratory/ Tracheostomy Care and Suctioning, which is part of the Quality of Care regulatory group. This regulation requires that a resident who needs respiratory care is provided with appropriate care that is consistent with the resident’s comprehensive care plan, - [CMS MDS Transition to iQIES Reference Info](https://cmscompliancegroup.com/blog/cms-mds-transition-to-iqies-reference-info/) - FYI - The Centers for Medicare & Medicaid Services (CMS) QIES Technical Support Office published information on April 3, 2023 related to "What to Expect with the Minimum Data Set (MDS) Transition to iQIES on April 17, 2023." There is an associated document that can be downloaded here for your reference. If you didn't have - [CMS Rescinds QSO-20-31-ALL and Releases QSO-23-10-NH](https://cmscompliancegroup.com/blog/cms-rescinds-qso-20-31-all-and-releases-qso-23-10-nh/) - The Centers for Medicare & Medicaid Services (CMS) announced that it is rescinding its QSO Memo, “Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes,” effective March 30, 2023. This Memo is rescinded – CMS directs readers to QSO-23-10-NH for information related to "Strengthened - [Ftag of the Week – F637 Comprehensive Assmt After Significant Change](https://cmscompliancegroup.com/blog/ftag-of-the-week-f637-comprehensive-assmt-after-significant-change/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Resident Assessments regulatory group, F637 Comprehensive Assessment After Significant Change. The intent of this regulation is to ensure that a resident who experiences a significant change in status has a comprehensive assessment completed within 14 days of the facility determining that - [CDC Alert - Increasing Threat of Spread of C. auris](https://cmscompliancegroup.com/blog/cdc-alert-increasing-threat-of-spread-of-c-auris/) - This antimicrobial-resistant fungus is getting a renewed focus by the CDC after 3 years of fighting COVID-19. In New York, as well as other states, a review of infection control compliance was underway in 2017 to strengthen readiness for C. auris in nursing homes and other healthcare entities after it was first identified in the - [Webinar - Food Safety in the LTC Setting](https://cmscompliancegroup.com/blog/nyshfa-nyscal-webinar-food-safety-in-the-ltc-setting-2023/) - Join CMS Compliance Group, Inc. for a NYSHFA | NYSCAL webinar on April 20, 2023: Food Safety Considerations in the Long-Term Care Setting Presenter: Kelly Hellberg, MS, RD, CDN, Consultant, CMS Compliance Group, Inc. View the Program Brochure here. Program Overview: Ensuring food safety to avoid negative outcomes in long-term care settings is a daily - [CMS Releases "End of PHE" Fact Sheet](https://cmscompliancegroup.com/blog/cms-end-of-phe-factsheet-released-02272023/) - When the Centers for Medicare & Medicaid Services (CMS) announced that the COVID-19 PHE was set to end on May 11, 2023, many providers were wondering how to return to "normal" after leveraging many waivers and flexibilities with great success over the past few years. Earlier this month, CMS released a set of resources and - [Ftag of the Week - F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 1)](https://cmscompliancegroup.com/blog/f690-bowel-bladder-incontinence-catheter-uti-pt1/) - Next up on the CMSCG Blog series, “Ftag of the Week,” we will be reviewing one of the regulations in the Quality of Care regulatory group, F690 Bowel/Bladder Incontinence, Catheter, UTI. CMSCG Clinical Consultant Mary Quinn is providing clinical insight for this Ftag series. F690 – The Regulation In a nutshell, here is the regulation - [LTCSP Survey Materials Updated (2/17/2023)](https://cmscompliancegroup.com/blog/ltcsp-survey-materials-updated-2-17-2023/) - The Centers for Medicare & Medicaid Services (CMS) released updated Long-Term Care Survey Process (LTCSP) materials on February 17, 2023. Per the Revision History, the following items were updated – ensure you have the most current resources: FIC Folder (Focus Infection Control Survey Protocol) (dated 2/2023)LTC Survey Pathway CMS-20068 Urinary Catheter or UTI (dated 2/2023)Appendix - [Ftag of the Week – F773 Lab Svcs Physician Order/Notify of Results](https://cmscompliancegroup.com/blog/ftag-of-the-week-f773-lab-svcs-physician-order-notify-of-results/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Laboratory, Radiology and Other Diagnostic Services regulatory group, F773. This regulation outlines the requirements for the provision of lab services only when there is an appropriate order and when the lab must notify the ordering provider of results. Regulation Overview F773 - [CMS PHE Resource Update](https://cmscompliancegroup.com/blog/cms-phe-resource-update/) - The Centers for Medicare & Medicaid Services (CMS) distributed the following announcement which may include helpful resources for providers as the COVID-19 Public Health Emergency (PHE) is set to end on May 11, 2023. There are specific pdf documents for different provider types, including skilled nursing, home health and hospice, in the links below. Via - [Ftag of the Week – F698 Dialysis (Pt 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f698-dialysis-pt2/) - As we mentioned in Part 1 of our CMSCG “Ftag of the Week” for F698 Dialysis, there are a lot of moving parts related to dialysis, so there are also a lot of requirements for associated policies and procedures. In this post, we will review what’s required for dialysis-specific policies/procedures. The nursing home must include - [CMS to Audit Schizophrenia Coding – and Adjust QMs – Based on Results](https://cmscompliancegroup.com/blog/cms-to-audit-schizophrenia-coding-and-adjust-qms-based-on-results/) - In a media release issued this morning, “Biden-Harris Administration Takes Additional Steps to Strengthen Nursing Home Safety and Transparency: CMS to increase oversight of inappropriate antipsychotic use,” the Centers for Medicare and Medicaid Services (CMS) announced some important changes that providers need to be aware of. As you are likely aware, CMS recently indicated that - [CMS to Post Citations Under Dispute on Care Compare](https://cmscompliancegroup.com/blog/cms-to-post-citations-under-dispute-on-care-compare-idr-iidr/) - The Centers for Medicare & Medicaid Services (CMS) just announced via a news release and associated QSO Memo that it will be increasing transparency by adding additional information to Care Compare. Per the January 18, 2023 press release: CMS is planning to publicly display survey citations that are under dispute by providers on Care Compare. - [Ftag of the Week – F698 Dialysis (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f698-dialysis-pt1/) - Next up on the CMSCG “Ftag of the Week” Blog series, we will be looking at F698 Dialysis. CMS Compliance Group Clinical Consultant Mary Quinn, RN, BSN, MA is lending some additional clinical expertise to the review of this regulation. Nursing home residents essentially have two options for how they can receive dialysis treatments – - [COVID-19 PHE Extended (1/11/2023)](https://cmscompliancegroup.com/blog/covid-19-phe-extended-01112023/) - Today, January 11, 2023, Health and Human Services (HHS) Secretary Xavier Becerra extended the Public Health Emergency (PHE) related to COVID-19. The PHE has been in place since January 27, 2020 and will continue for the next 90 days from this renewal. Read the "Renewal of Determination that a Public Health Emergency Exists" on the - [Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f686-treatment-svcs-to-prevent-heel-pressure-injuries-pt2/) - Last week in the first part of our “Ftag of the Week” for F686, CMSCG Consultant Mary Quinn provided information on key definitions and staging considerations. This week on the CMSCG Blog, we are reviewing assessment and prevention of pressure injuries. Assessment and Prevention of Pressure Injuries In order to prevent a resident from developing - [Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f686-treatment-svcs-to-prevent-heel-pressure-injuries-pt1/) - For our next “Ftag of the Week” on the CMSCG Blog, we will be delving into the extensive requirements related to the prevention and treatment of pressure injuries. Pressure injuries pose a significant risk to residents – as well as providers – so for this Ftag series, CMSCG Consultant Mary Quinn, RN, BSN, MA will - [CMS CY2023 Home Health PPS Rate Update 10/31/2022)](https://cmscompliancegroup.com/blog/cms-cy2023-home-health-final-rule/) - The Centers for Medicare & Medicaid Services (CMS) published the CY 2023 Home Health Prospective Payment System Rate Update final rule for home health agencies (HHAs) on October 31, 2022. According to a CMS.gov Newsroom Fact Sheet (10/31/2022), "CY 2023 Home Health Prospective Payment System Rate Update and Home Infusion Therapy Services Requirements - Final - [Ftag of the Week – F942 Resident’s Rights Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f942-residents-rights-training/) - Our next “Ftag of the Week” on the CMSCG Blog is F942 Resident’s Rights Training. F942 is another tag in the Training Requirements regulatory group that was included with the Requirements of Participation (RoPs), but limited Interpretive Guidance (IG) was included. As of October 24, 2022, surveyors are now using the revised SOM Appendix PP - [2022 New York State Survey Trends & Tips (Webinar)](https://cmscompliancegroup.com/blog/2022-new-york-state-survey-trends-tips-webinar/) - Please join CMS Compliance Group, Inc. for our 10th(!) annual NYSHFA "Survey Trends" presentation. This year, the webinar will be held on December 15, 2022 from 10AM-12PM. Earn 2.0 CEUs by attending. Presentation: 2022 New York State Survey Trends & Tips Presenter: Linda Elizaitis, President, CMS Compliance Group, Inc. Session Overview: The current regulatory environment - [NYSHFA | NYSCAL Fall 2022 Conference](https://cmscompliancegroup.com/blog/nyshfa-nyscal-fall-conference-2022/) - Attention CMSCG Assisted Living clients and colleagues! If you are attending the NYSHFA | NYSCAL Fall Education Conference on December 6-7, 2022, please join us CMS Compliance Group for our Assisted Living track presentation. We look forward to seeing you. This conference is recommended for Owners, Owners / Operators, Administrators, Executive Directors, Financial Directors, and - [Revised CMS Survey Resource Materials (10/26/2022)](https://cmscompliancegroup.com/blog/revised-cms-survey-resource-materials-10262022/) - On Wednesday, October 26, 2022, the Centers for Medicare & Medicaid Services (CMS) released a new QSO Memo with guidance for staff COVID-19 vaccination in all provider settings. Along with that updated QSO Memo, the following survey resources were updated, so ensure you are using the correct version: Appendix PP State Operations Manual (Revised 10/26/2022)Survey - [CMS LTCSP Survey Resources Effective 10/24/2022 Posted](https://cmscompliancegroup.com/blog/cms-ltcsp-survey-resources-effective-10242022/) - ** These materials have been updated as to 10/26/2022. Please view this post on the CMSCG Blog for the current materials: Revised CMS Survey Resource Materials (10/26/2022) ** The Centers for Medicare & Medicaid Services (CMS) released updated surveyor resources aligned with the changes that became effective yesterday, October 24, 2022. Per the Revision History, - [CMS Transmittal - Revisions to Appendix PP SOM - Effective 10/24/2022](https://cmscompliancegroup.com/blog/cms-transmittal-revisions-to-appendix-pp-som-effective-10242022/) - The Centers for Medicare & Medicaid Services (CMS) issued Transmittal #R208SOMA on October 10, 2022 with the subject, "Revisions to State Operation Manual (SOM), Appendix PP Guidance to Surveyors for Long Term Care Facilities." The implementation date for the updated SOM is Monday, October 24, 2022. Download the revised SOM (Publication # 100-07) on the - [NYSDOH Health Advisory - Testing / Cohorting / Visitation](https://cmscompliancegroup.com/blog/nysdoh-health-advisory-testing-cohorting-visitation-10132022/) - For CMSCG's New York clients and colleagues: NYSDOH issued a Health Advisory on October 13, 2022, "Nursing Home Testing, Cohorting and Visitation Guidance" that should be reviewed if you have not seen it. It provides information on DOH's take on key COVID-19 topics, including its interpretation of recent CDC recommendations regarding masking. Per the Advisory: - [Ftag of the Week – F940 Training Requirements – General](https://cmscompliancegroup.com/blog/ftag-of-the-week-f940-training-requirements-general/) - This week on the CMSCG Blog, we are reviewing a Phase 3 tag, F940 Training Requirements – General. When we initially posted our “Ftag of the Week” for F940 back in March 2019, there was limited information about what was actually expected under this regulatory requirement. The revised guidance to surveyors that was published as - [CMS Revises COVID-19 Testing Requirements for LTC Facilities](https://cmscompliancegroup.com/blog/cms-revises-covid-19-testing-requirements-for-ltc-facilities-092022/) - On September 23, 2022, the Centers for Medicare & Medicaid Services (CMS) released an updated QSO Memo, “Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements,” (Ref: QSO-20-38-NH). This QSO Memo was originally published by CMS on August - [CMS Updates Nursing Home Visitation Guidance – Again](https://cmscompliancegroup.com/blog/cms-updates-nursing-home-visitation-guidance-again-092022/) - On September 23, 2022, the Centers for Medicare & Medicaid Services (CMS) updated the QSO Memo, “Nursing Home Visitation – COVID-19 (REVISED)” (Ref: QSO-20-39-NH), which was originally issued September 17, 2020 and has seen several revisions ( March 2021, April 2021) throughout the COVID-19 Public Health Emergency (PHE). Let’s look at what’s been updated. New - [CDC Updates COVID-19 Infection Control Guidance for Healthcare Workers](https://cmscompliancegroup.com/blog/cdc-updates-covid-19-infection-control-guidance-for-healthcare-workers-092022/) - The Centers for Disease Control (CDC) updated its “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic” on September 23, 2022. Per the CDC webpage, the following updates were made in this revision: Updated to note that vaccination status is no longer used to inform source control, screening - [CDC Updates Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection/Exposure](https://cmscompliancegroup.com/blog/cdc-updates-guidance-for-managing-healthcare-personnel-with-sars-cov-2-infection-exposure-092022/) - On September 23, 2022, the Centers for Disease Control (CDC) updated its “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2” recommendations. Two key updates are listed: In most circumstances, asymptomatic HCP with higher-risk exposures do not require work restriction.Updated recommendations for testing frequency to detect potential for variants with shorter - [CMS Posts More Nursing Home Ownership Data](https://cmscompliancegroup.com/blog/cms-posts-more-nursing-home-ownership-data/) - The Centers for Medicare & Medicaid Services (CMS) announced in a news release on September 26, 2022 that additional nursing home ownership data is now publicly available on its data.cms.gov website. This is the second time nursing home ownership data has been released. In April 2022, HHS announced the release of ownership information including acquisitions - [Quality Measure Thresholds Increasing Soon](https://cmscompliancegroup.com/blog/quality-measure-thresholds-increasing-october-2022-refresh/) - Per a Centers for Medicare & Medicaid Services (CMS) Post-Acute Care Quality Reporting Programs email update (9/21/2022): Quality Measure Rating Threshold Changes with the October 2022 Refresh In March 2019, CMS released memorandum , which outlined a plan to update the quality measure (QM) rating thresholds every six months. The plan was to increase the - [Ftag of the Week – F741 Sufficient/Competent Staff – Behav Health Needs (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f741-sufficient-competent-staff-behav-health-needs-pt-1/) - This week’s “Ftag of the Week” on the CMSCG Blog is one that providers should be reviewing in detail, F741 Sufficient/Competent Staff – Behavioral Health Needs. We reviewed F725 Sufficient Nursing Staff in a prior blog post, but the requirements at F741 specifically relate to having sufficient staff to competently care for residents’ behavioral health - [Ftag of the Week – F941 Communication Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f941-communication-training/) - This week on the CMSCG Blog, our “Ftag of the Week” is another training requirement, F941 Communication Training. We had reviewed a couple of the training requirements in a March 2019 Ftag of the Week post, but now there’s significantly more guidance to work with. The regulation requires that nursing homes have mandatory training for - [Advance Copy of Critical Element Pathways Released](https://cmscompliancegroup.com/blog/advance-copy-of-critical-element-pathways-released-oct-2022/) - The Centers for Medicare & Medicaid Services (CMS) released advance copies of the updated Long-Term Care Survey Process (LTCSP) Critical Element Pathways. Surveyors will begin surveying with these new tools in October 2022. You can view the updated CE Pathways here (.zip). Review the changes to see what surveyors will be looking at on your - [Ftag of the Week – F945 Infection Control Training](https://cmscompliancegroup.com/blog/ftag-of-the-week-f945-infection-control-training/) - This week on the CMSCG Blog, our “Ftag of the Week” is one of the training regulations that lacked guidance until the draft revisions to State Operations Manual Appendix PP were published in June. Given the non-stop emphasis on everything related to infection prevention and control throughout the COVID-19 PHE, it’s unlikely nursing homes haven’t - [Top NYS Compliance Issues - and What You Need to Do to Fix Them!](https://cmscompliancegroup.com/blog/top-nys-compliance-issues-and-what-you-need-to-do-to-fix-them-nyshfa/) - Join CMS Compliance Group President Linda Elizaitis at the NYSHFA | NYSCAL 20th Nurse Leadership Conference. The Conference will be taking place at the Turning Stone Resort and Casino in Verona, NY. Top New York State Compliance Issues and What You Need to Do to Fix Them! Date: Friday, September 23, 2022 Time: 8:45AM-9:45AM Session - [Understanding the Impact of Revised Surveyor Guidance on Your Next Survey](https://cmscompliancegroup.com/blog/understanding-the-impact-of-revised-surveyor-guidance-on-your-next-survey-webinar/) - Join CMS Compliance Group President Linda Elizaitis on September 19, 2022 for a NYSHFA | NYSCAL webinar about the updated guidance to surveyors - and what that means for your next survey. Understanding the Impact of Revised Surveyor Guidance on Your Next Survey Date and Time: September 19, 2022 1PM-3PM EST Program Overview: The revised - [COVID-19 PHE Extended Again on July 15, 2022](https://cmscompliancegroup.com/blog/covid-19-phe-extended-again-july-15-2022/) - The COVID-19 Public Health Emergency (PHE) was extended for another ninety (90) days on Friday, July 15, 2022. View the current PHE Declaration "Renewal of Determination that a Public Health Emergency Exists" on the HHS.gov website. The PHE was initially declared on January 27, 2020 and has been renewed continuously since then. - [Ftag of the Week – F740 Behavioral Health Services (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f740-behavioral-health-services-pt1/) - Up next on the CMSCG Blog is our Ftag of the Week for F740 Behavioral Health Services. We delayed covering this regulation since we were anticipating additional significant guidance to surveyors in the State Operations Manual Appendix PP, and the Centers for Medicare & Medicaid Services (CMS) did not disappoint with its latest revisions. Behavioral - [CDC Recommends Enhanced Barrier Precautions in Nursing Homes](https://cmscompliancegroup.com/blog/cdc-recommends-enhanced-barrier-precautions-in-nursing-homes/) - The Centers for Disease Control (CDC) updated recommendations for the use of Enhanced Barrier Precautions (EBP) in nursing homes on July 12, 2022. On today's National Nursing Home Stakeholder call, the CDC presented an overview of why it is making these recommendations, and the Centers for Medicare & Medicaid Services (CMS) noted that at this - [Changes Coming with July 2022 Care Compare Refresh](https://cmscompliancegroup.com/blog/changes-coming-with-july-2022-care-compare-refresh/) - As promised in the January 7, 2022 QSO Memo,"Nursing Home Staff Turnover and Weekend Staffing Levels." the Centers for Medicare & Medicaid Services (CMS) is moving forward with factoring additional staffing information into its methodology for calculating the Five Star Quality Rating. These updates will be effective in the July 2022 Care Compare Refresh, per - [Advance Copy of Phase 3 RoPs & Updated Surveyor Guidance Released](https://cmscompliancegroup.com/blog/advance-copy-of-phase-3-rops-updated-surveyor-guidance-released/) - So much for a quiet summer. On June 30, 2022, the Centers for Medicare and Medicaid Services (CMS) the release of updated Requirements of Participation (RoPs) in a new QSO Memo. The Memo, “Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration Agreement Requirements, Investigating Complaints & Facility Reported - [Summer Break for "Ftag of the Week"](https://cmscompliancegroup.com/cmscg-updates/summer-break-for-ftag-of-the-week/) - It's time for a brief break from CMS Compliance Group's "Ftag of the Week" series on the CMSCG Blog. You'll still receive other important updates, but our weekly regulatory post will be back soon. Enjoy the summer! - [CMS Rescinds Surveyor COVID-19 Vaccination Requirement](https://cmscompliancegroup.com/blog/cms-rescinds-surveyor-covid-19-vaccination-requirement/) - On June 16, 2022, the Centers for Medicare and Medicaid Services (CMS) issued a new QSO Memo, “Rescission of the January 25, 2022 memo regarding Vaccination Expectations for Surveyors Performing Federal Oversight (QSO-22-10-ALL) and removal from its guidance repository.” The Memo, which is essentially the same as its long title, states that the Agency is - [Revisions to CMS Survey Process for COVID-19 Vaccination Announced](https://cmscompliancegroup.com/blog/revisions-to-cms-survey-process-for-covid-19-vaccination-announced/) - On June 14, 2022, the Centers for Medicare and Medicaid Services (CMS) announced changes regarding how compliance with the Omnibus COVID-19 vaccination requirement for staff will be reviewed. In a new QSO Memo, “Surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements,” the Agency announced that surveying for healthcare staff vaccination will continue - [Linda Elizaitis discusses surveys and complaints with McKnight's LTC News](https://cmscompliancegroup.com/cmscg-updates/linda-elizaitis-discusses-surveys-and-complaints-with-mcknights-ltc-news/) - CMS Compliance Group, Inc. President Linda Elizaitis, RN, BS, RAC-CT, CDS, spoke with McKnight's Long-Term Care News this week regarding the nursing home complaint investigation backlog and how delays to standard survey & certification activities have impacted providers in New York - and the rest of the country. Some of my clients do not feel - [LTC Survey Process Documents Updated 6/7/2022](https://cmscompliancegroup.com/blog/ltc-survey-process-documents-updated-06072022/) - On June 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released updates to the Long-Term Care Survey Process (LTCSP) Survey Resources. According to the Revision History document, the following changes were made: F-tag Waiver Guide updated (to reflect the recent blanket waiver terminations from May 2022 and June 2022)Removal of the K-tag Waiver - [Ftag of the Week – F677 ADL Care for Dependent Residents](https://cmscompliancegroup.com/blog/ftag-of-the-week-f677-adl-care-for-dependent-residents/) - Next up in our “Ftag of the Week” series on the CMSCG Blog, we will review F677 ADL Care Provided for Dependent Residents, which is the seventh most frequently cited Ftag on recertification surveys in the United States for 2022 (as of May 2022). In a prior post, we reviewed the requirements for the companion - [Reminder – Additional COVID-19 PHE Blanket Waivers Ending Soon](https://cmscompliancegroup.com/blog/reminder-additional-covid-19-phe-blanket-waivers-ending-soon-june-2022/) - Just a friendly reminder that an additional set of COVID-19 PHE Blanket Waivers are scheduled to end on June 6th – only a few days away. Some of the waivers are related to Life Safety and the physical environment, whereas others are care-related. For more information, visit this post on the CMSCG Blog which outlines - [CMS Revises Emergency Preparedness Exercise Scenarios QSO Memo](https://cmscompliancegroup.com/blog/cms-revises-emergency-preparedness-exercise-scenarios-qso-memo/) - On May 26, 2022, the Centers for Medicare and Medicaid Services (CMS) issued a revision to QSO-20-41-ALL, “Guidance related to Emergency Preparedness- Exercise Exemption based on A Facility’s Activation of their Emergency Plan.” The guidance, initially dated September 28, 2020, also had a prior revision in June 2021 due to the COVID-19 Public Health Emergency - [Ftag of the Week – F636 Comprehensive Assessments & Timing](https://cmscompliancegroup.com/blog/ftag-of-the-week-f636-comprehensive-assessments-timing/) - This week on the CMSCG Blog, we’re reviewing one of the Resident Assessment regulations, F636 Comprehensive Assessments & Timing. The intent of this regulation is to ensure that comprehensive assessments of each resident are conducted at required timeframes using the Resident Assessment Instrument (RAI). The RAI includes the Minimum Data Set (MDS), the Care Areas - [LTCSP Documents Folder Updated 5/9/2022](https://cmscompliancegroup.com/blog/ltcsp-documents-folder-updated-05092022/) - The Centers for Medicare & Medicaid Services (CMS) released an updated Long-Term Care Survey Process (LTCSP) documents folder. The folder contains additional regulatory references for surveyors, as well as the updated F-tag waiver guide to reflect the recently terminated COVID-19 Public Health Emergency (PHE) blanket waivers. Per the Revision History, these are the changes that - [Ftag of the Week – F760 Residents Are Free of Significant Med Errors](https://cmscompliancegroup.com/blog/ftag-of-the-week-f760-residents-are-free-of-significant-med-errors/) - In March, we dedicated a few “Ftag of the Week” posts on the CMSCG Blog to F759 Free of Medication Error Rates of 5% or More. Now we are circling back to an associated Ftag, F760 Residents Are Free of Significant Med Errors. These two tags share the same set of Interpretive Guidance (IG) from - [Reminder - COVID-19 PHE Waivers Ending This Weekend](https://cmscompliancegroup.com/blog/reminder-covid-19-phe-waivers-ending-this-weekend-may-2022/) - On April 7, 2022, the Centers for Medicare and Medicaid Services (CMS) released a new QSO Memo, “Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers.” The Memo states that CMS has continued to review the need for existing emergency blanket waivers throughout the pandemic and believes many need to be terminated. The first - [NYSCAL Webinar - Making Quality Assurance Work For You](https://cmscompliancegroup.com/blog/nyscal-webinar-making-quality-assurance-work-for-you-linda-elizaitis/) - Join CMS Compliance Group President Linda Elizaitis, RN, BS, RAC-CT, CDS on June 16, 2022 for a NYSCAL webinar "ACF/Assisted Living: Making Quality Assurance Work for You." Date & Time: June 16, 2022 10AM-11:30AM 1.5 CEUs are available. This webinar is open to NYSCAL Members as well as Non-Members. Program Overview: Quality Assurance requirements for - [HHS Releases Nursing Home Ownership Data (Press Release)](https://cmscompliancegroup.com/blog/hhs-releases-nursing-home-ownership-data/) - Via an April 20, 2022 CMS.gov Press Release: Today, the Department of Health and Human Services (HHS) is taking actions to promote competition and transparency in our nation’s health care system that can improve the safety and quality of nursing homes and hospitals. The Centers for Medicare & Medicaid Services (CMS) is releasing data publicly -- for the first - [Join CMS Compliance Group for a Seminar in Syracuse on 4/29/2022](https://cmscompliancegroup.com/blog/join-cms-compliance-group-for-a-seminar-in-syracuse-april-29-2022/) - On April 29, 2022, please join Linda Elizaitis, President of CMS Compliance Group for a New York Association of Long Term Care Administrators (NYALTCA) Seminar. Seminar Title: Understanding the Current Regulatory Landscape and Its Impact on Survey Agenda: After a long time focusing on COVID-19 and Infection Control-related requirements, it’s time for Administrators to ensure - [LTCSP Survey Resources Updated 4/7/2022](https://cmscompliancegroup.com/blog/ltcsp-survey-resources-updated-04072022/) - An updated Survey Resources folder for the Long-Term Care Survey Process was published on April 7, 2022. According to the Revision History, the following items have been updated: 1. FIC folder (FIC Survey Protocol, FIC Survey Entrance Conference Worksheet, CMS 20054-Infection Prevention Control and Immunization, QSO-20-39-NH Revised, QSO-20-38-NH Revised, Staff Matrix for F888 only) 2. - [CMS Ending COVID-19 PHE-related Blanket Waivers](https://cmscompliancegroup.com/blog/cms-ending-covid-19-phe-related-blanket-waivers/) - On April 7, 2022, the Centers for Medicare and Medicaid Services (CMS) released a new QSO Memo, “Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers.” The new Memo states that CMS has continued to review the need for existing emergency blanket waivers throughout the pandemic, and now plans to end multiple waivers in - [Ftag of the Week – F888 COVID-19 Vaccination of Facility Staff (Revised)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f888-covid-19-vaccination-of-facility-staff-revised-04052022/) - On April 5, 2022, the Centers for Medicare and Medicaid Services (CMS) released “Revised Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination (QSO-22-07-ALL, QSO-22-09-ALL, and QSO-22-11-ALL). The first in the series of these QSO Memos was issued in December 2021, and then two other versions were - [Ftag of the Week – F729 Nurse Aide Registry Verification, Retraining](https://cmscompliancegroup.com/blog/ftag-of-the-week-f729-nurse-aide-registry-verification-retraining/) - This week’s Ftag of the Week on the CMSCG Blog is part of the Nursing Services regulatory group, F729 Nurse Aide Registry Verification, Retraining. As its title implies, this regulation looks at nurse aide training and the provider’s responsibilities for ensuring that nurse aides are qualified to work in their facilities, including that they have - [Quality Measure Rating Thresholds Changing on Care Compare](https://cmscompliancegroup.com/blog/quality-measure-rating-thresholds-changing-on-care-compare-april-2022/) - In a sign that the Centers for Medicare and Medicaid Services (CMS) is getting back to “normal” after a focus on COVID-19 everything for the past couple years, the Agency made an announcement today that planned updates to Care Compare will be effective with the April 2022 refresh. Specifically, Quality Measure (QM) thresholds will be - [Ftag of the Week – Revised (again) F886 COVID-19 Testing – Residents & Staff](https://cmscompliancegroup.com/blog/ftag-of-the-week-revised-f886-covid-19-testing-residents-staff-03102022/) - On March 10, 2022, the Centers for Medicare and Medicaid Services (CMS) issued a revision to QSO-20-38-NH, “Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements.” That IFC, initially posted in August of 2020, established F886 COVID-19 Testing – Residents - [Webinar - Food Safety & Safe Food Handling in the LTC Setting](https://cmscompliancegroup.com/blog/webinar-food-safety-safe-food-handling-in-the-ltc-setting/) - Join CMS Compliance Group's Kelly Hellberg for a NYSHFA | NYSCAL webinar, "Food Safety & Food Handling in the Long Term Care Setting" on April 5, 2022 from 10AM-12PM. Session Overview: Food safety in long-term care settings presents a significant daily challenge for Food Service Directors. Whether it is ensuring proper handling, good infection control - [Ftag of the Week – F759 Free of Medication Error Rates of 5% or More (Pt. 1)](https://cmscompliancegroup.com/cmscg-updates/ftag-of-the-week-f759-free-of-medication-error-rates-of-5-or-more-pt1/) - Up next on the CMSCG Blog, we will be reviewing two additional regulations that are part of the Pharmacy Services regulatory group, F759 and the associated tag F760. First, we will review F759 Free of Medication Error Rates of 5% or More, and then will review F760 Residents Are Free of Significant Med Errors. SOM - [Ftag of the Week – F814 Dispose Garbage & Refuse Properly](https://cmscompliancegroup.com/blog/ftag-of-the-week-f814-dispose-garbage-refuse-properly/) - This week’s “Ftag of the Week” on the CMSCG Blog is F814 Dispose Garbage & Refuse Properly, which is part of the Food and Nutrition Services regulatory group. This is a short regulation, but there are a lot of ways it can be cited. According to Appendix PP of the State Operations Manual (SOM), facilities - [CMS Updates NH Visitation FAQs (2/2/2022)](https://cmscompliancegroup.com/blog/cms-updates-nh-visitation-faqs-02022022/) - The Centers for Medicare & Medicaid Services (CMS) issued an updated version of its "Nursing Home Visitation Frequently Asked Questions (FAQs) on February 2, 2022. The updates primarily focus on enhancing the safety of visitation, particularly as it relates to air flow and ventilation. The updated document can be on the CMS Current Emergencies webpage - [CMS Now Requiring Surveyors to Be Vaccinated for On-Site Surveys](https://cmscompliancegroup.com/blog/cms-now-requiring-surveyors-to-be-vaccinated-for-on-site-surveys-qso/) - After requiring healthcare providers to ensure their staff are fully vaccinated for COVID-19 in a series of QSO Memos over the past few weeks (QSO-22-07-ALL, QSO-22-09-ALL, QSO-22-11-ALL) the Centers for Medicare & Medicaid (CMS) has finally issued guidance requiring surveyors to be vaccinated as well. In recent months, providers have objected to Federal guidance that - [LTCSP Resources Updated - Again (1/25/2022)](https://cmscompliancegroup.com/blog/ltcsp-resources-updated-01252022/) - Do you have all the current LTCSP materials? The Centers for Medicare & Medicaid Services (CMS) released updated Long-Term Care Survey Process Survey Resources on January 25, 2022. This time around, there are two folders of resources. List of Revised FtagsEntrance Conference Worksheet (January 2022 - Valid for non-injunction states)CMS-20054 Infection Prevention Control and Immunization - [List of Revised Ftags (January 2022)](https://cmscompliancegroup.com/blog/list-of-revised-ftags-january-2022/) - Another year, another revision to the list of F-tags for long-term care. This updated January 2022 list includes the newly-added F888 COVID-19 Vaccination of Facility Staff regulation. View the current list here. - [Five-Star Technical Users’ Guide Updated to Reflect Staffing Methodology](https://cmscompliancegroup.com/blog/five-star-technical-users-guide-updated-to-reflect-staffing-methodology-january-2022/) - On January 14, 2022, an updated Design for Nursing Home Five-Star Quality Rating System: Technical Users’ Guide was released by the Centers for Medicare & Medicaid Services (CMS). The document includes revisions to two staffing-related changes that will be impacting nursing homes in 2022. First, effective with the January 2022 refresh of Care Compare, the - [Ftag of the Week – F700 Bed Rails (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f700-bed-rails-pt-1/) - Up next in CMS Compliance Group’s “Ftag of the Week” Blog Series is F700 Bed Rails, which is part of the Quality of Care regulatory group. For the purposes of F700, the Centers for Medicare and Medicaid Services (CMS) provides the following examples of bed rails: side rails, bed side rails, safety rails, grab bars - [Upcoming Changes to Care Compare & Five-Star Quality Rating System](https://cmscompliancegroup.com/blog/upcoming-changes-to-care-compare-five-star-quality-rating-system-staffing-turnover/) - The Centers for Medicare & Medicaid Services (CMS) announced in a January 7, 2022 QSO Memo that additional information about nursing home staffing is going to be added to the January 2022 Care Compare refresh. Nursing home providers have been submitting their staffing data to the Payroll-Based Journal (PBJ) System for several years now, so - [Bed Rails Making News Headlines Again](https://cmscompliancegroup.com/blog/bed-rails-making-headlines-again/) - As with all high-risk areas, the risk of entrapment from the use of bed rails comes in and out of the news cycle as the result of negative outcomes. Headlines are being made after a recent announcement from the U.S. Consumer Product Safety Commission (CPSC) about a recall on certain bed rails. The recall is - [Ftag of the Week – F774 Assist with Transport Arrangements to Lab Svcs](https://cmscompliancegroup.com/blog/ftag-of-the-week-f774-assist-with-transport-arrangements-to-lab-svcs/) - For our next “Ftag of the Week” on the CMSCG Blog, we will be reviewing a regulation from the Laboratory, Radiology, and Other Diagnostic Services regulatory group, F744. This regulation is not lengthy, nor is it frequently cited, but given the logistic and transportation issues that the country is experiencing, a little reminder about providing - [Survey & Oversight Changes in Nursing Homes – What to Know (Pt 1)](https://cmscompliancegroup.com/cmscg-updates/survey-oversight-changes-in-nursing-homes-what-to-know-pt-1/) - On November 12, 2021, the Centers for Medicare & Medicaid (CMS) released a QSO Memo, “Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes” (QSO-22-02-ALL). The Memo provides information on changes that CMS is making to help State Survey Agencies (SAs) get caught up with a significant backlog of recertification and complaint surveys. - [Nursing Home Visitation Restrictions Lifted in Time for Holidays](https://cmscompliancegroup.com/blog/nursing-home-visitation-restrictions-lifted-in-time-for-holidays/) - On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a revision to QSO-20-39-NH, “Nursing Home Visitation – COVID-19” (originally published 9/17/2020). The new visitation guidance generally allows visitation without restrictions at nursing homes across the country. This Federal guidance does not supersede State guidance, so guidance from your home State may - [Join CMSCG for a Survey Trends Webinar on December 10, 2021](https://cmscompliancegroup.com/blog/join-cmscg-for-a-survey-trends-webinar-12102021/) - Join members of CMS Compliance Group’s interdisciplinary team of compliance and quality improvement consultants on December 10, 2021 for a NYSHFA | NYSCAL webinar, “Survey Trends for 2021 & What Every Department Needs to Know for 2022.” Join members of CMS Compliance Group’s interdisciplinary team of compliance and quality improvement consultants on December 10, 2021 - [CMS Finalizes Home Health and Hospice Rule](https://cmscompliancegroup.com/blog/cms-finalizes-home-health-and-hospice-rule/) - The Centers for Medicare & Medicaid Services (CMS) issued Final Rule CMS-1747-F on November 2, 2021, "Medicare and Medicaid Programs; CY 2022 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model Requirements and Proposed Model Expansion; Home Health Quality Reporting Requirements; Home Infusion Therapy Services Requirements; Survey and Enforcement Requirements for Hospice - [Ftag of the Week – F850 Qualifications of Social Worker >120 Beds](https://cmscompliancegroup.com/blog/ftag-of-the-week-f850-qualifications-of-social-worker-120-beds/) - This week’s “Ftag of the Week” on the CMSCG Blog is part of the Administration regulatory group, F850 Qualifications of Social Worker >120 Beds. This regulation requires any nursing home that has more than 120 beds to have a full-time social worker on staff. The social worker must meet the following qualifications: Minimum of a - [OSHA COVID-19 Vaccination and Testing; Emergency Temporary Standard](https://cmscompliancegroup.com/blog/osha-covid-19-vaccination-and-testing-emergency-temporary-standard-11042021/) - As expected, the Occupational Safety and Health Administration (OSHA) issued an Emergency Temporary Standard (ETS) that impacts employers with 100 or more employees. The ETS can be viewed in the November 4, 2021 Federal Register. This rule is effective today, November 5, 2021. For information on the CMS vaccination mandate for healthcare providers published in - [Medicare and Medicaid Programs: Omnibus COVID-19 Health Care Vaccination](https://cmscompliancegroup.com/blog/medicare-and-medicaid-programs-omnibus-covid-19-health-care-vaccination-11052021/) - The highly anticipated healthcare vaccination interim final rule with comment period, "Medicare and Medicaid Programs: Omnibus COVID-19 Health Care Vaccination" has been published in the November 5, 2021 Federal Register. The document can be viewed online here or you can download the pdf here. - [CDC Posts FAQ for 2021-2022 Flu Season](https://cmscompliancegroup.com/blog/cdc-posts-faq-for-2021-2022-flu-season/) - The Centers for Disease Control (CDC) has published key points and Frequently Asked Questions (FAQ) for the 2021-2022 Influenza Season. The key points to be aware of include: The has been updated.All flu vaccines will be quadrivalent (four component), meaning designed to protect against four different flu viruses. For more information: .Licensure on one flu - [Updated Survey Resources Posted for LTCSP (9/14/2021)](https://cmscompliancegroup.com/blog/updated-survey-resources-posted-for-ltcsp-09142021/) - The Centers for Medicare & Medicaid Services (CMS) posted updated Long-Term Care Survey Process (LTCSP) resources on September 14, 2021. The Survey Resources folder dated 9/14/2021 can be downloaded here (.zip file). Per the Revision History, the following changes were made: Updated Entrance Conference FormCOVID-19 FIC survey folder:• Updated CMS 20054, Infection Prevention Control and - [Ftag of the Week – F655 Baseline Care Plan](https://cmscompliancegroup.com/blog/ftag-of-the-week-f655-baseline-care-plan/) - After a brief summer vacation break, it’s time to dive back into our “Ftag of the Week” series on the CMSCG Blog. In this post, we will be reviewing F655 Baseline Care Plan, which is one of the tags in the Comprehensive Resident Centered Care Plan regulatory group. The purpose of this regulation is to - [New QSO Memo re Removal of 2017 QSO Memo on Civil Monetary Penalties](https://cmscompliancegroup.com/blog/new-qso-memo-removal-of-2017-qso-memo-on-civil-monetary-penalties/) - The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo on July 28, 2021 regarding the Agency’s intent to remove prior guidance from 2017 from its guidance repository. The QSO Memo that is being removed is from July 7, 2017 (Ref: S&C: 17-37-NH), “Revision of Civil Monetary Penalty (CMP) Policies and CMP Analytic - [CMSCG's "Ftag of the Week" is on Vacation](https://cmscompliancegroup.com/blog/cmscg-ftag-of-the-week-is-on-vacation/) - We're pausing our "Ftag of the Week" series for the remainder of the summer - hopefully you are too busy on vacation to read it! See you in September. - [Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs](https://cmscompliancegroup.com/blog/ftag-of-the-week-f757-drug-regimen-is-free-from-unnecessary-drugs/) - Up next on the CMSCG Blog “Ftag of the Week” series is F757 Drug Regimen is Free from Unnecessary Drugs, which is part of the Pharmacy Services regulatory group. F757 includes only a set of regulatory requirements, with no Interpretive Guidance, however, deficient practices are widely cited under this regulation, and issues identified can be - [Ftag of the Week – F846 Facility Closure](https://cmscompliancegroup.com/blog/ftag-of-the-week-f846-facility-closure/) - This week’s Ftag of the Week on the CMSCG Blog is the second of two related Ftags in the Administration regulatory group, F846 Facility Closure. F846 requires that a nursing facility have policies and procedures in place that outline the duties of the Administrator in the event of a facility closure. This includes the provision - [Ftag of the Week – F845 Facility Closure – Administrator](https://cmscompliancegroup.com/blog/ftag-of-the-week-f845-facility-closure-administrator/) - This week’s Ftag of the Week on the CMSCG Blog is one of two related Ftags in the Administration regulatory group, F845 Facility Closure – Administrator. The second F-tag, F845 Facility Closure, will be reviewed in an upcoming post in our CMSCG Blog series. The American Healthcare Association/National Center for Assisted living (ACHA/NCAL) conducted a - [H.R. 3733 The Essential Caregivers Act Introduced to Congress – What to Know](https://cmscompliancegroup.com/blog/hr-3733-federal-essential-caregivers-act-introduced-to-congress-what-to-know/) - The Essential Caregivers Act, which came about earlier this year, was introduced to Congress in June 2021 with bipartisan support. The bill, H.R. 3733 “To amend titles XVIII and XIX of the Social Security Act to require skilled nursing facilities, nursing facilities, intermediate care facilities for the intellectually disabled, and inpatient rehabilitation facilities to permit - [Proposed Rule for Home Health Available](https://cmscompliancegroup.com/blog/proposed-rule-for-home-health-available/) - A Centers for Medicare and Medicaid Services (CMS) Proposed Rule was filed on June 28, 2021, with an expected publication date in the Federal Register of July 7, 2021. The document covers several significant areas for home health agencies. Key areas in the proposed rule include: Rate Update for the Home Health Prospective Payment System - [OSHA COVID-19 Emergency Temporary Standard Tools](https://cmscompliancegroup.com/blog/osha-covid-19-emergency-temporary-standard-tools/) - The Occupational Safety and Health Administration (OSHA) COVID-19 Emergency Temporary Standard, “Occupational Exposure to COVID-19; Emergency Temporary Standard” was published in the June 21, 2021 Federal Register, with an effective date of June 21, 2021. There are two compliance dates associated with this standard, and both are tight time frames: July 6, 2021 and July - [Current LTCSP Forms & Materials 6/19/2021 – Are You Using the Right Version?](https://cmscompliancegroup.com/blog/current-ltcsp-forms-materials-6-19-2021-are-you-using-the-right-version/) - The Centers for Medicare & Medicaid Services (CMS) makes periodic updates to the Long-Term Care Survey Process materials. The most current version is dated 6/19/2021. Ensure you have the current information, including the Entrance Conference Form, Matrix and Critical Element Pathways – they may not all be the same since the LTCSP was implemented. You - [CMS Releases Updated LTCSP Resources (6/19/2021)](https://cmscompliancegroup.com/blog/cms-releases-updated-ltcsp-resources-6-19-2021/) - Today, the Centers for Medicare & Medicaid Services published revised Long-Term Care Survey Process (LTCSP) documentation dated 6/19/2021. The following updates are included: LTCSP Entrance Conference Form UpdatedThe COVID-19 Focused Infection Control survey folder includes updated files, including:CMS 20054 Infection Prevention Control and Immunization updatedRevised QSO-20-38 includedUpdated COVID-19 FICS protocol and Entrance Conference FormAdded QSO-21-19-NHCMS - [Ftag of the Week – F804 Nutritive Value/Appear, Palatable/Pref Temp](https://cmscompliancegroup.com/blog/ftag-of-the-week-f804-nutritive-value-appear-palatable-pref-temp/) - Next up in CMS Compliance Group’s “Ftag of the Week” Blog series is F804 Nutritive Value/Appear, Palatable/Pref Temp, which is part of the Food and Nutrition Services regulatory group. This regulation is being cited more frequently, particularly in certain regions of the country, so it is one to pay attention to. F804 – What’s Required? - [Ftag of the Week – F884 Reporting – National Health Safety Network (Revised)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f884-reporting-national-health-safety-network-revised/) - This week on the CMSCG Blog, we will revisit F884 – Reporting – National Health Safety Network, which is part of the Infection Control regulatory group and is only for use by Federal surveyors. When we initially wrote our Ftag of the Week for F884 in May 2020, providers had until June 2020 to submit - [GAO Releases Report on COVID-19 in Nursing Homes (May 2021)](https://cmscompliancegroup.com/blog/gao-releases-report-on-covid-19-in-nursing-homes-may-2021/) - The Government Accountability Office (GAO) released a new report, “COVID-19 in Nursing Homes – Most Homes Had Multiple Outbreaks and Weeks of Sustained Transmission from May 2020 through January 2021.” The report looks at the average frequency of COVID-19 outbreaks* (including by length) in nursing homes over the same time period, separating the outbreaks either - [CMS Interim Final Rule – COVID-19 Vaccine Immunization Requirements for Residents and Staff](https://cmscompliancegroup.com/blog/cms-issues-interim-final-rule-covid-19-vaccine-immunization-requirements-for-residents-and-staff/) - On May 11, 2021, The Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo, “Interim Final Rule – COVID-19 Vaccine Immunization Requirements for Residents and Staff.” The interim final rule establishes requirements related to educating nursing home staff and residents/ representatives about the COVID-19 vaccine, including benefits and potential side effects of - [Ftag of the Week – F887 COVID-19 Immunization](https://cmscompliancegroup.com/blog/ftag-of-the-week-f887-covid-19-immunization/) - If providers thought that COVID-19-related compliance requirements were dwindling, the newly issued Interim Final Rule – COVID-19 Vaccine Immunization Requirements for Residents and Staff that was released in a May 11, 2021 QSO Memo (Ref: QSO-21-19-NH) shows us otherwise. In our last “Ftag of the Week” post, we started to work through the regulatory requirements - [Reminder - Some SNF COVID Waivers Ending 5/10/2021](https://cmscompliancegroup.com/blog/reminder-some-snf-covid-emergency-waivers-ending-may-10-2021/) - On April 8, 2021, the Centers for Medicare & Medicaid Services (CMS) released a QSO Memo that outlines changes to some of the active blanket waivers in place for the COVID-19 Public Health Emergency (PHE). May is just around the corner, so here's a reminder that several waivers will end on May 10, 2021. Emergency - [Ftag of the Week – F732 Posted Nurse Staffing Information](https://cmscompliancegroup.com/blog/ftag-of-the-week-f732-posted-nurse-staffing-information/) - This week’s Ftag of the Week on the CMSCG Blog is F732 Posted Nurse Staffing Information, which is part of the Nursing Services regulatory group. Facilities are required to post specific information regarding nurse staffing as well as have if available upon request and retain it per regulatory requirements. The nurse staffing data needs to - [CMS Issues Two QSO Memo Revisions for Nursing Homes](https://cmscompliancegroup.com/blog/cms-issues-two-qso-memo-revisions-for-nursing-homes/) - The Centers for Medicare & Medicaid Services (CMS) issued revisions to two QSO Memos today, April 27, 2021. CMS QSO Memo "Interim Final Rule (IFC), CMS-2401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool" (Ref: QSO-20-38-NH) - [CDC Updated Nursing Home Recommendations for Vaccinated Residents](https://cmscompliancegroup.com/blog/cdc-updated-nursing-home-guidance-for-vaccinated-residents/) - The Centers for Disease Control (CDC) released revised guidance for nursing homes related to vaccinated residents. The "Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination" released on April 27, 2021, provides for a loosening of restrictions for fully vaccinated nursing home residents. CMSCG will update this post on what providers need - [Ftag of the Week – F813 Personal Food Policy](https://cmscompliancegroup.com/blog/ftag-of-the-week-f813-personal-food-policy/) - Our next “Ftag of the Week” on the CMSCG Blog is one that facilities may not have had to deal with frequently due to COVID-19 visitation restrictions, F813 Personal Food Policy. The lack of visitors may have contributed a reduced need to think about storing, reheating and discarding personal food items, but now that visitation - [CDC COVID-19 Guidance for Adult Day Service Centers](https://cmscompliancegroup.com/blog/cdc-covid-19-guidance-for-adult-day-service-centers/) - The Centers for Disease Control (CDC) has issued COVID-19 guidance for Adult Day Service Centers. The guidance includes information for administration, staff, volunteers and participants. General information can be found on the CDC COVID-19 Guidance for Older Adults webpage. Additional guidance is available on these pages: Guidance for Adult Day Services Centers - Strategies for - [SOM Appendix Z – Emergency Preparedness (Effective 4/16/2021)](https://cmscompliancegroup.com/blog/som-appendix-z-emergency-preparedness-effective-04162021/) - The updated CMS Manual State Operations Manual Appendix Z – Emergency Preparedness effective April 16, 2021 can be found here. CMS announced the release of the updated Appendix Z in a March 26, 2021 QSO Memo (QSO-21-15-ALL). These changes are applicable to all provider types. - [CMS Survey Resources Folder Updated 4/8/2021 re Ftag Waiver Guide](https://cmscompliancegroup.com/blog/cms-survey-resources-folder-updated-04082021-ftag-waiver-guide/) - As we mentioned last week in our post about the current LTCSP materials, CMS does make updates to its survey documents, particularly the survey resources folder, and once again, there was an update on April 8, 2021. This time, the update only includes the information related to the Ftag Waiver Guide in the Survey Resources - [Current LTCSP Forms & Materials 2/5/2021 – Are You Using the Right Version?](https://cmscompliancegroup.com/blog/current-ltcsp-forms-materials-02052021-are-you-using-the-right-version/) - These materials have been updated as of 6/19/2021, so please be advised that this post has been archived. - Please refer to this CMSCG Blog Post. The Centers for Medicare & Medicaid Services (CMS) makes periodic updates to the Long-Term Care Survey Process materials. The most current version is dated 2/5/2021. Ensure you have the - [CMS Releases Updated Emergency Preparedness Guidance (Appendix Z)](https://cmscompliancegroup.com/blog/cms-releases-updated-emergency-preparedness-guidance-appendix-z/) - The Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo today, March 26, 2021, that includes updated guidance for Emergency Preparedness requirements. Appendix Z of the State Operations Manual (SOM) has been updated throughout, including with expanded information as it relates to Emerging Infectious Diseases as well as additional Interpretive Guidance. View - [New York Provider Alert - Updated Visitation Guidance](https://cmscompliancegroup.com/blog/new-york-provider-alert-updated-visitation-guidance-snf-acf/) - The New York State Department of Health has released updated visitation guidance for nursing homes and adult care facilities. View the guidance here: Revised Adult Care Facility Visitation (3/25/2021)Health Advisory - Revised Skilled Nursing Facility Visitation (3/25/2021)Reopening Guidance for Medical Model Adult Day Health Care Program (3/24/2021) - [Ftag of the Week – F843 Transfer Agreement](https://cmscompliancegroup.com/blog/ftag-of-the-week-f843-transfer-agreement/) - This week’s “Ftag of the Week” on the CMSCG Blog is F843 Transfer Agreement, which is part of the Administration regulatory group. F843 is another one of those regulations that can fall off a provider’s radar, so this week’s post is a reminder to review your transfer agreement(s). Regulatory Requirements Nursing homes must have in - [Nursing Home Visit Infographic Available](https://cmscompliancegroup.com/blog/nursing-home-visit-infographic-available/) - In case you missed them, the Centers for Medicare & Medicaid Services (CMS) posted a Nursing Home Visitation Infographic that provides information on the CMS visitation guidance issued on March 10, 2021. The English version can be downloaded here. A Spanish version is available for download here. - [CMS Updated Nursing Home Visitation Guidance (3/10/2021)](https://cmscompliancegroup.com/blog/cms-updated-nursing-home-visitation-guidance-qso-03102021/) - The Centers for Medicare & Medicaid Services (CMS) released an update to its September 17, 2020 QSO Memo on Nursing Home Visitation. The revised Memo, "Nursing Home Visitation - COVID-19 (REVISED)" (Ref: QSO-20-39-NH), dated March 10, 2021, can be found here. While providers can use this for guidance, it is also important to ensure visitation - [Ftag of the Week – F755 Pharmacy Svcs/Procedures/Pharmacist/Records (Pt 3)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f755-pharmacy-svcs-procedures-pharmacist-records-pt-3/) - Welcome back to the CMSCG Blog and Part 3 of our “Ftag of the Week” series for F755 Pharmacy Services. As you have seen from the prior two posts, this is an expansive regulation that requires tight systems for compliance, as well as a competent, well-trained staff. To begin, let’s look at some additional components - [New York Provider Alert - DOH Visitation Guidance](https://cmscompliancegroup.com/blog/new-york-provider-alert-nysdoh-visitation-guidance-nursing-homes/) - On February 22, 2021, New York State Governor Cuomo announced expanded guidelines for nursing home visitation in New York State skilled nursing facilities. Visitation, in general, can resume on February 26, 2021. NYSDOH released a Health Advisory on February 22, 2021 with the guidelines, "Health Advisory: Revised Skilled Nursing Facility Visitation." This document superersedes and - [Ftag of the Week – F755 Pharmacy Svcs/Procedures/Pharmacist/Records (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f755-pharmacy-svcs-procedures-pharmacist-records-pt1/) - Next up in CMSCG’s “Ftag of the Week” Blog series is F755 - Pharmacy Services, which is part of the regulatory group with the same name. Since there are multiple parts to this regulation, the next few CMSCG Blog posts will dig into the requirements. F755 Pharmacy Services – Regulatory Requirements Overview Per Appendix PP - [Webinar - Food Safety Considerations in the Long-Term Care Setting](https://cmscompliancegroup.com/blog/webinar-food-safety-considerations-in-the-long-term-care-setting/) - Join CMS Compliance Group, Inc. Consultant Kelly Hellberg, MS, RD, CDN for a NYSHFA-NYSCAL webinar on April 6, 2021. Food Safety Considerations in the Long-Term Care Setting Program Date and Time: April 6, 2021 10AM EST-12PM EST Program Overview: Ensuring food safety to avoid negative outcomes in long-term care settingsis a daily challenge for Food - [LTCSP Procedure Guide and LTCSP Resources Updated (2/6/2021)](https://cmscompliancegroup.com/blog/ltcsp-procedure-guide-and-ltcsp-resources-updated-02062021/) - The Centers for Medicare & Medicaid Services (CMS) updated the Long-Term Care Survey Process (LTCSP) Procedure Guide and the associated survey resource files have been updated as well. Per the Revision History log, the updates made to the Procedure Guide are about Complaints and Facility-Reported Incidents (FRIs), but information and guidance that was provided in - [Upcoming OIG Reports Signal Coming Regulatory Priorities](https://cmscompliancegroup.com/blog/upcoming-oig-reports-signal-coming-regulatory-priorities-hha-snf/) - The Office of the Inspector General (OIG) at Health and Human Services (HHS) added a significant number of reports to its active Work Plan in 2020. While some, as expected, relate to Infection Control and COVID-19, the bulk of the reports look at long-standing concerns of regulators – and are areas that providers should be - [CDC Updates SARS-CoV-2 Antigen Testing in Long Term Care Facilities Guidance](https://cmscompliancegroup.com/blog/cdc-updates-sars-cov-2-antigen-testing-in-long-term-care-facilities-guidance-01072021/) - On January 7, 2021, the Centers for Disease Control (CDC) updated the SARS-CoV-2 Antigen Testing in Long Term Care Facilities - Considerations for Use in Nursing Homes and other Long-Term Care Facilities webpage and associated documentation. There is a flowchart available as well. The update is as follows: Revised guidance on when to perform confirmatory - [Changes Coming to Your Five-Star Quality Rating](https://cmscompliancegroup.com/blog/changes-coming-to-your-five-star-quality-rating-2021/) - 2021 has arrived after a long and challenging year for post-acute/ long-term care providers. While the Centers for Medicare & Medicaid Services (CMS) made multiple adjustments to survey and certification activities in 2020, in December the Agency made an important announcement – changes to the Five-Star Quality Rating were coming with the new year. Most - [Ftag of the Week – F697 Pain Management (Pt. 2)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f697-pain-management-pt2/) - In Part 1 of CMSCG’s Ftag of the Week – F697 Pain Management, we discussed how potential issues with pain recognition can be identified by surveyors on interview and observation. We also looked at the importance of evaluations and ongoing assessments for pain recognition. In Part 2, we will continue to explore effective pain management. - [CMS launches web-based tool for 1135 Waiver Requests/ Inquiries](https://cmscompliancegroup.com/blog/cms-launched-web-based-tool-for-1135-waiver-requests-inquiries-2021/) - The Centers for Medicare & Medicaid Services (CMS) announced that a web-based tool is now available for providers where 1135 Waiver requests and inquiries can be submitted. This system is expected to be used for all 1135 waiver requests and/or PHE-related inquiries submitted on or after January 11, 2021. View the January 11, 2021 CMS - [Ftag of the Week – F697 Pain Management (Pt. 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f697-pain-management-pt1/) - This week’s Ftag of the Week on the CMSCG Blog is F697 Pain Management, which is part of the Quality of Care regulatory group. Nursing home providers are required by regulation to ensure that residents who require pain management receive necessary treatment and care in a manner that is consistent with professional standards of practice, - [CMS Updates Surveyor Guidance - 5 New Factors Could Trigger a Focused Infection Control Survey](https://cmscompliancegroup.com/blog/cms-updates-surveyor-guidance-5-new-factors-could-trigger-an-focused-infection-control-survey/) - On January 4, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a revised QSO Memo, “Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes.” The QSO Memo was originally issued on June 1, 2020 and now includes updates to the COVID-19 Survey - [LTCSP Survey Resources Updated 1/4/2021](https://cmscompliancegroup.com/blog/ltcsp-survey-resources-updated-01042021/) - The Centers for Medicare & Medicaid Services (CMS) released updated Long-Term Care Survey Process (LTCSP) materials on January 4, 2021. The new resource materials include: Resuming Long-Term Care (LTC) Standard Recertification Health Surveys; and Emergency Preparedness and Life Safety Code Surveys for all Provider Types – Frequently Asked Questions (FAQ)List of Blanket 1135 Waived FTags - [CMS Posts Nursing Home COVID-19 Testing FAQs (12/7/2020)](https://cmscompliancegroup.com/blog/cms-posts-nursing-home-covid19-testing-faqs-12072020/) - The Centers for Medicare & Medicaid Services (CMS) posted a Frequently Asked Questions document for Nursing Home COVID-19 Testing on December 7, 2020. Topics include: County positivity ratesTesting frequencyOutbreak testingStaff TestingFalse-positive antigen test results View the full FAQ here. - [CDC ACIP Recommendation for Vaccine Prioritization](https://cmscompliancegroup.com/blog/cdc-acip-recommendation-for-vaccine-prioritization/) - Via the Centers for Disease Control Advisory Committee on Immunization Practices (ACIP) webpage: December 1, 2020 Meeting Recommendation ACIP approved the following recommendation by majority (13-1) vote at its December 1, 2020 emergency meeting. When a COVID-19 vaccine is authorized by FDA and recommended by ACIP, vaccination in the initial phase of the COVID-19 vaccination - [Nursing Home Health Inspection Rating & Quality Measure Ratings for NHC to Be Unfrozen](https://cmscompliancegroup.com/blog/nursing-home-health-inspection-rating-quality-measure-ratings-for-nhc-2021/) - The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo on December 4, 2020 which alerts providers to upcoming changes to the Five-Star Quality Rating System and Nursing Home Compare. Due to the COVID-19 Public Health Emergency (PHE), CMS made many changes to the survey process and requirements for providers, including a multitude - [Long-Term Care Survey Process (LTCSP) Updated (Effective 11/21)](https://cmscompliancegroup.com/blog/long-term-care-survey-process-ltcsp-updated-11212020/) - The Centers for Medicare & Medicaid Services has updated the LTCSP materials to incorporate the Focused Infection Control Survey into the survey process. Updated material links are here for your reference: CMS-802 - Updated 11/25/2020 LTCSP Initial Pool Care Areas - Updated 11/25/2020LTCSP Procedure Guide - Updated 11/25/2020LTC Survey Pathways - Updated 11/25/2020Survey Resources - - [CMS Statement re: Holiday Season COVID-19 Guidelines for Nursing Homes (11/18/2020)](https://cmscompliancegroup.com/blog/cms-statement-on-holiday-season-covid-guidelines-for-nursing-homes-press-release/) - Via the CMS.gov Newsroom: FOR IMMEDIATE RELEASENovember 18, 2020 Contact: CMS Media Relations(202) 690-6145 | CMS Urging Nursing Homes to Follow Established COVID Guidelines This Holiday Season Today, in advance of the approaching holiday season, the Centers for Medicare & Medicaid Services (CMS) is urging nursing home staff, residents and visitors to follow established guidelines - [CMS Urges Nursing Homes to Complete Targeted COVID-19 Training](https://cmscompliancegroup.com/blog/cms-urges-nursing-homes-to-complete-targeted-covid-19-training/) - In a November 17, 2020 media release, “CMS Releases Nursing Home COVID-19 Training Data with Urgent Call to Action,” the Centers for Medicare & Medicaid Services (CMS) encouraged nursing home providers to have their staff take the free CMS Targeted COVID-19 Training for Frontline Nursing Home Staff & Management as there is an uptick in - [CMS Releases Toolkit to Help States Strengthen Home and Community-Based Services](https://cmscompliancegroup.com/blog/cms-releases-toolkit-to-help-states-strengthen-home-and-community-based-services-ltss-hcbs/) - The Centers for Medicare & Medicaid Services (CMS) released a toolkit aimed at assisting State Medicaid agencies with developing and expanding the use of Home and Community-Based Services (HCBS) with the intent of reducing the industry’s reliance of institutional-based care. The Long-Term Services and Supports (LTSS) Rebalancing Tool includes examples of what states have done - [Register Now! Survey Tips & Trends 2020 Webinar](https://cmscompliancegroup.com/blog/survey-trends-tips-2020-webinar-linda-elizaitis/) - Join NYSHFA | NYSCAL on Thursday, December 3rd for the Survey Tips & Trends 2020 Webinar. The program is being presented by Linda Elizaitis, RN, BS, RAC-CT, CDS, President of CMS Compliance Group, Inc. In a year that has been predominantly focused on Infection Prevention & Control, it behooves providers to look beyond this regulatory hotspot - [11/4/2020 CDC Update - Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic](https://cmscompliancegroup.com/blog/11-4-2020-cdc-update-interim-infection-prevention-and-control-recommendations-for-healthcare-personnel-during-the-coronavirus-disease-2019-pandemic/) - On November 4, 2020, the Centers for Disease Control (CDC) updated its Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. The webpage lists the following summary of changes to the prior CDC guidance: Provided different options for screening individuals (healthcare personnel, patients, visitors) prior to their entry - [October 2020 Update - CMS Five-Star Quality Measure System Technical Users’ Guide](https://cmscompliancegroup.com/blog/october-2020-update-cms-five-star-quality-measure-system-technical-users-guide/) - The Centers for Medicare & Medicaid Services (CMS) recently released the October 2020 version of the Five-Star Quality Measure System Technical Users’ Guide. It includes several revisions and updates for the Staffing, Quality Measure and Health Inspection ratings, including: Staffing Rating CMS completed its October 2020 Nursing Home Compare data refresh on October 28, 2020. Providers - [OIG to Review State Survey Agency Nursing Home Oversight during COVID-19](https://cmscompliancegroup.com/blog/oig-to-review-state-survey-agency-nursing-home-oversight-during-covid-19/) - The Office of the Inspector General (OIG) has added a new item to its Work Plan. OIG plans to review the extent to which State Survey Agencies (SSAs) and the Centers for Medicare & Medicaid Services (CMS) have conducted on-site surveys during the COVID-19 pandemic. As you know, CMS suspected standard survey activity for a - [CMS Guidance to Surveyors re EPP Testing Exercise Requirements and COVID-19](https://cmscompliancegroup.com/blog/cms-guidance-to-surveyors-re-epp-testing-exercise-requirements-and-covid-19/) - On September 28, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo, “Guidance related to the Emergency Preparedness Testing Exercise Requirements- Coronavirus Disease 2019 (COVID-19). The Memo reiterates the requirements for providers to conduct specific testing exercises to validate their Emergency Preparedness Plans (EPPs), but also notes that there is a - [CMS Reminds Providers of Residents’ Right to Vote Requirement](https://cmscompliancegroup.com/blog/cms-reminds-providers-of-residents-right-to-vote-requirement/) - In an October 5, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) reminded long-term care providers that they are responsible for ensuring their residents are able to exercise their Constitutional right to vote, despite the on-going COVID-19 Public Health Emergency (PHE). Citing several regulations, CMS noted that facilities are expected to have - [CMS Releases Updated Nursing Home Visitation QSO Memo](https://cmscompliancegroup.com/blog/cms-releases-updated-nursing-home-visitation-qso-memo/) - On September 17, 2020, the Centers for Medicare & Medicaid Services (CMS) released a new QSO memo, “Nursing Home Visitation – COVID-19.” The purpose of the document is to provide “reasonable” ways for nursing homes to facilitate in-person visitation at nursing homes in a safe manner that will also address the psychosocial needs of their - [SNF Healthcare-Associated Infections (HAI) Measure Call for Public Comment](https://cmscompliancegroup.com/blog/snf-healthcare-associated-infections-hai-measure-call-for-public-comment/) - Via a CMS Post-Acute Care Quality Reporting Programs email: Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Measure Call for Public Comment The Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is seeking input from the public as part of the measure development process. CMS has posted Draft Measure - [OIG to Review Accuracy of Nursing Home Compare Data](https://cmscompliancegroup.com/blog/oig-to-review-accuracy-of-nursing-home-compare-data/) - The Office of the Inspector General (OIG) added new items to its Work Plan in August, one of which is “Accuracy of Nursing Home Compare Website’s Reported Health, Fire Safety and Emergency Preparedness Deficiencies.” The report, expected in FY 2021, will provide a review of the data included on Nursing Home Compare to determine whether - [NHC Five-Star State-Level Cut Point Table Updated (August 2020)](https://cmscompliancegroup.com/blog/nhc-five-star-state-level-cut-point-table-updated-august-2020/) - The Centers for Medicare & Medicaid Services (CMS) updated the Nursing Home Compare Five-Star Quality Rating System Technical Users' Guide State-Level Health Inspection Cut Point Table. The August 2020 document is available for download here. - [List of Revised F-tags Released (8/31/2020)](https://cmscompliancegroup.com/blog/list-of-revised-f-tags-released-83102020/) - The list of Ftags, including the new F886 COVID-19 Testing Residents & Staff, has been updated by CMS and is available for download here. - [CMS Resumes Nursing Home Survey & Certification Activities](https://cmscompliancegroup.com/blog/cms-resumes-nursing-home-survey-and-certification-activities/) - On August 17, 2020, the Centers for Medicare & Medicaid Services (CMS) made an announcement regarding the Agency’s plan to resume routine inspections for all providers, including nursing homes, and issued updated enforcement guidance. Highlights of the press announcement include: Resumption of onsite revisit surveysResumption of non-Immediate Jeopardy Complaint SurveysResumption of annual recertification surveys Resumption - [Special Focus Facility List updated for first time since February 2020](https://cmscompliancegroup.com/blog/special-focus-facility-list-updated-for-first-time-since-february-2020/) - On July 29, 2020, The Centers for Medicare & Medicaid Services (CMS) updated the Special Focus Facility (SFF) List for the first time since the February 2020 update. With the COVID-19 pandemic underway after that, CMS had limited its scope of survey activity to ensure targeted infection control surveys were completed at every facility in - [Home Health QRP COVID-19 PHE Tip Sheet](https://cmscompliancegroup.com/blog/home-health-qrp-covid19-phe-tip-sheet/) - The Centers for Medicare & Medicaid Services (CMS) released a Home Health Quality Reporting Program COVID-19 Public Health Emergency Tip Sheet. Per a Home Health QRP email update: The Home Health COVID-19 PHE Tip Sheet is now available. This tip sheet is designed to assist Home Health providers in understanding the status of the Home - [SNF QRP COVID-19 PHE Tip Sheet](https://cmscompliancegroup.com/blog/snf-qrp-covid19-phe-tip-sheet/) - The Centers for Medicare & Medicaid Services (CMS) issued a Skilled Nursing Facility Quality Reporting Program (SNF QRP) COVID-19 Public Health Emergency (PHE) Tip Sheet. Per a CMS Post-Acute Care Quality Reporting Programs update: SNF QRP COVID-19 PHE Tip Sheet is Available - The SNF COVID-19 PHE Tip Sheet is now available. This tip sheet - [COVID-19 Resources for Healthcare Providers (Updated 7/24/2020)](https://cmscompliancegroup.com/blog/covid-19-resources-for-healthcare-providers-updated-07242020/) - Much information is being shared regarding COVID-19 Guidance for healthcare providers, so we are compiling a list of available information for your reference. CDC: Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Situation Summary CDC Print Resources (includes informational posters/handouts that can be used for awareness and prevention)CDC Coronavirus Disease 2019 (COVID-19) - [Nursing Home Point-of-Care Tests – What to Know](https://cmscompliancegroup.com/blog/nursing-home-point-of-care-tests-what-to-know/) - The Department of Health and Human Services (HSS) announced on July 14, 2020 a new initiative that would provide more testing availability to nursing homes. In a press release, “Trump Administration Announces Initiative for More and Faster COVID-19 Testing in Nursing Homes,” HHS announced the large-scale procurement of FDA-authorized rapid tests to be distributed to - [Double-Check Your Nursing Home COVID-19 Reporting Data](https://cmscompliancegroup.com/blog/double-check-your-nursing-home-covid-19-reporting-data/) - In looking through the Nursing Home COVID-19 Reporting Data Public Use Files, the CMSCG team has noticed that for the past several weeks, while compliance with reporting is generally in good shape nationally, there are between 500-550 providers each week that have submitted data but did not pass the Quality Assurance check that is being - [CMS Reminds Nursing Homes about Resident Communication Assistance](https://cmscompliancegroup.com/blog/cms-reminds-nursing-homes-about-resident-communication-assistance/) - The Centers for Medicare & Medicaid Services (CMS) revised its April 24, 2020 QSO guidance on July 9, 2020 to remind nursing home providers of their obligation to providing residents with access to the long-term care ombudsman and facilitating communication with residents and their family/friends that complies with federal disability rights laws. Specifically: Facilities are - [Updates Coming to Nursing Home Compare & Five Star Quality Rating System](https://cmscompliancegroup.com/blog/updates-coming-to-nursing-home-compare-five-star-quality-rating-system/) - In a June 25, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) made multiple announcements regarding Nursing Home Compare and the end to emergency blanket waivers that were enacted as part of the COVID-19 Public Health Emergency (PHE). First, let’s look at the changes related to the Payroll-Based Journal (PBJ) and staffing - [CMS Clarifies Nursing Home Reopening Recommendations with FAQs](https://cmscompliancegroup.com/blog/cms-clarifies-nursing-home-reopening-recommendations-with-faqs/) - The Centers for Medicare & Medicaid Services (CMS) issued Frequently Asked Questions (FAQs) on Nursing Home Visitation on June 23, 2020. The FAQs provide clarification to many common provider questions since CMS published its reopening nursing home recommendations on May 18, 2020. Here are some of the key points to be aware of. Factors to - [CDC Updates Coronavirus Symptom List](https://cmscompliancegroup.com/blog/cdc-updates-coronavirus-symptom-list/) - The Centers for Disease Control (CDC) recently updated its list of Symptoms of Coronavirus, with a prior update to include additional respiratory symptoms having occurred in late April. The CDC symptoms webpage now includes (but is not limited to) the following symptoms: Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of - [COVID-19 Nursing Home Data Refreshed](https://cmscompliancegroup.com/blog/covid-19-nursing-home-data-refreshed-wkend06072020/) - The Centers for Medicare & Medicaid Service (CMS) has updated the COVID-19 Nursing Home Data for the week-ending June 7, 2020. View the data here. - [COVID-19 Resources for Healthcare Providers (Updated 6/18/2020)](https://cmscompliancegroup.com/blog/covid-19-resources-for-healthcare-providers-updated-06172020/) - Much information is being shared regarding COVID-19 Guidance for healthcare providers, so we are compiling a list of available information for your reference. CDC: Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Situation Summary CDC Print Resources (includes informational posters/handouts that can be used for awareness and prevention)CDC Coronavirus Disease 2019 (COVID-19) - [OIG Adds Even More Nursing Home Reports to Work Plan](https://cmscompliancegroup.com/blog/oig-adds-even-more-nursing-home-reports-to-work-plan/) - The Office of the Inspector General (OIG) added three nursing home-related items to its Work Plan in May, and now it has added additional items for June. The May items were related to Infection Control and oversight in nursing homes during the COVID-19 pandemic, as well as prevalence of psychotropic drug use. The two new - [CMS Alert re: Nursing Home Residents' Stimulus Checks](https://cmscompliancegroup.com/blog/cms-alert-nursing-home-residents-stimulus-checks/) - The Centers for Medicare & Medicaid Services (CMS) issued a News Alert on June 11, 2020 regarding nursing home residents' rights to retain their Federal Economic Incentive Payments (aka "Stimulus Checks). CMS notes that there have been allegations that nursing homes have been seizing their residents' stimulus checks and although the Agency has not received - [CMS issues 2 new QSO Memos on Inspection & COVID-19 Data](https://cmscompliancegroup.com/blog/cms-issues-2-new-qso-memos-on-inspection-covid-19-data/) - The Centers for Medicare & Medicaid Services (CMS) released a QSO Memo on June 4, 2020, “Posting of Nursing Home Inspections,” that provides information on the health inspection data that CMS made publicly available today. The survey information that was published is not being calculated into nursing homes’ health inspection star ratings, as was the - [COVID-19 Nursing Home Data Published](https://cmscompliancegroup.com/blog/covid-19-nursing-home-data-published/) - As promised, the Centers for Medicare & Medicaid Services released Nursing Home COVID-19 data based on CDC NHSN reporting. Submitted data for the week ending 5/31/2020 can be viewed here. CMS cautions that this data may change and fluctuate as providers become more used to submitting data. - [CMS Leaning on Nursing Homes – and Surveyors – to Improve Infection Control Compliance (Pt. 2)](https://cmscompliancegroup.com/blog/cms-leaning-on-nursing-homes-and-surveyors-to-improve-infection-control-compliance-pt2/) - In Part 1 of our post about the new actions the Centers for Medicare & Medicaid Services (CMS) will be taking to improve infection control compliance, we discussed some of the initial data findings from the new CDC mandatory reporting. We also explained how CMS has “encouraged” State Agencies to get their Focused Infection Control - [CMS Leaning on Nursing Homes – and Surveyors – to Improve Infection Control Compliance (Pt. 1)](https://cmscompliancegroup.com/blog/cms-leaning-on-nursing-homes-and-surveyors-to-improve-infection-control-compliance-pt1/) - On June 1, 2020, The Centers for Medicare & Medicaid Services (CMS) released a media announcement, “Trump Administration Unveils Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results,” with an accompanying QSO Memo and overview of what early results of the new infection surveillance reporting requirement has shown. What the Initial Data - [CDC Considerations for Preventing COVID-19 in Assisted Living Facilities](https://cmscompliancegroup.com/blog/cdc-considerations-for-preventing-covid-19-assisted-living-facilities/) - The Centers for Disease Control (CDC) updated its webpage, “Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities” on May 29, 2020 and is now encouraging assisted living providers to participate in weekly reporting to the National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) COVID-19 module. Assisted living facilities, the CDC notes, are - [Phase 3 of Reopening Nursing Homes – How? When?](https://cmscompliancegroup.com/blog/phase-3-of-reopening-nursing-homes-how-when/) - The Centers for Medicare & Medicaid Services (CMS) released recommendations for how to safely reopen nursing homes in the US in a May 18, 2020 QSO Memo (Ref: QSO-20-30-NH). Nursing homes, as it has been widely covered in the media, are not really allowed to “fully” reopen until Phase 3 of Opening Up America Again. - [Payroll-Based Journal FAQ (April 2020)](https://cmscompliancegroup.com/blog/payroll-based-journal-faq-april-2020/) - The Centers for Medicare & Medicaid Services (CMS) added a Payroll-Based Journal Frequently Asked Questions (FAQ) to the PBJ webpage on May 28, 2020. View the FAQ here. - [OIG Adds Additional Nursing Home Items to Work Plan](https://cmscompliancegroup.com/blog/oig-adds-additional-nursing-home-items-to-work-plan/) - The Office of the Inspector General (OIG) added additional nursing home-related items to its May Work Plan. Not surprisingly, both reports will focus on infection control. The first report, “Audit of Nursing Home Infection Prevention and Control Program Deficiencies,” is expected to be issued this fiscal year. The Work Plan notes that as of February - [Reopening Nursing Homes – Phase 2 – What’s Recommended?](https://cmscompliancegroup.com/blog/reopening-nursing-homes-phase-2-whats-recommended/) - On May 18, 2020, The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo that provided recommendations on reopening nursing homes. Phase 2 of Reopening Nursing Homes and Opening Up America Again requires multiple criteria to be met before implementation. These include: Case status in the community has met the criteria for starting - [No Surprise – GAO Finds Infection Control Deficiencies Widespread Prior to COVID-19](https://cmscompliancegroup.com/blog/no-surprise-gao-finds-infection-control-deficiencies-widespread-prior-to-covid19/) - In a report issued May 20, 2020, The Government Accountability Office (GAO) found that infection control deficiencies in nursing homes were “widespread and persistent” prior to COVID-19. However, since the report is from the GAO, it emphasizes what The Centers for Medicare & Medicaid Services (CMS) and State Agencies did – and didn’t – do - [Reopening Nursing Homes – Phase 1 - How Does It Begin?](https://cmscompliancegroup.com/blog/reopening-nursing-homes-phase-1-how-does-it-begin/) - On May 18, 2020, The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo, “Nursing Home Reopening Recommendations for State and Local Officials.” These recommendations include a list of factors and considerations for making decisions on when it is safe to reopen nursing homes as part of the larger US “Opening Up America - [CMS issues Nursing Home Reopening Recommendations](https://cmscompliancegroup.com/blog/cms-issues-nursing-home-reopening-recommendations/) - The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo on May 18, 2020, “Nursing Home Reopening Recommendations for State and Local Officials.” Much like the title of the Memo implies, CMS has provided recommendations in this document to assist state and local officials with determining the level of mitigation required to prevent - [Psychotropic Drug Use in Nursing Homes Getting Another Look](https://cmscompliancegroup.com/blog/psychotropic-drug-use-in-nursing-homes-getting-another-look/) - The Office of the Inspector General (OIG) updated its Work Plan in May 2020. One of the items added is a new report expected to be issued in FY 2021, “Monitoring Psychotropic Drug Use in Nursing Homes.” Despite the significant improvements by nursing homes, as evidenced by the continued achievements cited by the National Partnership - [MDS 3.0 Item Sets v1.17.2 and Techincal Specs Updated](https://cmscompliancegroup.com/blog/mds-item-sets-and-techincal-specs-updated-may-2020/) - Via a CMS Post-Acute Care Quality Reporting Program update: "In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, - [COVID-19 Resources for Healthcare Providers (Updated 6/1/2020)](https://cmscompliancegroup.com/blog/covid-19-resources-for-healthcare-providers-051520-update/) - Much information is being shared regarding COVID-19 Guidance for healthcare providers, so we are compiling a list of available information for your reference. Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Situation Summary (this page is expected to be updated routinely by the CDC)CMS.gov Current Emergencies Website - includes all memos, press - [CMS COVID-19 "Best Practices" Toolkit for Nursing Homes](https://cmscompliancegroup.com/blog/cms-covid19-best-practices-toolkit-for-nursing-homes/) - The Centers for Medicare & Medicaid Services (CMS) released a nursing homes best practices toolkit for combating COVID-19 on May 13, 2020. Per the associated press release: "The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare - [COVID-19 Focused Survey Updated to Include Reporting Requirements](https://cmscompliancegroup.com/blog/covid-19-focused-survey-updated-to-include-reporting-requirements/) - In a May 6, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) announced that it has updated the COVID-19 Focused Survey for Nursing Homes. The updated materials include the following changes: Entrance Conference Worksheet #9 - Updated to include list of staff responsible for notifying all residents, representatives and families of confirmed - [CMS Interim Final Rule Published in Federal Register](https://cmscompliancegroup.com/blog/cms-interim-file-rule-published-05082020-in-federal-register/) - The lengthy-titled CMS Interim Final Rule with Comment Period, "Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program" was published in the Federal Register today, May 8, 2020, - [CMS Updates Blanket Waivers for Nursing Homes](https://cmscompliancegroup.com/blog/cms-updates-blanket-waivers-for-nursing-homes/) - On April 29, 2020, the Centers for Medicare & Medicaid Services (CMS) updated its list of blanket waivers for the COVID-19 Public Health Emergency (PHE). There are several new waivers that have been added since the last update on April 21, 2020. Quality Assurance and Performance Improvement (QAPI) Waiver It seems like Phase 3 of - [GAO Recommendations to HHS will Enhance Abuse Reporting & Data](https://cmscompliancegroup.com/blog/gao-recommendations-to-hhs-will-enhance-abuse-reporting-data/) - The Government Accountability Office (GAO) issued its list of priority open recommendations for the Department of Health and Human Services (HHS) on April 23, 2020. The document includes ten areas with 55 priority recommendations. One section of particular importance is the public health-related programs and issues section. Two areas covered in the document relate to - [CARES Act Funding to Boost Nursing Home Survey Efforts](https://cmscompliancegroup.com/blog/cares-act-funding-to-boost-nursing-home-survey-efforts/) - On April 30, 2020, The Centers for Medicare & Medicaid Services (CMS) announced that approximately $81 million in CARES Act funding would be provided to State Agencies through September 20, 2023. This funding is to be used for: Completing Focused Infection Control Surveys in nursing homes through July 2020Increasing the number of Complaint surveys based - [CMS Interim Final Rule for Nursing Home COVID-19 Reporting](https://cmscompliancegroup.com/blog/cms-interim-final-rule-nursing-home-covid-19-reporting/) - On Friday, May 1, 2020, The Centers for Medicare & Medicaid Services (CMS) issued an Interim Final rule, “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” that - [ISDA Recommendations – Infection Prevention in Patients with Suspected/Known COVID-19](https://cmscompliancegroup.com/blog/isda-recommendations-infection-prevention-patients-with-suspected-known-covid19/) - The Infectious Diseases Society of America (ISDA) released a set of eight recommendations on April 27, 2020 as part of its Guidelines on Infection Prevention in Patients with Suspected or Known COVID-19. The recommendations cover the following areas: N95 Masks and Respirators (Routine Patient Care)ISDA recommends in conventional settings that healthcare staff caring for patients - [CDC Updates Coronavirus Symptoms List](https://cmscompliancegroup.com/blog/cdc-updates-coronavirus-symptoms-list/) - Earlier this week, the Centers for Disease Control (CDC) updated its list of Coronavirus symptoms. While noting that individuals with COVID-19 may have a wide range of symptoms based on what has been reported, these are the signs and symptoms to look for: CoughShortness of breath or difficulty breathing Or at least 2 of the - [Coronavirus Safety & Quality Commission for Nursing Homes Announced](https://cmscompliancegroup.com/blog/coronavirus-safety-quality-commission-for-nursing-homes-announced/) - Via a WhiteHouse.gov - Fact Sheet: "President Donald J. Trump Remains Committed to Caring for Our Nation’s Seniors During the Coronavirus Pandemic and Beyond" This Fact Sheet outlines multiple initiatives the Trump Administration is undertaking. A few to note: The new rule requiring information about COVID-19 cases in nursing homes to be reported directly to - [CMS Publishes List of Nursing Home Staffing Levels](https://cmscompliancegroup.com/blog/cms-publishes-list-of-nursing-home-staffing-levels/) - In an April 24, 2020 QSO Memo, “Nursing Home Five-Star Quality Rating System Updates, Nursing Home Staff Counts, and Frequently Asked Questions,” the Centers for Medicare & Medicaid Services announced that it is using Payroll-Based Journal (PBJ) data to support the Agency’s response to the COVID-19 pandemic. CMS released a file that includes the average - [CMS Announces Temporary Freeze to Five-Star Quality Rating Domain](https://cmscompliancegroup.com/blog/cms-announces-temporary-freeze-to-five-star-quality-rating-domain/) - In a new QSO Memo dated April 24, 2020, the Centers for Medicare & Medicaid Services (CMS) announced a temporary freeze to the Five-Star Quality Rating Health Inspection Domain. The decision to hold the survey data constant was based on the Agency’s earlier guidance regarding the suspension of certain survey activities (3/4/2020 Ref: QSO-20-12-ALL) and - [CMS Updating Requirements for Nursing Home Infection Surveillance & Reporting](https://cmscompliancegroup.com/blog/cms-updating-requirements-for-nursing-home-infection-surveillance-reporting-covid19/) - The Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo on Sunday, April 19, 2020, “Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons Under Investigation) Among Residents and Staff in Nursing Homes.” The QSO Memo outlines reporting requirements for nursing homes to provide data directly to the Centers for Disease Control - [Infection Prevention & Control - Beyond COVID-19](https://cmscompliancegroup.com/blog/infection-prevention-control-beyond-covid-19/) - From the Desk of Linda Elizaitis, President, CMS Compliance Group, Inc. Life in our nursing homes with COVID-19 at or in our door is no fun! The onslaught of COVID-19 will slow and eventually end, and we are all going to have improved infection control practices due to these tough times. We, as an industry, - [CMS QSO Memo – COVID-19 Long-Term Care Facility Transfers](https://cmscompliancegroup.com/blog/cms-qso-memo-covid-19-long-term-care-facility-transfers/) - The Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo on April 13, 2020, “2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios” which includes information related to transfer and discharge of residents between facilities for the purposes of cohorting residents based on COVID-19 status. The supplemental information provided includes information related - [CMS Key Recommendations to Nursing Homes (4/2/2020)](https://cmscompliancegroup.com/blog/cms-key-recommendations-to-long-term-care-facilities-04022020/) - Via CMS.gov - April 2, 2020 Press Release: "Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments": "The recommendations announced today include: Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control. As nursing homes are a critical part of the healthcare system, - [Coronavirus Waivers & Flexibilities - LTC/HHA/Hospice](https://cmscompliancegroup.com/blog/coronavirus-waivers-flexibilities-ltc-hha-hospice/) - The Centers for Medicare & Medicaid Services (CMS) has a list of waivers and flexiblities for healthcare providers that can be found here. It includes information on blanket waivers, but also has provider-specific fact sheets, including for Long-Term Care Facilities, Home Health Agencies, Hospices and others. There is also a list of state-specific Coronavirus 1135 - [COVID-19 Focused Survey Entrance Conference Worksheet & Materials](https://cmscompliancegroup.com/blog/covid-19-focused-survey-entrance-conference-worksheet-materials/) - Please be advised that as part of the Centers for Medicare & Medicaid Services (CMS) Infection Control Focused Survey process, updated surveyor resources have been published. There is a different Entrance Conference Worksheet that will be used for the focused surveys. The Entrance Conference Worksheet for the COVID-19 Survey now requests the following information, and - [CMS Prioritizing Certain Survey Types for 3 weeks](https://cmscompliancegroup.com/blog/cms-prioritizing-certain-survey-types-snf-hha/) - In a press release issued March 23, 2020, “CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19,” The Centers for Medicare & Medicaid Services (CMS) announced its findings from its inspection of the Kirkland, Washington nursing home where the first COVID-19 outbreak in the country - [Skilled Nursing, Home Health & Hospice QRPs](https://cmscompliancegroup.com/blog/skilled-nursing-home-health-hospice-quality-reporting/) - The Centers for Medicare & Medicaid Services (CMS) announced exceptions/extensions for upcoming quality measure reporting and data submission deadlines for many CMS programs, including: Skilled Nursing Facility Quality Reporting ProgramSkilled Nursing Facility Value-Based Purchasing ProgramHome Health Quality Reporting Program Hospice Quality Reporting Program Per the email update from CMS, the 2019 QPP Data Submission Guide - [Ftags of the Week – Infection Control Ftags Recap (F880, F881, F882 and F883)](https://cmscompliancegroup.com/blog/ftags-of-the-week-infection-control-ftags-recap-f880-f881-f882-f883/) - While we have not repeated any Ftags of the Week on the CMSCG Blog since there are so many regulations to go through, we are breaking the trend this week given the shift in Infection Control emphasis by the regulators. Here are the CMSCG Ftags of the Week for the entire Infection Control regulatory group: - [CMS Issues New Guidance for Infection Control & COVID-19 Prevention](https://cmscompliancegroup.com/blog/cms-issues-new-guidance-for-infection-control-covid-19-prevention/) - Yesterday, the Centers for Medicare & Medicaid Services (CMS) issued several QSO Memos in conjunction with several updates from its website that coincided with an update provided by Vice President Pence and his Task Force members. CMS issued an initial QSO Memo on February 6, 2020, “Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness - [CMS Issues New Nursing Home Survey QSO Memo](https://cmscompliancegroup.com/blog/cms-issues-new-nursing-home-survey-qso-memo/) - Yesterday afternoon, the Centers for Medicare & Medicaid Services (CMS) made several announcements about the Agency’s shift in focus to Infection Control in healthcare facilities due to concerns over COVID-19. In this CMSCG Blog, we will look at the QSO Memo related to surveys. Surveys In a March 4, 2020 CMS QSO Memo, “Suspension of - [COVID-19 Resources for Healthcare Providers (Updated 5/8/2020)](https://cmscompliancegroup.com/blog/covid-19-resources-for-healthcare-providers/) - Much information is being shared regarding COVID-19 Guidance for healthcare providers, so we are compiling a list of available information for your reference. Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Situation Summary (this page is expected to be updated routinely by the CDC)CMS.gov Current Emergencies Website - includes all memos, press - [Ftag of the Week – F838 Facility Assessment (Pt 1)](https://cmscompliancegroup.com/blog/ftag-of-the-week-f838-facility-assessment-pt1/) - This week’s Ftag of the Week is F838 Facility Assessment, which is part of the Administration regulatory group. The Facility Assessment requirement has been in effect for long enough that most facilities have a document put together, but now it may be time for a review or enhancement based on changes made for Phase 3 - [QSO Memo re: Coronavirus with CDC information released](https://cmscompliancegroup.com/blog/qso-memo-coronavirus-with-cdc-information-released-for-all-providers/) - The Centers for Medicare & Medicaid Services (CMS) issued a new QSO Memo on February 6, 2020, "Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV)" (Ref: QSO 20-09-ALL). The memo includes information from the Centers for Disease Control and Prevention (CDC) on the 2019 Novel Coronavirus, which CMS recommends healthcare providers review. CMS - [SNF QRP Table Update for FY 2022 SNF QRP APU available](https://cmscompliancegroup.com/blog/snf-qrp-table-update-fy-2022-snf-qrp-apu-available/) - Via the CMS.gov Skilled Nursing Facility (SNF) Quality Reporting Program Measures and Technical Information webpage: "January 30, 2020: The SNF QRP Table for Reporting Assessment-Based Measures and SPADEs for the FY 2022 SNF QRP APU is now available in the Downloads section below. This table indicates the MDS data elements CMS will use for FY 2022 - [CMS releases Draft MDS 3.0 Item Set Change History for October 2020](https://cmscompliancegroup.com/blog/cms-releases-draft-mds-item-set-change-history-for-october-2020/) - Via CMS.gov - January 23, 2020 update: New DRAFT version of the MDS 3.0 Item Set Change History for October 2020 A new DRAFT version of the MDS 3.0 Item Set Change History for October 2020 (v1.18.0) was posted. This document reflects the changes in the DRAFT version of the 2020 MDS item sets (v1.18.0) - [Join Linda Elizaitis at the ACHCA NY Chapter 51st Annual Convention](https://cmscompliancegroup.com/blog/linda-elizaitis-achca-ny-chapter-convention-presentation/) - CMS Compliance Group President Linda Elizaitis, RN, BS, RAC-CT, CDS will be presenting at the American College of Healthcare Administrator's New York Chapter's 51st Annual Convention on Monday, March 16, 2020. Session: What to Expect on Your Next Survey Date/Time: March 16, 2020 10:45AM-12PMPM Overview: The presenter will review the most frequently cited health deficiencies - [2020 National Survey Update Webinar 3/18/2020](https://cmscompliancegroup.com/blog/2020-national-survey-update-webinar-linda-elizaitis/) - Please join CMS Compliance Group, Inc. President Linda Elizaitis for a Pharmscript webinar on March 18, 2020, "2020 National Survey Update." Details: Date/Time: March 18, 2020 10:30AM EST - 11:20AM EST 1 CEU credit available for Nursing Home Administrators and Nurses. Register here: https://register.gotowebinar.com/register/1561169476852012813 March 2020 - Webinar - National Survey UpdateDownload - [DRAFT version of the 2020 MDS item sets v1.18.0](https://cmscompliancegroup.com/blog/draft-version-of-the-2020-mds-item-sets-v1-18/) - Via CMS.gov: A new DRAFT version of the 2020 MDS item sets (v1.18.0) was posted. This version is scheduled to become effective October 1, 2020. Please note that Section G has been removed from all Federal item sets. The files are located in the Downloads section of the MDS 3.0 Technical Information webpage: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html The - [Ftag of the Week – F840 Use of Outside Resources](https://cmscompliancegroup.com/blog/ftag-of-the-week-f840-use-of-outside-resources/) - We anticipated that for this Ftag of the Week and those in the near future that we would be trying to read through a tremendous amount of new Interpretive Guidance related to the newly effective Phase 3 Ftags. However, as you are aware, the Centers for Medicare & Medicaid Services (CMS) announced last week that - [CMS: Phase 3 RoPs Effective 11/28/19 – Expect Interpretive Guidance Q2 2020](https://cmscompliancegroup.com/blog/cms-phase-3-rops-effective-112819-expect-interpretive-guidance-q2-2020/) - The Centers for Medicare and Medicaid Services issued a new QSO Memo on November 22, 2019, “Updates and Initiatives to Ensure Quality and Safety in Nursing Homes.” The Memo states: Phase 3 of the Requirements of Participation are still effective on November 28, 2019. Providers are expected to be in compliance with all regulations.Updated Interpretive - [SNF QRP Data Submission Deadline Extended](https://cmscompliancegroup.com/blog/snf-qrp-data-submission-deadline-extended/) - Via the CMS SNF QPR webpage: October 31, 2019 Data Submission Deadline Extended The submission deadline for the Skilled Nursing (SNF) Facility Quality Reporting Program (QRP) MDS assessment data submitted for April 1 – June 30 (Q2) of calendar year (CY) 2019 has been extended to November 18, 2019. All data must be submitted no - [October 2019 Changes to Nursing Home Compare and Five Star Rating](https://cmscompliancegroup.com/blog/october-2019-changes-to-nursing-home-compare-and-five-star-rating/) - The Centers for Medicare and Medicaid Services (CMS) issued two QSO memos on Monday, October 7, 2019. The second QSO memo, “Updates to Nursing Home Compare website and the Five Star Quality Rating System,” is not receiving as much attention as the first, which addresses consumer alerts on Nursing Home Compare for facilities that have - [Facilities will be flagged for abuse and neglect on Nursing Home Compare](https://cmscompliancegroup.com/blog/facilities-will-be-flagged-for-abuse-and-neglect-on-nursing-home-compare/) - The Centers for Medicare & Medicaid Services (CMS) issued two new QSO memos on Monday, October 7, 2019. The first memo, “Consumer Alerts added to the Nursing Home Compare website and the Five Star Quality Rating System,” states that CMS will be adding an “abuse indicator” to Nursing Home Compare starting October 23, 2019. The - [Updated PDPM Grouper Package (10/7/19) released](https://cmscompliancegroup.com/blog/updated-pdpm-grouper-package-10719/) - Via the CMS.gov MDS 3.0 webpage: October 7, 2019 A revision to the PDPM DLL Package (V1.0003 FINAL) was posted, and the previous version (V1.0002 FINAL) was removed. This version corrects four bugs that were identified after the V1.0002 release. The package contains updated test files and documentation. You can find the updated file in - [MDS 3.0 RAI Manual v1.17.1 effective October 1, 2019 available](https://cmscompliancegroup.com/blog/mds-rai-manual-effective-october-1-2019-available/) - Via the CMS.gov MDS 3.0 RAI Manual webpage: September 18, 2019 MDS 3.0 RAI Manual This page contains the MDS 3.0 RAI Manual v1.17.1 and MDS forms, effective October 1, 2019. This version of the MDS 3.0 RAI Manual incorporates clarifications to existing coding and transmission policy; it also addresses clarifications and scenarios concerning complex - [CMS Blog (8/28/19) - Ensuring Safety and Quality In Nursing Homes](https://cmscompliancegroup.com/blog/cms-blog-082819-ensuring-safety-and-quality-in-nursing-homes/) - In case you missed this August 28, 2019 blog post from the Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma's "deep dive" into the Agency's Five-Part Strategy for ensuring safety and quality in nursing homes, you can view it on the CMS blog here. At the beginning of August, Administrator Verma participated in - [Ftags of the Week – F923 Ventilation and F924 Corridor Handrails](https://cmscompliancegroup.com/blog/ftags-of-the-week-f923-ventilation-f924-corridor-handrails/) - This week on the CMSCG Blog, we are reviewing two more Ftags that are part of the Physical Environment regulatory group, F923 Ventilation and F924 Corridors Have Firmly Secured Handrails. F923 Ventilation This regulation requires that facilities “have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two.” A - [CMS Revises Immediate Jeopardy Guidance for Surveyors (July 2019)](https://cmscompliancegroup.com/blog/cms-revises-immediate-jeopardy-guidance-for-surveyors-july-2019/) - The Centers for Medicare & Medicaid Services (CMS) issued an updated QSO memo, “Revisions to Appendix Q, Guidance on Immediate Jeopardy” on July 31, 2019. The original QSO memo, dated March 5, 2019, has been revised to include guidance to surveyors related to referring criminal acts to law enforcement. In a “CMS: Beyond the Policy” - [Seema Verma Hints that Nursing Home Survey Timeframes May Change](https://cmscompliancegroup.com/blog/seema-verma-hints-that-nursing-home-survey-timeframes-may-change/) - In a new “CMS: Beyond the Policy” podcast, CMS Administrator Seema Verma and Dr. Kate Goodrich, CMS Chief Medical Officer discuss the 5-point strategy announced recently that aims to improve oversight in nursing homes. Here are some key takeaways: Survey timeframes shifting? President Trump asked Congress to provide CMS with the ability to adjust the - [Linda Elizaitis discusses care planning with Hospice News](https://cmscompliancegroup.com/blog/linda-elizaitis-hospice-news-article-care-planning/) - CMS Compliance Group, Inc. President, Linda Elizaitis, discussed hospice care planning with Hospice News for an article published yesterday, "Hospices Avoid Regulatory Deficiencies with Careful Care Planning." View the article on hospicenews.com. - [CDC updates Measles Infection Prevention & Control Recommendations](https://cmscompliancegroup.com/blog/cdc-updates-measles-infection-prevention-control-recommendations/) - The Centers for Disease Control (CDC) released updated Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings on July 24, 2019. CDC recommends that this guidance be implemented as part of a comprehensive infection prevention program to prevent the spread of germs in healthcare settings among patients, staff and visitors. Healthcare settings include - [CMS Proposed Changes to RoPs – Delays Ahead? (Part 3)](https://cmscompliancegroup.com/blog/cms-proposed-changes-to-rops-delays-ahead-pt3/) - Here is the third and final part of CMSCG’s look into the proposed rule, “Medicare & Medicaid Programs; Requirements for Long-Term Care Facilities; Regulatory Provisions to Promote Efficiency and Transparency.” In this post, we will look at changes proposed to the Administration regulatory group, including the Facility Assessment, Quality Assurance and Performance Improvement and Compliance - [CMS Proposed Changes to RoPs (Part 2)](https://cmscompliancegroup.com/blog/cms-proposed-changes-to-rops-pt2/) - As promised, CMS Compliance Group is diving into the proposed rule, “Medicare & Medicaid Programs; Requirements for Long-Term Care Facilities; Regulatory Provisions to Promote Efficiency and Transparency” published in the Federal Register on July 18, 2019. We’ll look at proposed changes related to Behavioral Health, Pharmacy Services, Food and Nutrition Services and the Physical Environment - [CMS Proposes Changes to RoPs, Delay of Some Phase 3 Requirements (Part 1)](https://cmscompliancegroup.com/blog/cms-proposes-changes-to-rops-delay-of-phase-3-requirements-pt1/) - The Centers for Medicare & Medicaid Services (CMS) announced a proposed rule, “Medicare & Medicaid Programs; Requirements for Long-Term Care Facilities; Regulatory Provisions to Promote Efficiency and Transparency” on July 17, 2019. The proposed rule would make some changes to the already implemented Requirements of Participation (RoPs) as well as change and delay some of - [OIG Adds New Post-Acute Focused Items to Work Plan](https://cmscompliancegroup.com/blog/oig-adds-new-post-acute-focused-items-to-work-plan/) - The Office of the Inspector General (OIG) has added/updated three new items to its Work Plan that focus on Home Health Agencies (HHAs) and Nursing Homes. Home Health - The OIG plans to look at whether home health claims were paid in accordance with federal requirements in a report that will be titled, “Home Health - [Linda Elizaitis to present at 2019 PHCA Convention](https://cmscompliancegroup.com/blog/linda-elizaitis-phca-convention-presentation-what-to-expect-on-survey/) - Are you attending the Pennsylvania Health Care Association's 2019 Convention in Valley Forge, PA? If so, please join CMS Compliance Group's President, Linda Elizaitis for the following session: What to Expect on Your Next DOH Survey (B-9) Wednesday, September 25, 2019 2:45PM-3:45PM Linda will be discussing survey trends, tips and reminders about the Phase 3 - [OIG Report – CMS Could Identify Potential Abuse/Neglect with Claims Data](https://cmscompliancegroup.com/blog/oig-report-cms-could-identify-potential-abuse-neglect-with-claims-data/) - The Office of the Inspector General (OIG) released a new audit report on June 12, 2019, “CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect.” This report was based on Medicare claims from January 2015 to January 2017 that included one or more of 17 diagnosis codes that OIG identified as - [OIG Report – Potential Abuse & Neglect at SNFs Not Always Reported/Investigated](https://cmscompliancegroup.com/blog/oig-report-potential-abuse-neglect-at-snfs-not-always-reported-investigated/) - The Office of the Inspector General (OIG) released a new report on June 12, 2019, “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated,” which continues the OIG’s look at potential abuse in nursing homes. In August 2017, the OIG issued an “early alert” to The Centers for - [Seema Verma explains Special Focus Facility selection criteria](https://cmscompliancegroup.com/blog/seema-verma-explains-special-focus-facility-selection-criteria-sff/) - The Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma outlined the Special Focus Facility (SFF) selection methodology in a May 3, 2019 letter to Senator Robert Casey, Jr. The letter, which is a response to an inquiry about the Special Focus Facility program and the public availability of the full candidate list for - [MDS 3.0 RAI Manual v1.17 October 1, 2019 available now](https://cmscompliancegroup.com/blog/mds-manual-v1-17-october-1-2019-available-now/) - Via the CMS.gov MDS 3.0 RAI Manual page: May 20, 2019 The PDF file labeled “MDS 3.0 RAI Manual v1.17 October 1, 2019” is now available in the Related Links section below. Please note this early release is being provided in response to stakeholder feedback. The MDS 3.0 RAI Manual v1.17 contains many updates including - [OIG report on nursing home deficiency trends](https://cmscompliancegroup.com/blog/oig-report-nursing-home-deficiency-trends/) - The Office of the Inspector General (OIG) released a new data brief, “Trends in Deficiencies at Nursing Homes Show That Improvements Are Needed To Ensure the Health and Safety of Residents.” The brief includes an analysis of nursing home deficiencies cited during CY2013-CY2017 across the United States to identify trends. At CMS Compliance Group, we - [MDS 3.0 errata posted for DRAFT MDS version (v3.00.1)](https://cmscompliancegroup.com/blog/mds-3-0-errata-posted-for-draft-mds/) - The Centers for Medicare & Medicaid Services (CMS) posted an update on the MDS 3.0 Technical Information webpage dated April 5, 2019: April 05, 2019 An errata (V3.00.1) was posted for the DRAFT version (v3.00.1) of the MDS 3.0 Data Specifications, which will go into effect on October 1, 2019. Twenty-one issues were identified. One new - [CMS Blog - "Ensuring Safety and Quality in America’s Nursing Homes"](https://cmscompliancegroup.com/blog/cms-blog-ensuring-safety-and-quality-in-americas-nursing-homes/) - Via the CMS Blog: CMS BLOG https://www.cms.gov/blog/ensuring-safety-and-quality-americas-nursing-homes April 15, 2019 By: Seema Verma, Administrator, Centers for Medicare & Medicaid Services Ensuring Safety and Quality in America’s Nursing Homes CMS is charged with developing and enforcing quality and safety standards across the nation’s health care system, a responsibility we consider a sacred trust. While we support - [OIG to examine post-hospital skilled nursing care in newly added report](https://cmscompliancegroup.com/blog/oig-post-hospital-skilled-nursing-care-report/) - The Office of the Inspector General (OIG) added a new item to its Work Plan in March, “Post-Hospital Skilled Nursing Facility Care Provided to Dually Eligible Beneficiaries.” This report will identify whether the post-hospital SNF care provided to these beneficiaries met the level of care requirements by looking at whether the SNF level of care - [Specialized Infection Prevention & Control Training for Nursing Home Staff](https://cmscompliancegroup.com/blog/cdc-specialized-infection-prevention-control-training-for-nursing-home-staff/) - Nearly a year after the Centers for Medicare & Medicaid Services (CMS) announced that it would be collaborating with the Centers for Disease Control (CDC) to develop an infection prevention and control course for nursing home staff, the online training is now available. In a new QSO memo, CMS provides an overview of the new - [Ftags of the Week – F940, F941 and F942 – Training Requirements](https://cmscompliancegroup.com/blog/ftags-of-the-week-training-f940-f941-f942/) - When the Requirements of Participation were updated, a new regulatory group, Training Requirements, was added. The majority of the requirements in this section become effective in Phase 3, however, several of the regulations are already in effect. F943 Abuse, Neglect and Exploitation Training, F947 Required In-Service Training for Nurse Aides and F948 Training for Feeding - [Phase 3 Competencies & Training - Not Just for Nursing (Webinar)](https://cmscompliancegroup.com/blog/phase-3-competencies-training-not-just-for-nursing-webinar/) - Please join us for our next webinar with Pharmscript, "Phase 3 Competencies & Training - Not Just for Nursing" on March 19, 2019 at 1PM EST. This webinar will be presented by Linda Elizaitis, President of CMS Compliance Group, Inc. Objectives: 1. Recognize the regulatory changes effective November 27, 2019 2. Understand the impact of training and - [CMS Revises Appendix Q Guidance on Immediate Jeopardy](https://cmscompliancegroup.com/blog/cms-revises-appendix-q-guidance-on-immediate-jeopardy/) - The Centers for Medicare & Medicaid Services (CMS) has finally released the long anticipated revisions to Appendix Q of the State Operations Manual (SOM) which provides guidance on identifying immediate jeopardy situations. The new QSO memo applies to all provider types, but includes additional information for LTC surveyors. Updates to Appendix Q include: In order - [April 2019 Five-Star Quality Rating System Technical Guide](https://cmscompliancegroup.com/blog/april-2019-five-star-quality-rating-system-technical-guide/) - Related to its announcement about changes to Nursing Home Compare and the Five Star Quality Rating System coming next month, the Centers for Medicaid & Medicare Services (CMS) has released a new Technical Guide. The Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide (April 2019) includes details about the changes coming. - [April 2019 Nursing Home Compare & Five Star Changes](https://cmscompliancegroup.com/blog/april-2019-nursing-home-compare-five-star-changes/) - Yesterday, the Centers for Medicare & Medicaid Services (CMS) issued a press release, “CMS Improving Nursing Home Compare in April 2019” and alongside that, issued a new QSO memo that details all the changes to Nursing Home Compare and the Five Star Rating System that will be occurring. We provided an overview of the changes - [Nursing Home Compare Star Ratings Changing in April](https://cmscompliancegroup.com/blog/nursing-home-compare-april-2019-updates/) - The Centers for Medicare & Medicaid Services (CMS) announced its next set of updates to Nursing Home Compare and the Five-Star Quality Rating System that will be arriving in April 2019. Changes coming include: Health Inspection Star Ratings will be unfrozen – CMS will be ending the freeze on the health inspection star rating score - [OIG to review nursing home staffing levels and CMS oversight](https://cmscompliancegroup.com/blog/oig-nursing-home-staffing-pbj/) - The Office of the Inspector General (OIG) added a new item to its Work Plan in February, “Nursing Facility Staffing: Reported Levels and CMS Oversight.” The OIG will be issuing two reports related to nursing home staffing, the first of which will provide information on nursing staffing levels as reported via Payroll-Based Journal (PBJ). After - [MDS 3.0 QM User’s Manual Version 12.0 Now Available](https://cmscompliancegroup.com/blog/mds-qm-users-manual-version-12-0/) - Via the CMS.gov Quality Measures webpage: February 21, 2019: MDS 3.0 QM User’s Manual Version 12.0 Now Available The MDS 3.0 QM User’s Manual Version 12.0 has been posted. The MDS 3.0 QM User’s Manual V12.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V12.0 can be found - [OIG tells CMS that State Agencies don’t do enough to verify compliance](https://cmscompliancegroup.com/blog/oig-report-survey-deficiencies/) - In the past few years, the Office of the Inspector General (OIG) has released multiple reports related to State Agencies (SAs) not verifying correction of deficiencies identified on nursing home surveys. Those reports looked at the State Agency practices in New York, Florida, North Carolina, Missouri, Kansas, Nebraska, Arizona, Oregon and Washington. Now, in a - [MDS 3.0 Data Specifications effective October 1, 2019 published](https://cmscompliancegroup.com/blog/mds-3-0-pdpm/) - Via the CMS.gov MDS 3.0 Technical Information webpage: February 05, 2019 A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted. This version is scheduled to become effective October 1, 2019. Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), - [CMS updates SOM Appendix Z – Emergency Preparedness](https://cmscompliancegroup.com/blog/updated-som-appendix-z-epp/) - The Centers for Medicare & Medicaid Services (CMS) released updates to Appendix Z of the State Operations Manual which covers the Emergency Preparedness Requirements for healthcare providers. The EPP requirements were effective November 15, 2017. The updates to Appendix Z include changes to the “all-hazards approach” definition, clarifications related to alternate source power and emergency - [New CDC Online Training - Prevent Legionnaires' Disease](https://cmscompliancegroup.com/blog/cdc-water-mgmt-training/) - The January 31, 2019 MLNConnects Newsletter included information on a CDC training program related to preventing Legionnaire's Disease. Please see the following details: Prevent Legionnaires' Disease: Water Management Program Training Did you know? The number of people with Legionnaires’ disease grew 5.5 times from 2000 to 2017 and is deadly for 25% of people who - [CMS Notice of Final Rule Adjusting CMPs for Inflation](https://cmscompliancegroup.com/blog/cms-cmp-final-rule/) - The Centers for Medicare & Medicaid Services (CMS) issued a QSO memo, “Notice of Final Rule Adjusting Civil Monetary Penalties (CMPs) for Inflation) on January 22, 2019. The final rule provides a list of updated CMP amounts and ranges that were effective October 11, 2018 when the final rule was published in the Federal Register. - [Webinar – What to Expect on Your Next Survey](https://cmscompliancegroup.com/blog/webinar-survey-update/) - CMS Compliance Group President Linda Elizaitis will be presenting a Pharmscript webinar, “What to Expect on Your Next Survey.” The webinar will be on February 26, 2019 from 1PM-2PM EST. Objectives: Recognize the most frequently cited health deficiencies nationally Gain an understanding of systems issues related to the most frequently cited deficient practices and quality - [Home Health Agency CoPs FAQ released](https://cmscompliancegroup.com/blog/qso-hha-cops-faq/) - In a January 23, 2019 QSO Memo, The Centers for Medicare & Medicaid Services (CMS) provided a list of Frequently Asked Questions (FAQs) related to the Home Health Agency Conditions of Participation that were effective in January 2018. The list of FAQs is based on requests for clarification that the Agency received about the regulations. - [All-Cause Harm Prevention in Nursing Homes](https://cmscompliancegroup.com/blog/all-cause-harm-prevention-nh/) - The Centers for Medicare & Medicaid Services (CMS) and the Quality Innovation Network National Coordinating Center collaborated on a new change package related to prevention of all-cause harm in nursing homes. The Office of the Inspector General (OIG) in a 2014 report stated that 59% of adverse and temporary harm events that occurred during a - [MDS 3.0 DRAFT Item Set Available (October 1, 2019 version)](https://cmscompliancegroup.com/blog/mds-draft-october-2019/) - The Centers for Medicare & Medicaid Services (CMS) released a draft version of the 2019 MDS item sets on January 3, 2019. MDS 3.0 (v1.17.0) is effective October 1, 2019. The information can be downloaded from the MDS 3.0 Technical Information webpage Downloads section. - [Ftag of the Week - F837 Governing Body](https://cmscompliancegroup.com/blog/ftag-of-the-week-f837-gov-body/) - Welcome to 2019 and the first installment of CMS Compliance Group’s “Ftag of the Week” blog series. This week we are looking at F837 Governing Body, which is part of the Administration regulatory group. The governing body is the group of people who are legally responsible for establishing and implementing policies related to the operations/management - [How Would Your Nursing Facility Fare on a Weekend Survey?](https://cmscompliancegroup.com/blog/weekend-surveys-coming/) - According to a new QSO memo from the Centers for Medicare & Medicaid Services (CMS), some nursing homes are going to find out just how they would do with surveyors in their building over the weekend. CMS has identified concerns in nursing home staffing levels using the Payroll-Based Journal (PBJ) data, including multiple days with - [OIG to Review Nursing Home Involuntary Transfers and Discharges](https://cmscompliancegroup.com/blog/oig-transfers-discharges/) - The Office of the Inspector General (OIG) has added a new item to its 2019 Work Plan. The OIG will be reviewing nursing home involuntary transfers and discharges to determine the extent to which: State Long-Term Care Ombudsman work on addressing involuntary transfers/discharges State Agencies (SAs) investigated and took action against nursing homes for inappropriate - [CMS Launches Patient Driven Payment Model (PDPM) Webpage](https://cmscompliancegroup.com/blog/cms-patient-driven-payment-model/) - The Centers for Medicare & Medicaid Services (CMS) has launched a new webpage for the Patient Driven Payment Model (PDPM) that becomes effective October 1, 2019. The webpage includes: Fact Sheets Frequently Asked Questions PDPM 101 Training Presentation Resources for PDPM (crosswalks and classification info) View the PDPM webpage on the CMS website to download - [CMS Announces CMPRP Nursing Home Staff Competency Assessment Tools](https://cmscompliancegroup.com/blog/cmprp-nh-staff-competencies/) - The Centers for Medicare & Medicaid Services (CMS) announced just before Thanksgiving that it utilized Civil Monetary Penalty (CMP) reinvestment funds to develop a three year program that will help with reducing adverse events, improve dementia care, and improve nursing home staffing quality. The tools launched on November 21, 2018 are focused on assessing staff - [US Antibiotic Awareness Week is November 12-18](https://cmscompliancegroup.com/blog/us-antibiotic-awareness-week/) - Next week is US Antibiotic Awareness Week (November 12-18, 2018). CMS Compliance Group is a Be Antibiotics Aware Partner and will be sharing information from the CDC about the importance of antibiotic stewardship all week via our social media accounts. You can follow us on Twitter - @cmscompliance and @lindaelizaitis - to see our updates. - [Survey Trends in New York - NYSHFA Audio Conference 12/14/18](https://cmscompliancegroup.com/blog/nyshfa-survey-trends-121418/) - Linda Elizaitis, President of CMS Compliance Group will be presenting on survey trends in New York state on our end of year NYSHFA audio conference, "Survey Trends - What We've Learned in 2018 and Where to Focus in 2019." Date: December 14, 2018 10AM-12PM EST Program Description: Join NYSHFA on December 14th for the "Survey - [SNF QRP Data now on Nursing Home Compare](https://cmscompliancegroup.com/blog/snf-qrp-data-on-nhc/) - Via CMS Media Relations at CMS.gov Newsroom: Fact Sheet For Immediate Release October 24, 2018 Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Data on Nursing Home Compare This fact sheet contains information about the inaugural release of the SNF QRP data on the Nursing - [CMS releases FY2019 Mission & Priorities (MPD)](https://cmscompliancegroup.com/blog/cms-releases-fy2019-mpd/) - In a new Admin memo dated October 4, 2018, the Centers for Medicare & Medicaid Services (CMS) released its Fiscal Year 2019 Mission and Priority Document (MPD), which is the document that governs the work the QSO group and CMS ROs and SAs complete for the year. There are several items of note to be - [Healthcare Leaders to be Honored by United Hebrew of New Rochelle at Gala](https://cmscompliancegroup.com/blog/linda-elizaitis-honored/) - Four Healthcare Leaders to be Honored by United Hebrew of New Rochelle at its 99th Anniversary Gala Celebration NEW ROCHELLE, NY -- Nonprofit organizations rely heavily on contributions from individuals, government, and business in order to provide the services and support those in need require. To thank four individuals who have helped United Hebrew of - [Ftag of the Week – F679 Activities Meet Interest/ Needs of Each Resident](https://cmscompliancegroup.com/blog/ftag-of-the-week-f679-activities/) - This week’s “Ftag of the Week” is part of the Quality of Life regulatory group, F679 Activities Meet Interest/ Needs of Each Resident. The regulatory requirement has been updated under the new RoPs to state that “based on the comprehensive assessment and care plan and preferences of each resident,” facilities must provide ongoing resident-centered activities - [Proposed Post-Acute Provider Rule Recap – Burden Reduction](https://cmscompliancegroup.com/blog/proposed-rule-epp-changes/) - The Centers for Medicare & Medicaid Services (CMS) published a proposed rule in the Federal Register on September 20, 2018, “Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency and Burden Reduction” which includes proposals for multiple provider types. CMS states that the proposed rule would reduce burden on healthcare providers and allow - [Life Safety Code Survey Forms – July 2018 update](https://cmscompliancegroup.com/blog/lsc-survey-forms-july-2018-update/) - The Centers for Medicare & Medicaid Services (CMS) has updated the survey forms used for Health Care Life Safety Code Surveys as of July 2018. The updated documents can be found on the CMS Life Safety Code & Health Care Facilities Code Requirements webpage. - [LTCSP Procedure Guide and Surveyor Materials Updated](https://cmscompliancegroup.com/blog/ltcsp-procedure-guide-update/) - Please be advised that the Centers for Medicare & Medicaid Services (CMS) has released updated Long-Term Care Survey Process (LTCSP) surveyor materials with a date of August 8, 2018. The LTCSP Frequently Asked Questions (FAQs) has been updated with a significant amount of information. There is also now a revision history document for the updates - [Home Health Agency (HHA) Interpretive Guidelines Released](https://cmscompliancegroup.com/blog/hha-interpretive-guidelines/) - On August 31, 2018, the Centers for Medicare & Medicaid Services (CMS) published a QSO memo that includes the final HHA Interpretive Guidelines for the Conditions of Participation (CoPs) that became effective on January 13, 2018. Home Health providers have been eagerly awaiting the IG, which will become part of the State Operations Manual Appendix - [OIG to review CMS oversight of Nursing Facility Staffing](https://cmscompliancegroup.com/blog/oig-nursing-facility-staffing/) - Nursing facility staffing levels continue to draw attention from both the regulators as well as the media. The transition to publishing Payroll-Based Journal (PBJ) data on the Nursing Home Compare website was a long-time in the making, with the Centers for Medicare & Medicaid Services (CMS) looking for a way to verify staffing data in - [PBJ Data updated on NHC – next submission deadline in August!](https://cmscompliancegroup.com/blog/pbj-data-hnc-q1-2018/) - The Centers for Medicare & Medicaid Services (CMS) has made its update to the Nursing Home Compare website which utilized Q1 2018 staffing information with submitted Payroll-Based Journal (PBJ) data. The public use files have also been updated, which now includes information on hours worked by non-nursing staff. CMS announced at a SNF Open Door - [CMS proposes PDGM & remote monitoring for home health](https://cmscompliancegroup.com/blog/pdgm-remote-monitor-hha/) - In case you missed this announcement from the Centers for Medicare & Medicaid Services (CMS) while on vacation last week, the Agency has announced proposed updates to “modernize” home health care. The two significant changes follow efforts to innovate across other healthcare provider types. First, CMS proposes to allow the cost of remote patient monitoring - [CMS updates healthcare Legionella management surveyor guidance](https://cmscompliancegroup.com/blog/qso-memo-legionella/) - The Centers for Medicare & Medicaid Services (CMS) revised its June 2, 2017 S&C memo, “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)” on July 7, 2018. The revision clarifies both healthcare provider and surveyor expectations related to Legionella management. Nursing homes are expected - [NYSDOH Adult Care Facility DALs re wheelchairs and hot weather](https://cmscompliancegroup.com/blog/nysdoh-dals-wheelchairs-heat/) - The New York State Department of Health (NYSDOH) has issued two new DALs that should be reviewed if they have not. DAL 18-16: Amended 18 NYCRR Regulations This May 30, 2018 DAL alerts adult care facilities that regulations have been put into place that prevent providers from excluding applicants solely on the basis that the - [Webinar - Understanding Appropriate Transfers & Discharges](https://cmscompliancegroup.com/blog/webinar-transfers-discharges-2/) - Join CMS Compliance Group President Linda Elizaitis and Pharmscript on August 14, 2018 for a webinar, "Understanding Appropriate Transfers and Discharges." This webinar is back by popular demand, as registration was at capacity when we did this webinar in March. Linda will share the following learning objectives: 1. Understand the criteria for appropriate transfer and - [April 2018 Antipsychotic Med Use Reporting (National Partnership)](https://cmscompliancegroup.com/blog/april-2018-antipsychotic-report/) - The most recent National Partnership to Improve Dementia Care in Nursing Homes Antipsychotic Medication Use report from April 2018 shows how much success our industry has had in reducing the number of long-stay residents who receive antipsychotics. There has been a steady focus on this initiative by nursing facilities, and the associated chart provided with - [NHC Five-Star Technical Guide – May 2018](https://cmscompliancegroup.com/blog/5-star-technical-guide-may-2018/) - In case you missed it, the Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide was updated in May. This revision follows updates from February related to the Survey star rating and April related to the Payroll-based Journal staffing measures in use on Nursing Home Compare. The most current update for May - [Texas Provider Letter re: Surveyor Electronic Records Access](https://cmscompliancegroup.com/blog/texas-pl-ehr-access-survey/) - Texas Health and Human Services (HHS) issued a new LTC Regulatory Provider Letter PL 18-10 (NF) which replaces existing PL 17-20. This letter outlines the requirements that providers must understand so that surveyors can have timely access to electronic health records (EHRs) on both surveys and complaint investigations. The contents of this letter provide good - [CMS SNFVBP Program Review and Corrections update](https://cmscompliancegroup.com/blog/snfvbp-review-correct/) - Via the SNF VBP Team at CMS: Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program Review and Corrections The Centers for Medicare & Medicaid Services (CMS) would like to thank all skilled nursing facilities (SNFs) that participated in Phase One of the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program’s Review and Corrections process. The - [LTCSP Procedure Guide updated May 6, 2018 & Surveyor Training](https://cmscompliancegroup.com/blog/ltcsp-procedure-guide-training/) - The Long Term Care Survey Process Procedure Guide that is used by surveyors under the LTCSP has been updated as of May 6, 2018. The updated procedure guide and other changes are also outlined in a new CMS Surveyor Training that is also available to providers. Some highlights from the training that explain changes to - [Happy National Nurses Week from CMS Compliance Group!](https://cmscompliancegroup.com/blog/happy-national-nurses-week-2/) - Happy National Nurses Week from the team at CMS Compliance Group! Thank you for all that you do. - [Transition to PBJ Staffing Measures on Nursing Home Compare](https://cmscompliancegroup.com/blog/pbj-nhc-5star/) - The transition to using Payroll-Based Journal (PBJ) data for Nursing Home Compare and the Five Star Quality Rating is finally upon us. In a new QSO memo dated April 6, 2018, the Centers for Medicare & Medicaid Services (CMS) announced that this month the Agency will being to use Payroll-Based Journal data (which was originally - [Lawmakers looking for info on nursing home oversight from CMS](https://cmscompliancegroup.com/blog/nursing-home-oversight/) - An April 2, 2018 letter written by several members of the House of Representatives queried the Centers for Medicare & Medicaid Services (CMS) about the oversight it is providing to nursing homes, as well as how the Agency is ensuring that standards of quality are met. The letter, which cites the death of nursing home residents in - [CMS and CDC teaming up to create infection prevention & control training course](https://cmscompliancegroup.com/blog/cms-cdc-ipic-training/) - In a QSO memo dated March 16, 2018, The Centers for Medicare & Medicaid Services (CMS) announced that it is working with the Centers for Disease Control (CDC) to develop a specialized Infection Prevention and Control Training program for nursing staff who work in long-term care settings. Infection Prevention & Control is a large part - [Happy LTC Administrator's Week from CMSCG](https://cmscompliancegroup.com/blog/happy-ltc-administrators-week/) - Happy Long Term Care Administrator's Week from the CMS Compliance Group team! Thank you for doing what you do to provide the highest quality of care and services to your residents. - [Five-Star Quality Rating System Survey Star Methodology Update](https://cmscompliancegroup.com/blog/5star-rating-survey-methodology/) - The Centers for Medicare & Medicaid Services (CMS) has updated its Five-Star Quality Rating System Technical Users’ Guide to explain changes made to the survey star rating methodology. The changes, which we reported on in November of 2017, have remained consistent with the information outlined in the CMS memo “Temporary Enforcement Delays for Certain Phase - [Reminder – PBJ reporting deadline is February 14, 2018](https://cmscompliancegroup.com/blog/reminder-pbj-reporting-021418/) - Just a quick reminder that the deadline for Fiscal Q1 Payroll-Based Journal reporting is Wednesday February 14, 2018. Ensure you leave enough time for your data to be fully submitted so you don’t miss the deadline. View more information on the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal webpage. - [SNF Advanced Beneficiary Notice of Non-Coverage revised](https://cmscompliancegroup.com/blog/snfabn-form-revised/) - The Centers for Medicare & Medicaid Services (CMS) has announced that effective May 7, 2018, the Notice of Exclusion from Medicare Benefits (NEMB-SNF) will no longer be used, and in its place, a reviewed SNFABN will be used. The SNFABN will replace the five existing SNF Denial letters as well. Per the CMS FFS SNFABN - [SNF QRP Quality Measure (QM) and Review and Correct Report Data Issues](https://cmscompliancegroup.com/blog/snf-qrp-quality-measure-report/) - Via The Centers for Medicare and Medicaid Services (CMS): A calculation error has been identified for the three assessment-based quality measures reported on the SNF QRP Facility- and Resident-Level QM report and the SNF QRP Review and Correct reports (NQF #0678, NQF #0674, and NQF #2631). Duplicate stays and invalid admission dates can appear on - [Webinar - Understanding Appropriate Transfers & Discharges](https://cmscompliancegroup.com/blog/webinar-snf-transfers-discharges/) - Join CMS Compliance Group President Linda Elizaitis and our friends at Pharmscript for a webinar on an important compliance topic, "Understanding Appropriate Transfers and Discharges." Phase 2 of the Requirements of Participation heavily emphasizes discharge planning, and new regulatory initiatives highlight the importance of appropriate transfer and discharges. Attendees will gain an understanding of the - [OIG to look at potential abuse and neglect in new report](https://cmscompliancegroup.com/blog/oig-abuse-neglect/) - The Office of the Inspector General (OIG) added a new report to its Workplan in January with an expected issue date of FY2018. The OIG plans to determine the prevalence of potential abuse or neglect of Medicare beneficiaries in in-patient and out-patient settings as well as determining whether the potential for abuse or neglect occurred - [Federal Oversight Support Survey (FOSS) Process National Pilot underway](https://cmscompliancegroup.com/nursing-homes-skilled-nursing/foss-survey-pilot-2018/) - To update the Federal Oversight Support Survey Process (FOSS) to be in line with the new Long-Term Care Survey Process (LTCSP), the Centers for Medicare & Medicaid Services (CMS) issued Admin Info:10-06-NH on January 5, 2018 that outlines the process for a FOSS national pilot that is currently underway. The FOSS pilot started this month, - [Home Health Agency (HHA) Survey Protocol released](https://cmscompliancegroup.com/home-health-agencies/hha-survey-protocol/) - The new Conditions of Participation (CoPs) for Home Health Agencies (HHAs) became effective on January 13, 2018. On the heels of that, the Centers for Medicare & Medicaid Services (CMS) Quality, Safety & Oversight Group (f.k.a. “Survey & Certification Group) released the revised HHA survey protocol which is State Operations Manual (SOM) Appendix B. Information - [CMS stance on texting patient information among providers](https://cmscompliancegroup.com/blog/cms-stance-on-texting-patient-info/) - In a December 28, 2017 S&C memo for all providers, the Centers for Medicare & Medicaid Services (CMS) clarified its position related to healthcare providers and texting. The Agency states that it does not permit physicians or other health care providers to text orders. Texting orders from a provider to a member of a care - [CMS ROs reviewing facility-initiated discharges](https://cmscompliancegroup.com/blog/facility-initiated-discharges/) - Late in December, the Centers for Medicare & Medicaid Services (CMS) issued a S&C memo announcing an initiative to address facility-initiated discharges that violate federal regulations. The Agency is review State Agency’s (SA) practices for discharge complaints, which are one of the most frequent complaints made to State LTC Ombudsman Programs across the country. Due - [Happy Holidays from the CMSCG Team!](https://cmscompliancegroup.com/blog/happy-holidays-from-the-cmscg-team/) - Wishing you a wonderful holiday and a healthy, happy new year! - [CMS State Operations Manual Appendix PP 11-23-17](https://cmscompliancegroup.com/blog/som-appendix-pp-11-23-17/) - The Centers for Medicare and Medicaid Services (CMS) has issued the revised State Operations Manual for Long-Term Care Facilities Appendix PP Guidance to Surveyors dated 11-23-2017. The document can be downloaded here. - [CMS Surveyor Training for Providers – ASPEN & LTCSP](https://cmscompliancegroup.com/blog/surveyor-training-aspen-ltcsp/) - The Centers for Medicare and Medicaid Services (CMS) has published new training for providers, “ASPEN and the Long Term Care Survey Process.” The on-demand course can be found on the CMS S&C ISTW website. - [CMS Surveyor Training for Providers – LTC Regs and Guidance](https://cmscompliancegroup.com/blog/cms-surveyor-training-ltc-regs/) - The Centers for Medicare and Medicaid Services (CMS) released a Surveyor Training presentation on December 13, 2017. The presentation, “CMS Surveyor Training – Long Term Care Regulations and Guidance,” can be downloaded here. - [No delays – The Long-Term Care Survey Process is effective November 28, 2017](https://cmscompliancegroup.com/blog/no-delays-to-ltc-survey-process/) - Any provider hoping for a delay in the new Long-Term Care Survey Process (LTCSP) needs know that the Centers for Medicare & Medicaid Services (CMS) plans to launch the LTCSP tomorrow – November 28, 2017. This means the renumbered Ftags will be in effect – check out the updated LTC regulatory groups list here and - [Changes coming to Five Star & Nursing Home Compare in 2018](https://cmscompliancegroup.com/blog/five-star-nhc-changes-2018/) - In a new S&C memo dated November 24, 2017, the Centers for Medicare & Medicaid Services (CMS) outlines changes to its Nursing Home Compare website. November 28th is the effective date for Phase 2 RoPs as well as the new Long-Term Care Survey Process (LTCSP), and with those changes, changes to the Five-Star Quality Rating - [Phase 2 RoPs – Temporary Enforcement Delays for Certain Ftags](https://cmscompliancegroup.com/blog/phase-2-moratorium-ftags/) - As you are aware, Phase 2 of the Requirements of Participation is effective tomorrow, November 28, 2017. The Centers for Medicare and Medicaid Services (CMS) issued a new S&C memo on November 24, 2017 that outlines information regarding the imposition of a temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements and - [CMS posts new SNF QRP quarterly Q&A document](https://cmscompliancegroup.com/blog/snf-qrp-quarterly-qa-doc/) - The Centers for Medicare & Medicaid Services (CMS) has published a new Skilled Nursing Facility Quality Reporting Program (SNF QRP) Question and Answer document that covers frequently asked questions received by the SNF QRP Help Desk in Q2 2017. The September 2017 document can be viewed on the SNF QRP webpage, along with the June - [Ftag of the Week – F744 Treatment/Service for Dementia](https://cmscompliancegroup.com/blog/f744-treatment-service-dementia/) - November 28th is less than two weeks away, so hopefully this regulatory requirement isn’t news to you. In case it is, this week’s “Ftag of the Week” is F744 Treatment/Service for Dementia. Deficiencies related to dementia care have been generally cited under F309, but beginning November 28th, dementia care services has its own stand-alone Ftag. - [Updated LTC Regulatory Groups & Ftags](https://cmscompliancegroup.com/blog/updated-ltc-regulatory-groups/) - In case you missed it, here is the link with the updated regulatory groups and renumbered Ftags: CMS List of Ftags. The document is via CMS.gov with a July 2017 date. If you're looking for information on the updated Ftags and what they're all about, check out CMSCG Blog Series "“Ftag of the Week.” Want - [Payroll-Based Journal public use data file available November 1, 2017](https://cmscompliancegroup.com/blog/payroll-based-journal-public-use/) - In a new S&C memo, the Centers for Medicare & Medicaid Services (CMS) announced that a public-use data file containing the raw data submitted to the Payroll-Based Journal (PBJ) system will be available beginning November 1, 2017. The file will contain submitted staffing hours as well as daily resident census information. An updated Payroll-Based Journal - [LTC Survey Process SME Video PDFs posted for providers](https://cmscompliancegroup.com/blog/ltc-survey-process-sme-training/) - The Centers for Medicare & Medicaid Services (CMS) has posted PDFs of the presentations used for the new LTC survey process in the Provider training section. The video links are still listed as incomplete, but there are links to download below each video for: Admission, Transfer and Discharge Behavioral Health Facility Assessment Freedom from Abuse, - [It’s Falls Prevention Awareness Day!](https://cmscompliancegroup.com/blog/its-falls-prevention-awareness-day/) - September 22, 2017 is the 10th annual Falls Prevention Awareness Day. This year’s theme is “10 Years Standing Together to Prevent Falls.” Falls are the leading cause of injuries for older Americans, and the National Council on Aging has created some great information to help prevent falls in older adults, including: NCOA Falls Prevention Fact - [Keys to Understanding the new LTC Survey Process](https://cmscompliancegroup.com/blog/new-ltc-survey-process-webinar/) - CMS Compliance Group President Linda Elizaitis will be joining our colleagues at Pharmscript for a webinar on the new LTC survey process. The complimentary webinar, "Keys to Understanding the New LTC Survey Process," will take place on October 26, 2017 from 10AM-11AM. Learning objectives: 1. Participants will gain an understanding of the key changes between the existing - [Update: SNF QRP Report Issues Partially Resolved](https://cmscompliancegroup.com/blog/snf-qrp-report-partial-fix/) - A new update has been provided by CMS on the issues related to SNF QRP reports that had been identified in August. Via CMS.gov An issue was identified within the SNF Review and Correct Report, if one or more modification records are submitted for a patient stay, the most recent submitted assessment, which was accepted - [CMS Emergency Preparedness Training Course Online](https://cmscompliancegroup.com/blog/emergency-prep-surveyor-training/) - In a September 1, 2017 S&C memo, the Centers for Medicare & Medicaid Services (CMS) provided information on the publicly-available online training on Emergency Preparedness. The Emergency Preparedness Basic Surveyor Training Course is required for all RO and SA surveyors. Surveys for Emergency Preparedness begins November 15, 2017, and surveyors must have completed the course - [Our Information Technology Services continue to expand](https://cmscompliancegroup.com/blog/healthcare-it-services/) - Technology is touted as the “way forward” in the healthcare industry, and as such, we continue to develop and evolve our consulting services to assist providers with addressing their needs. Here are some of the IT consulting services that CMSCG provides: Technology Program Advisory Services IT Strategy Process Analysis/Redesign for Operational Efficiencies and Compliance Technology - [OIG Alert – CMS procedures for potential abuse/neglect in SNFs inadequate](https://cmscompliancegroup.com/blog/oig-abuse-neglect-snfs-alert/) - The Office of the Inspector General (OIG) issued an “early alert” to the Centers for Medicare & Medicaid Services (CMS) on August 24, 2017. The memo provides results of the OIG’s ongoing review of potential abuse or neglect of Medicare beneficiaries in skilled nursing facilities (SNFs), with the finding that CMS does not have adequate - [Harvey provides a reminder – Get your Emergency Preparedness Plans underway!](https://cmscompliancegroup.com/blog/harvey-emergency-preparedness/) - One news story after another has been posted about the devastation that Harvey is leaving in its wake as it moves through Texas and into Louisiana, bringing to the forefront the urgent need for providers to ensure they have their Emergency Preparedness Plans (EPPs) in place ahead of the November 2017 CMS requirement. Disasters can - [New LTC Survey Pathways & Entrance Conference Form](https://cmscompliancegroup.com/blog/ltc-survey-pathways-entrance-form/) - As promised, the Centers for Medicare & Medicaid Services (CMS) has published documents related to the new LTC survey process that goes into effect on November 28, 2017. The survey process, which combines elements of the traditional survey and the QIS survey, includes a long list of Critical Element Pathways to help surveyors. Pathways include: - [Update: SNF QRP Report Issues & Data Submission Deadline Extension](https://cmscompliancegroup.com/blog/snf-qrp-submission-extension/) - Via CMS.gov: Update: SNF QRP Report Issues & Data Submission Deadline Extension We recently notified Skilled Nursing Facility providers that we found two issues in our technical coding of the Review and Correct Report, one of which also affects the Confidential Feedback Report (due for release in October 2017). Due to technical coding issues, CMS - [Termination Notices available via the S&C website for all providers](https://cmscompliancegroup.com/blog/termination-notices-sc-website/) - The Centers for Medicare & Medicaid Services (CMS) issued a new Survey & Certification letter for all providers regarding termination notices. The Agency notes that it will post public notices for certified provider, supplier and lab involuntary terminations on the CMS S&C website. Public termination notices will remain for 6 months and then be removed. - [CMS announces launch of Hospice Compare website](https://cmscompliancegroup.com/blog/cms-hospice-compare-website/) - via The Centers for Medicare & Medicaid Services: CMS unveiled the new Hospice Compare website. The site displays information in a ready to use format and provides a snapshot of the quality of care each hospice facility provides to its patients. CMS works diligently to make healthcare quality information more transparent and understandable for consumers - [SNF Quality Reporting Program: Non-Compliance Letters](https://cmscompliancegroup.com/blog/snf-qrp-non-compliance-letters/) - Via MLNConnects: CMS notified Skilled Nursing Facility (SNFs) that are non-compliant with SNF Quality Reporting Program (QRP) requirements for Quarter 4 of CY 2016, which will affect their FY 2018 annual payment update. CMS mailed non-compliance letters and placed them in the Quality Improvement and Evaluation System (QIES) - Certification and Survey Provider Enhanced Reporting - [Home Health Agency Conditions of Participation effective date](https://cmscompliancegroup.com/blog/home-health-cop-date/) - After pushback from providers, the Centers for Medicare & Medicaid Services (CMS) has extended the effective date for the updated Conditions of Participation (CoP) for home health agencies (HHAs) back 6 months. Originally effective July 13, 2017, the effective date is now set to be January 13, 2018. Information on the delay can be found in - [CMS issues memo for certain providers seeking new certification](https://cmscompliancegroup.com/blog/cms-sc-reasonable-assurance/) - The Centers for Medicare & Medicaid Services (CMS) issued a new S&C memo for all providers, “Reasonable Assurance Will Apply to Providers and Suppliers Who Voluntarily Terminate and Seek New Certification If a Termination Action by the State Agency Had Been Initiated.” The letter defines “reasonable assurance” as it applies to certification of terminated providers - [CMS issues new guidance for formatting Plans of Correction](https://cmscompliancegroup.com/blog/plan-of-correction-sc-letter/) - The Centers for Medicare & Medicaid Services (CMS) issued an S&C memo to all providers regarding new guidance for how plans of correction are to be formatted. The following list of required elements must be included for an acceptable Plan of Correction (PoC) or credible Allegation of Compliance (AoC): The plan for correcting the specific - [Advance Beneficiary Notice of Noncoverage update effective 6/21/17](https://cmscompliancegroup.com/blog/abn-snf-062117/) - In March, the Advance Beneficiary Notice of Noncoverage form and instructions were approved for renewal with the inclusion of language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if required. Skilled nursing facilities are required to use the ABN for items and/or services that - [The new long-term care survey process is here](https://cmscompliancegroup.com/blog/new-ltc-survey-process/) - With November 28, 2017 right around the corner, we had been eagerly awaiting information on the new long-term care survey process. We will provide information on the CMSCG blog in a series of posts to make the information easily digestible, particularly for providers who were not one of the QIS states. The new survey process - [Emergency Preparedness Plan Interpretive Guidance is here](https://cmscompliancegroup.com/blog/epp-interpretive-guidance/) - As if the renumbering of the F-tag list and the update to the LSC K-tags wasn’t enough, the Centers for Medicare & Medicaid Services (CMS) is throwing another set of numbers out there – E-tags. These tags will be related to Emergency Preparedness, and both health and safety inspectors and LSC surveyors will be able - [Nursing Facility Infection Control Requirement – Legionnaires Disease](https://cmscompliancegroup.com/blog/sc-legionnaires-disease/) - The Centers for Medicare & Medicaid Services (CMS) issued a S&C letter for all Medicare certified healthcare facilities regarding its expectation that facilities have water management policies and procedures in place to reduce the risk of growth/spread of Legionella and other opportunistic pathogens in building water systems. CMS notes that Legionella outbreaks have been linked - [CMS Proposed Revision Requirements for LTC Arbitration Agreements](https://cmscompliancegroup.com/blog/cms-binding-arbitration-proposal/) - Via CMS.gov: FACT SHEET FOR IMMEDIATE RELEASE June 5, 2017 Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries CMS Issues Proposed Revision Requirements for Long-Term Care Facilities’ Arbitration Agreements The Centers for Medicare & Medicaid Services (CMS) issued proposed revisions to arbitration agreement requirements for long-term care facilities. These proposed revisions would - [SNF QRP Review and Correct Reports Now Available](https://cmscompliancegroup.com/blog/snf-qrp-review-correct-reports/) - Via the Centers for Medicare & Medicaid Services (CMS): The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Review and Correct reports are now available on demand in the CMS Certification and Survey Provider Enhanced Reporting (CASPER) application. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS - [Oh no, Big Data!](https://cmscompliancegroup.com/blog/oh-no-big-data/) - As part of our ongoing blog post series explaining new technical terms, we will address “Big Data” in this post. Due to the new CMS requirements regarding Facility Assessments, Emergency Preparedness, and QAPI, long term care facilities are being forced to take a more quantitative approach to care delivery. How to approach the data management - [CMS Compliance Group is now a Weather-Ready Nation Ambassador](https://cmscompliancegroup.com/blog/cmscg-weather-ready-nation/) - At CMS Compliance Group, we take emergency preparedness planning seriously. That’s why we are proud to be a Weather-Ready Nation Ambassador, which shows our commitment to engaging stakeholders in preparing their healthcare organizations for extreme weather, water and climate events. The Weather-Ready Nation initiative is part of the NOAA’s National Weather Service, and its purpose - [SNF QRP FY2018 payment determination extended to June 1, 2017](https://cmscompliancegroup.com/blog/snf-qrp-extension/) - Due to extenuating circumstances, the reporting deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Fiscal Year 2018 payment determination has been extended from May 15, 2017 to June 1, 2017. The MDS assessment data for October-December (Q4) of calendar year 2016 are due with this submission deadline. For a list of measures - [CMS S&C Memo – Notice of Transfer or Discharge](https://cmscompliancegroup.com/blog/notice-of-transfer-discharge/) - In a recent two-topic S&C letter dated May 12, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined the requirements for notification of transfers and discharges. One of the big changes to Phase 1 of the RoPs required providers to start sending transfer and discharge notices to the LTC Ombudsman Office. CMS now clarifies - [CMS S&C memo – Substandard Quality of Care](https://cmscompliancegroup.com/blog/substandard-quality-of-care/) - In a May 12, 2017 S&C letter addressed to nursing homes, The Centers for Medicare & Medicaid Services (CMS) provide an updated definition on Substandard Quality of Care (SQC) and how it will be implemented by Phase in the updated Requirements of Participation. In the updated RoPs, the definition for SQC was included without substantive - [NY Initiates Review of Infection Control Compliance at Brooklyn/Queens Nursing Homes](https://cmscompliancegroup.com/blog/c-auris-infection-control-ny/) - Brooklyn and Queens nursing homes, take note of this press release issued Friday: https://www.health.ny.gov/press/releases/2017/2017-05-05_c_auris.htm State Health Commissioner Issues Health Advisory to Strengthen Readiness for Candida Auris Fungus in Hospitals and Nursing Homes State Reinforces Enhanced Surveillance for Reporting Candida auris Cases and Effective Infection Control Practices State Initiates Review of Infection Control Compliance at all - [Happy Nurses Week!](https://cmscompliancegroup.com/blog/happy-nurses-week/) - Happy Nurses Week to our nurses and all of the nurses that we work with every day. Thank you! - [CMS S&C memo – Payroll Based Journal update](https://cmscompliancegroup.com/blog/cms-sc-payroll-based-journal/) - The Centers for Medicare & Medicaid Services (CMS) issued a S&C letter on April 21, 2017 providing an update on the Payroll-Based Journal (PBJ). There are some interesting details in this update beyond just the data specification updates that CMS made on the PBJ website last week. CMS notes that 91% of LTC providers submitted - [Join Linda Elizaitis & Pharmscript 6/8/17](https://cmscompliancegroup.com/blog/managing-behaviors-webinar/) - CMS Compliance Group President Linda Elizaitis will be presenting "Managing Behaviors and Unnecessary Drugs" for a Pharmscript, LLC webinar on June 8, 2017 from 10AM-11AM EST. Program Overview: Managing residents who are exhibiting behavioral issues related to cognitive disorders is a complex problem to solve. Linda will provide solutions on assessing and understanding these behaviors, as - [PBJ Policy Manual and PBJ Manual FAQ updated 4/18/17](https://cmscompliancegroup.com/blog/pbj-policy-manual-41717/) - CMS has updated two Payroll-Based Journal documents to reflect changes made to submission guidelines. The affected documents are: PBJ Policy Manual (V2.3) 4-17-17 PBJ Policy Manual FAQ 4-17-17 The FAQ document provides information on entering hire date and termination dates for employees, something that was a concern to providers. The Hire Date and Termination Date - [Home Health CoPs – Potential Delay of Effective Date](https://cmscompliancegroup.com/blog/home-health-cops-delay/) - A proposed rule has been published in the Federal Register that would delay the effective date of the updated Conditions of Participation for Home Health Agencies. The HHA CoPs “focus on the care delivered to patients to HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and - [CMS: Test your emergency plans sooner rather than later](https://cmscompliancegroup.com/blog/testing-emergency-prep-plans/) - The Centers for Medicare & Medicaid Services (CMS) issued a S&C letter regarding the training and testing components of the Emergency Preparedness Requirements for healthcare providers. The Final Rule is effective November 15, 2017, and by this date, providers must have completed the training and testing exercises required. The required testing exercise include a “full-scale, - [MLN Connects Call on Emergency Preparedness Final Rule 4/27/17](https://cmscompliancegroup.com/blog/mln-emergency-prep-call-04272017/) - The Centers for Medicare & Medicaid Services (CMS) sent out a S&C memo, “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 call will be held on April 27, 2017 from 2:30-3:30PM EST and will - [Help, my nursing home may end up in the SFF Program!](https://cmscompliancegroup.com/blog/my-nursing-home-is-a-sff/) - Help, my nursing home may end up in the SFF Program! Many nursing homes don’t know much about the Special Focus Facility (SFF) Program, other than it’s a bad sign and a letter you don’t want to receive from the Centers for Medicare & Medicaid Services (CMS) shows up. CMS has indicated that it has - [How Nursing Homes are Selected as Special Focus Facilities](https://cmscompliancegroup.com/blog/nursing-home-selection-sff/) - In a recent blog post, we alerted you that CMS published an update for FY 2017 on the Special Focus Facility Program. Being selected as a Special Focus Facility (SFF) is problematic for several reasons for a nursing home, included being surveyed at least once every six months versus the traditional recertification survey cycle. Nursing - [Adidas reminds us about “behaviors” and knowing our residents](https://cmscompliancegroup.com/blog/adidas-video-person-centered-care/) - Have you seen the Adidas video “Break Free” yet? If not, it’s a perfect reminder about how “behaviors” may not necessarily be behaviors at all. If you take the time to really get to know your residents, then you will begin to understand how to provide truly person-centered care in your nursing home. Go for - [NYC Nursing Home Emergency Preparedness Webinar](https://cmscompliancegroup.com/blog/nyc-nursing-home-disaster-plan/) - CMS Compliance Group's Jason Elizaitis, Technology and Risk Consultant, will be presenting on Emergency Preparedness Planning for Southern New York Association (SNYA) on March 21, 2017. SNYA members can contact Effie Battis for additional information. - [CMS strengthens SFF program with FY 2017 Special Focus Facility S&C Memo](https://cmscompliancegroup.com/blog/cms-sc-special-focus-facilities/) - In a newly released S&C letter, the Centers for Medicare & Medicaid Services (CMS) sets out the enhanced process in place for Special Focus Facilities (SFF). Special Focus Facilities are nursing facilities that are consistent poor performers on survey, with a persistent pattern of poor quality on their last three standard surveys and complaint surveys. - [Top Trending Nursing Home Deficiencies - 2017](https://cmscompliancegroup.com/blog/nursing-home-deficiencies-2017/) - Using the most recently available Centers for Medicare and Medicaid Services (CMS) data from the end of February (2/28/17), we ran a quick analysis to see what deficiencies have been highly cited for the first few months of 2017 across the country – and found no surprises. There is usually a slight lag in data reporting, so - [CMS S&C Memo – Revisions to SOM Appendix PP](https://cmscompliancegroup.com/blog/cms-sc-som-appendix-pp/) - In a February 17, 2017 CMS S&C letter, the Agency notifies nursing home providers that the revised regulatory text for Appendix PP of the State Operations Manual has been updated and released as of February 10, 2017. Please note that the Interpretive Guidance is still not available. We posted the link to CMS Transmittal 167 - [Payroll-Based Journal Update – Hires, Rehires, Terminations](https://cmscompliancegroup.com/blog/pbj-hires-rehires-terminations/) - CMS posted an update on February 17, 2017 to the PBJ website that includes information on changes that will make it easier for providers to submit hire, rehire and termination information. Specifically: PBJ Data Submission Specifications Errata V2.00.3 for PBJ Data Submission Specifications V2.00.0 We are aware that some vendors and providers had difficulty submitting - [State Operations Manual Appendix PP – Effective February 10, 2017](https://cmscompliancegroup.com/blog/som-appendix-pp-feb2017/) - CMS has released the updates to Appendix PP of the State Operations Manual that incorporate the revisions that were made to regulatory language published October 6, 2016. Only the regulation text has been revised, and updated Interpretive Guidance is not yet available. View CMS Transmittal 167, “Revision to State Operations Manual (SOM) Appendix PP – - [Oh No, CyberSecurity!](https://cmscompliancegroup.com/blog/oh-no-cybersecurity/) - As many of us have suspected, CyberSecurity has gained the attention of the CMS and is now driving the creation of CyberSecurity programs (not the software type) in the healthcare industry. As we mentioned in Part 1 of this series on risk management, the CMS has recommended the inclusion of CyberSecurity in the All-Hazards approach - [EPP & CyberSecurity: parts of a holistic risk management approach](https://cmscompliancegroup.com/blog/emergency-planning-cybersecurity/) - CMS has recently recommended the inclusion of CyberSecurity into Emergency Preparedness planning for post-acute and long term care providers as part of the required “all hazards” approach. Although at first glance, Emergency Preparedness and CyberSecurity may appear to be two separate disciplines, the core message CMS is emphasizing to healthcare providers is one of integrated - [OIG FY 2017 Work Plan Highlights](https://cmscompliancegroup.com/blog/oig-fy-2017-work-plan-highlights/) - The Office of the Inspector General’s FY 2017 Work Plan contains a significant number of reports that are expected to be issued in FY 2017 related to post-acute and long term care providers. Historically, when the OIG issues reports, they serve as a reminder to CMS that they have improvements to make in those areas, - [CMS nursing home cyber security recommendations](https://cmscompliancegroup.com/blog/cms-nursing-home-cyber-security/) - In a January 13, 2017 S&C memo, “Recommendations to Providers Regarding Cyber Security,” CMS provides resources for nursing homes and other providers to assist with reviewing their cyber security programs. A review of cybersecurity policies and procedures is recommended by the Agency as part of the “all hazards approach” to emergency preparedness, but is not - [Understanding the Updated LSC & Emergency Preparedness Requirements](https://cmscompliancegroup.com/blog/life-safety-emergency-prep-nyshfa/) - Join NYSHFA and CMS Compliance Group's Jim Houle, ME/Life Safety Consultant and Jason Elizaitis, Technology and Risk Consultant for a 2-hour audio conference on March 17, 2017, "Understanding the Updated Life Safety Code & Emergency Preparedness Requirements." Session Overview: The sweeping regulatory changes of 2016 for healthcare providers did not just affect health-related compliance requirements, but also impacted - [Staffing Data Submission Reminder: Submit by February 14, 2017](https://cmscompliancegroup.com/blog/pbj-staffing-data-reminder/) - Via CMS.gov: Staffing Data Submission Reminder: As of July 1, 2016, electronic submission of staffing data through the Payroll-Based Journal (PBJ) is mandatory for all Long-Term Care Facilities. You have up to 45 days after the end of the quarter to submit data for Federal Fiscal Quarter 1 (October 1, 2016-December 31, 2016.) The final - [CMS final Conditions of Participation for Home Health Agencies](https://cmscompliancegroup.com/blog/home-health-final-cops/) - The unpublished Federal Register version of the final rule Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies provides updates to the CoPs for HHAs. Keys to the new requirements include: Focusing on the care delivered to patients receiving home health services Taking an interdisciplinary view towards patient care Providing greater flexibility for - [Happy Holidays from CMS Compliance Group!](https://cmscompliancegroup.com/blog/happy-holidays-from-cmscg/) - Happy Holidays from the CMS Compliance Group team! Wishing you all the very best for the coming year! - [CMS Civil Monetary Penalty Reinvestment Webpage](https://cmscompliancegroup.com/blog/civil-monetary-penalties-webpage/) - CMS issued a S&C memo providing information on the new webpage that it has created regarding Civil Monetary Penalty fund reinvestment support activities. Improving enforcement activities is a focus of the FY 2016- FY 2017 Nursing Home Action Plan, including improving enforcement policies by tracking the use of enforcement remedies by states, monitoring the use - [CMS 2017 Update on Infection Control Pilot](https://cmscompliancegroup.com/blog/infection-control-pilot-update/) - CMS provided an update on its infection control pilot program in a November 18, 2016 S&C memo. The pilot program, which CMS announced December 23, 2015, is a three year program to improve the assessment of infection control and infection prevention regulations in LTC facilities, hospitals and during transitions of care between providers. This is - [CMS S&C: FY 2015 MDS Focused Survey Summary](https://cmscompliancegroup.com/blog/mds-focused-survey-summary/) - The Centers for Medicare and Medicaid Services issued a new S&C letter on November 4, 2016 providing an overview of the results of the FY 2015 MDS Focused Survey pilot. In late 2012, the Office of the Inspector General issued a couple of reports reviewing nursing homes that reflected the need for increased scrutiny on - [Advance Copy - Revisions to State Operations Manual (SOM), Appendix PP-Revised Regulations and Tags](https://cmscompliancegroup.com/blog/appendix-pp-som-revision/) - A new CMS S&C memo has been issued that provides an advanced copy of revisions to the State Operations Manual Appendix PP. This revision includes the updated regulatory text made effective by the Final Rule in draft version. Most regulatory sections have been revised and re-designated as per the Final Rule, so the updates included - [DNS/DSW Role in Preventing Resident-Resident Altercations](https://cmscompliancegroup.com/blog/resident-resident-altercations/) - CMS Compliance Group President Linda Elizaitis will be speaking at LeadingAge New York's 2016 Annual DNS/DSW Conference. Session Topic: The DNS/DSW Role in Preventing Resident-to-Resident Altercations Date/Time: November 17, 2016 11:30 AM- 1:00PM Session Description: Research data finds that abuse, including resident-to-resident altercations, may be more prevalent in nursing facilities than actually identified. During this - [CMS S&C memo: Emergency Preparedness Regulation Implementation](https://cmscompliancegroup.com/blog/cms-sc-emergency-prep-reg/) - The Centers for Medicare & Medicaid Services (CMS) provided information on the implementation requirements for Emergency Preparedness for the seventeen provider types included in the final rule that was announced on September 16, 2016. The rule, “Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers” becomes effective November 15, 2016, however, providers have - [Final Rule - Requirements of Participation for LTC facilities Links](https://cmscompliancegroup.com/blog/cms-sc-16-24-nh/) - Here are some links that pertain to the newly issued Final Rule for Long Term Care Facility Requirements of Participation: Notification of Final Rule Published- Reform of Requirements for Long-Term Care (LTC) Facilities (Ref: S&C: 16-42-NH) October 4, 2016 Federal Register including: Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities We are - [Office of Civil Rights clearance procedure change](https://cmscompliancegroup.com/blog/ocr-procedure-change/) - CMS released a new S&C letter for all providers outlining revisions to the Office of Civil Rights (OCR) clearance practice for new providers, as well as for Changes of Ownership (CHOW). The conditions of participation for Medicare require providers to establish and maintain compliance with civil rights requirements. The SA provides the OCR Certification Information - [Finalized emergency preparedness rule for healthcare providers](https://cmscompliancegroup.com/blog/emergency-preparedness-rule/) - The September 16, 2016 Federal Register will include the long-awaited emergency preparedness rule for healthcare providers and suppliers, including long term care, home health agencies, PACE programs and others. The updated regulation identifies four key elements of emergency preparedness programs while allowing providers the flexibility to design their plans based on their unique facility-based and - [Skilled nursing facility noncompliance Civil Monetary Penalties adjusted](https://cmscompliancegroup.com/blog/snf-noncompliance-cmps/) - The September 6, 2016 Federal Register includes the Department of Health and Human Service (HHS) Interim Final Rule regarding the adjustment of Civil Monetary Penalties for inflation. This new regulation ensures that the amount of CMPs issued by CMS and other agencies is appropriately adjusted for inflation. The adjusted Civil Monetary Penalty amounts apply to: - [State Operations Manual Appendix I updated – Life Safety Code](https://cmscompliancegroup.com/blog/som-appendix-i-lsc/) - In a new S&C letter dated August 19, 2016, CMS provides a set of revisions to the State Operations Manual Appendix I. This guidance is for Life Safety Code (LSC) surveyors. The two changes include: A portion of SOM Appendix I, Task 4 - Information Gathering had been inadvertently removed from the guidance to surveyors - [New Quality Measures Added to Nursing Home Compare](https://cmscompliancegroup.com/blog/nhc-new-quality-measures/) - CMS has updated Nursing Home Compare to include the five new Quality Measures announced earlier this year. This update was expected on July 27, but was published on August 10, 2016 after a brief delay. The five new QMs are: Percentage of short-stay residents who were successfully discharged to the community (Medicare claims- and Minimum - [MDS 3.0 Section GG Training Videos](https://cmscompliancegroup.com/blog/mds-3-0-section-gg-training-videos/) - CMS has released several new training videos for MDS Section GG - Functional Goals and Abilities. Follow these links to watch the training videos on YouTube: Section GG - Part 1 Section GG - Part 2 Section GG - Part 3 Section GG - Part 4 The updated MDS Manual, which includes this section, is effective October - [Nursing Home Compare Five Star Ratings Change July 27, 2016](https://cmscompliancegroup.com/blog/nhc-qms-july-27/) - In March, CMS announced that it would be adding six new Quality Measures to Nursing Home Compare in July. The data from those six QMs is now publicly available, but not yet being considered as part of the Five Star Quality Rating score. That is about to change though, as five of these six new - [Nursing Home Compare now includes a Penalties Section](https://cmscompliancegroup.com/blog/nursing-home-compare-penalties/) - In its effort to provide consumers with a growing amount of information about nursing homes they may be considering, CMS has added a new section to Nursing Home Compare. The profile for all facilities now includes these tabs: General Information Health & Fire Safety Inspections Staffing Quality Measures Penalties This update to Nursing Home Compare - [Could you be cited under F-223 for a social media issue?](https://cmscompliancegroup.com/blog/abuse-deficiency-social-media/) - Did that get your attention? We thought so. No one wants a citation related to abuse, and while we already have multiple forms of abuse to worry about in our nursing homes – sexual, physical, mental and so on – there’s another area where you could have exposure for abuse: Social Media. In March, after - [CMS publishes revisions to State Operations Manual](https://cmscompliancegroup.com/blog/som-revisions-062016/) - CMS has published several transmittals that outline revisions made to the State Operations Manual that you should be aware of. Key updates include: Revisions to State Operations Manual – Chapter 2 (Effective Date 6/10/16) – This revision clarifies guidance to surveyors regarding Exit Conferences at the end of survey for long term care facilities as - [Study: 1 in 5 nursing home residents involved in resident-resident abuse](https://cmscompliancegroup.com/blog/resident-to-resident-abuse/) - A new study published in the Annals of Internal Medicine, “The Prevalence of Resident-to-Resident Elder Mistreatment in Nursing Homes” examined data from ten New York nursing homes to look at the incidence of resident-resident abuse. Researchers reviewed 2,011 residents in these facilities. The findings include: 407 of 2,011 (20.2%) residents experienced at least one Resident-Resident - [CMS releases nursing home enforcement information report](https://cmscompliancegroup.com/blog/nursing-home-enforcement/) - In a June 3, 2016 S&C letter, “Public Release of Nursing Home Enforcement Information Announcement,” CMS released a report full of data on nursing home enforcements covering the years 2006-2014. This information will be posted on the CMS website going forward to provide transparency, but also to analyze the consistent application of enforcement remedies across - [CMS S&C Nursing Home Action Plan - Recap](https://cmscompliancegroup.com/blog/nh-action-plan-recap/) - In case you missed CMS Compliance Group's posts on the CMS FY 2016 - FY 2017 Nursing Home Action Plan, here's a link to each strategy for quality improvement in the Plan: CMS S&C Nursing Home Action Plan – Strategy 1 CMS S&C Nursing Home Action Plan - Strategy 2 CMS S&C Nursing Home Action - [CMS S&C Nursing Home Action Plan – Strategy 5](https://cmscompliancegroup.com/blog/cms-nursing-home-action-plan-5/) - Strategy Five of the Nursing Home Action Plan is the final strategy listed in this document. Strategy 5, “Create Strategic Approaches through Partnerships” looks at how different entities – from consumers to providers to the S&C Group – can work together for effective quality assurance. CMS outlines the work that it has done with different - [CMS S&C Nursing Home Action Plan – Strategy 4](https://cmscompliancegroup.com/blog/nursing-home-action-plan-4/) - It seems the overarching theme of the whole CMS Nursing Home Action plan should have been quality improvement, but CMS waited until Strategy 4 to discuss the topic. We have written about Strategies 1-3 on the CMSCG Blog in the past few days, so be sure to catch up if you haven’t, otherwise feel free - [CMS Report on FY 2015 Focused Dementia Care Surveys](https://cmscompliancegroup.com/blog/focused-dementia-survey-report/) - In a new S&C letter, “Update Report on the National Partnership to Improve Dementia Care in Nursing Homes,” CMS includes a report on the progress of the National Partnership, as well as information on what has occurred since it released the 2014 Interim Report on the CMS National Partnership to Improve Dementia Care in Nursing - [CMS S&C Nursing Home Action Plan – Strategy 3](https://cmscompliancegroup.com/blog/nursing-home-action-plan-3/) - The FY 2016 – FY 2017 Nursing Home Action Plan recently released by the Centers for Medicare & Medicaid Services (CMS) includes five strategies to help guide CMS towards achieving its goal. We have discussed Strategy 1, “Enhance Consumer Awareness and Assistance” and Strategy 2, “Strengthen Survey Processes, Standards and Training” on the CMSCG Blog - [CMS S&C Nursing Home Action Plan - Strategy 2](https://cmscompliancegroup.com/blog/nursing-home-action-plan-2/) - In case you missed it, we have been discussing the CMS Survey & Certification group’s Nursing Home Action Plan on the CMSCG Blog, and this post will focus on the second strategy that CMS outlines, which is probably one of the most “near and dear” to our hearts at CMSCG, since we work with many of - [CMS S&C Nursing Home Action Plan – Strategy 1](https://cmscompliancegroup.com/blog/nursing-home-action-plan-1/) - As we posted last week, CMS released the Survey and Certification group’s FY2016-FY2017 Nursing Home Action Plan which included five actionable strategies that mean more pressure on providers to perform. The first strategy for the Plan is to "Enhance Consumer Awareness and Assistance." The most obvious tool to assist with that strategy is Nursing Home - [Reminder: 30 days until Payroll-Based Journal (PBJ) go-live](https://cmscompliancegroup.com/blog/pbj-july-1-2016/) - Did you receive the friendly reminder from the Centers for Medicare & Medicaid Services in your inboxes today titled "30 Days Until Go Live for Payroll-Based Journal (PBJ)?" Well if not, CMS has sent a reminder that the electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all LTC facilities and - [CMS issues draft RAI 3.0 User’s Manual v 1.14](https://cmscompliancegroup.com/blog/draft-mds-manual-v1-14/) - In a May 20, 2016 CMS S&C letter, CMS announced that a draft version of the RAI manual is set to go into effect on October 1, 2016, and is now available for preview. The new MDS manual, version 1.14 includes the following changes: New Chapter 3, Section GG: Functional Abilities and Goals Chapter 2 - [CMS FY 2016-2017 Nursing Home Action Plan](https://cmscompliancegroup.com/news/cms-nursing-home-action-plan/) - As if we haven’t had enough indications that the Centers for Medicare & Medicaid Services (CMS) will be doing everything it can to ensure nursing homes are providing the highest quality of care, a new CMS S&C letter released last week details the FY 2016 to FY 2017 Nursing Home Action Plan. The Plan is - [OSHA to require more data for tracking workplace injuries and illnesses](https://cmscompliancegroup.com/blog/osha-electronic-data-reporting/) - The 5/12/16 Federal Register includes the OSHA final rule to “Improve Tracking of Workplace Injuries and Illnesses,” which will require certain industries, including nursing facilities, to electronically submit injury and illness data to OSHA. Employers are required to keep this documentation as part of the existing regulations, but it is not publicly available. That will - [CMS publishes new Life Safety Code rule, effective immediately](https://cmscompliancegroup.com/blog/cms-life-safety-code-update/) - CMS issued a new S&C letter on May 6, 2016 alerting healthcare providers, including long term care facilities, that new Life Safety Code (LSC) requirements have been adopted. These fire safety requirements are updated and distributed every three years by the National Fire Protection Association (NFPA). The final rule, “Medicare and Medicaid Programs; Fire Safety - [OIG: Insufficient home health & SNF claims documentation led to payment errors](https://cmscompliancegroup.com/blog/oig-fy2015-payments/) - A May 2016 Office of the Inspector General (OIG) report found that insufficient documentation was a serious cause of improper payments for both home health claims as well as skilled nursing facility claims in FY2015. The report, “US Department of Health and Human Services Met Many Requirements of the Improper Payments Information Act of 2002 - [Join Linda Elizaitis at the Memory Care Forum in Austin, TX](https://cmscompliancegroup.com/news/26-memory-care-forum/) - CMS Compliance Group President Linda Elizaitis will be presenting “Understanding the Dementia Focused Survey” at the Memory Care Forum in Austin, TX on February 25-26, 2016. Linda’s session overview is as follows: Understanding the Dementia Focused Survey Linda Elizaitis, R.N., RAC-CT, B.S., President, CMS Compliance Group The initial success that CMS has with its 2014 - [States’ legislative initiatives underway](https://cmscompliancegroup.com/news/15-legislative-initiatives/) - There are several legislative initiatives underway in some states for the beginning of 2016 that could have an impact on nursing homes and assisted living facilities. Pennsylvania – The State cannot enact part of the Older Adults Protective Services Act which would enforce a lifetime criminal ban on working in nursing homes for those convicted - [2015 White House Conference on Aging Report findings](https://cmscompliancegroup.com/news/13-wh-conf-on-aging-report/) - Late in December, the White House released the 2015 report for its conference that was held in July. A wide range of topics were discussed, with one key section in particular of interest – Long-Term Services and Supports. The report notes three themes that cover the topics discussed by participants: Promote Person-Centered Care that Maximizes - [CMS announces nursing home infection control pilot project](https://cmscompliancegroup.com/news/28-infection-control-pilot/) - CMS announces nursing home infection control pilot project In a new S&C letter, the Centers for Medicare & Medicaid Services (CMS) announced that it has received funding from the Center for Disease Control (CDC) for a three year pilot program to improve the assessment of infection control and prevention regulations in nursing homes and hospitals, - [Holiday Greetings from CMS Compliance Group!](https://cmscompliancegroup.com/news/23-holiday-greetings/) - The team at CMS Compliance Groups wishes you the happiest of holidays and all the best for 2016! We thank our clients for the opportunity to work with you and advise you on your compliance initiatives and look forward to working with you all in the coming year. - [NJ law requires some health facilities to be generator ready](https://cmscompliancegroup.com/news/11-nj-law-generators/) - Citing Hurricane Sandy as an example of damaging power outages, a piece of legislation in New Jersey requiring health facilities to be generator ready has been signed into law. Law A-1341, signed into legislation on December 9, 2015 requires that certain healthcare facilities be either equipped with an emergency generator or be equipped with an - [GAO examines whether nursing home quality is improving](https://cmscompliancegroup.com/news/04-gao-nursing-home-quality/) - In a new Government Accountability Report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight,” the GAO analyzed CMS quality data for nursing homes to see whether it has improved in the last decade in these facilities. As the report shows, it’s not really a simple yes or no answer, thanks to a - [CMS releases Focused Dementia Care Survey Tools](https://cmscompliancegroup.com/news/03-focused-dementia-survey/) - In a new S&C memo, the Centers for Medicare & Medicaid Centers (CMS) released the tools that were used for the Focused Dementia Care Survey Pilot in 2014 and the 2015 initiative to test the survey type in a few more states. This survey type examined the process by which nursing homes prescribed antipsychotic medications - [OIG releases FY 2016 Work Plan](https://cmscompliancegroup.com/news/10-oig-fy-2016-work-plan/) - The Office of the Inspector General (OIG) has released its FY2016 Work Plan, which includes several initiatives relevant to post-acute and long term care providers. Some of these key initiatives include: Nursing Homes National Background Check Program for long-term-care employees – This report, expected in FY 2016, will review the implementation status of early results - [End of life planning now covered by Medicare](https://cmscompliancegroup.com/news/05-end-of-life-planning/) - In a final rule to be published in the November 13, 2015 Federal Register, the Centers for Medicare and Medicaid Services (CMS), notes that end of life planning discussions will be covered by Medicare starting January 1, 2016. Advance Care Planning, as it relates to the explanation/discussion of advance directives, discussions that happen face to - [Person-centered care key to proposed discharge planning rule](https://cmscompliancegroup.com/news/05-discharge-planning/) - Late last month, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to modernize discharge planning rules for nursing facilities and other providers. The intended result of these changes would be better quality of care outcomes. The rule would also implement the discharging planning requirements of the IMPACT Act, requiring that home - [NYS OMIG launches compliance webinar series](https://cmscompliancegroup.com/news/02-nys-omig-compliance-webinar/) - The New York State Office of the Medicaid Inspector General (OMIG) has created a nine-part webinar series on the state’s mandatory compliance program. The purpose of these compliance programs is to organize provider resources to quickly and efficiently resolve payment discrepancies and detect inaccurate billings, as well as provide a system of checks and balances - [Care Transition Strategies](https://cmscompliancegroup.com/news/26-care-transition-strategies/) - A new study published in the October 2015 edition of P&T takes a look at care transitions and provides strategies for improved communication and reduced readmissions. While many of the comments are geared towards hospitals, there are suggestions for post-acute providers as well that are discharging residents into the community. Some takeaway from “Exploring Transitional - [OIG Report: SNF therapy billing way too high](https://cmscompliancegroup.com/news/05-oig-snf-therapy-billing/) - The OIG’s September 2015 report on skilled nursing facilities, “The Medicare Payment System for Skilled Nursing Facilities Needs to be Reevaluated” found that Medicare payments for therapy “greatly exceeded” SNFs’ costs for therapy, amounting to a $1.1 billion increase in payments in FYs 2012 and 2013. The cause? SNFs billed for the highest level of - [MDS 3.0 Quality Measures User’s Manual 9.0 in effect](https://cmscompliancegroup.com/news/1-mds-quality-measures-manual/) - The new MDS 3.0 QM User’s Manual 9.0 is effective as of October 1, 2015. The updated version includes two changes regarding flu vaccine measures: Change in time period for calculation of the measures and a change to a single calculation per year Change to the missing values for risk adjusted measures, such that missing - [MDS 3.0 RAI Manual v1.13 update announced](https://cmscompliancegroup.com/news/28-mds-manual-october-2015/) - October 1, 2015 is right around the corner, and with it comes the annual update of the MDS 3.0 Manual. In this updated version of the Manual, there were no new items added and no items deleted. Modifications were made for grammar/typos, as well as: Chapter 2 regarding new facilities and changes in ownership Chapter - [New Jersey legislators looking to bolster nursing home CNA headcounts](https://cmscompliancegroup.com/news/22-nj-cna-legislation/) - In a recently proposed bill in New Jersey’s legislature, the minimum number of Certified Nursing Assistants (CNAs) in nursing homes is under question. The proposal includes minimum CNA to resident ratios to ensure residents are receiving care in a time manner. Proposed ratios include: Ratio Shift 1 CNA: 6 Residents Day Shift 1 CNA: 9 - [Home Health Agency surveyor training guidelines updated](https://cmscompliancegroup.com/news/18-home-health-agency-survey/) - In a September 11, 2015 CMS S&C letter, the Agency updates the guidelines for the Home Health Agency (HHA) Survey Protocols. CMS provides training on the use of these protocols that are used to assist HHA surveyors with determining whether a Condition-level deficiency should be issued. The letter notes that the trainings used to emphasize - [Illinois legalizes nursing home electronic monitoring devices](https://cmscompliancegroup.com/news/17-il-ltc-electronic-monitor/) - Last month, Illinois enacted Public Act 099-0430, “Authorized Electronic Monitoring in Long-Term Care Facilities,” which allows electronic monitoring devices to be used in nursing home resident rooms. The devices, rather than being the controversial “hidden cameras,” must be put in a conspicuous location in the resident’s room, and a sign must be posted at the - [CDC & Joint Commission push antibiotic guidance and education](https://cmscompliancegroup.com/news/15-cdc-tjc-antibiotics/) - This week, both the Joint Commission (TJC) and Centers for Disease Control (CDC) announced initiatives regarding antibiotic education and stewardship. On September 14, 2015, the Joint Commission announced its “Speak Up on Antibiotics” campaign. The campaign was created to help educate the public on the appropriate and safe use of antibiotics, as well as potential - [Quality Indicator Survey (QIS) surveyors getting more training](https://cmscompliancegroup.com/news/16-quality-indicator-survey/) - In an August 28, 2015 CMS S&C letter, CMS outlines the revisions it has made to the Quality Indicator Survey (QIS) training process. The letter outlines the QIS training requirements, including: CMS Approved QIS Training – includes the specific training that Surveyors are required to obtain before being able to be a QIS surveyor. QIS - [SOM update: Home health agency change of address](https://cmscompliancegroup.com/news/15-hha-som-update/) - In an August 28, 2015 CMS S&C letter, the Centers for Medicare & Medicaid Services (CMS) noted that it has revised Section 20158 of the State Operations Manual (SOM) “HHA Change of Address.” The previous notification timeframe for Home Health Agencies (HHAs) to notify their Medicare Administrative Contractor (MAC) that they had changed their address - [CMS Extends Comment Period for Proposed LTC Regulations](https://cmscompliancegroup.com/news/11-15-ltc-regs-comments/) - The September 15, 2015 Federal Register will include notification from CMS that the comment period for the major overhaul of the LTC industry’s regulations will be extended. The comment period opened on July 16, 2015 for the sweeping set of regulations, which includes a mandatory Facility Assessment and competency-based staffing requirements. The Agency notes that - [GAO to review the nursing home Five-Star Rating system](https://cmscompliancegroup.com/news/31-gao-five-star-review/) - A few weeks ago, several Senators requested that the GAO assess the nursing home Five Star Quality Rating system to ensure that it is accurate and useful to consumers. The Five Star system was re-ranked earlier this year, in part due to scathing media coverage about its accuracy. According to an August 28, 2015 press - [Changing LTC Regulations Means New Staffing Requirements](https://cmscompliancegroup.com/news/26-long-term-living-webinar/) - The IMPACT Act of 2014 mandated that nursing homes submit electronically staffing data based on payroll and other verifiable and auditable data using a uniform format. In the newly released “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and - [Final Rule: SNFRM, Quality Measures & SNF Staffing](https://cmscompliancegroup.com/news/13-snfrm-qrp-staffing-rule/) - On August 4, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule, “Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection.” The proposed rule was issued earlier this year, and much of - [Senators ask GAO to review Five Star Rating System accuracy](https://cmscompliancegroup.com/news/12-gao-5-star-assessment/) - Last week, a Pennsylvania Senator wrote a letter to the Government Accountability Office (GAO) requesting that an assessment of the nursing home Five Star Quality Rating System be conducted to ensure its accuracy and usefulness to consumers. Senator Bob Casey, joined by Oregon Senator Ron Wyden, asked the GAO to use the most recent set - [CMS S&C Letter: Reform of Requirements for LTC Facilities](https://cmscompliancegroup.com/news/24-cms-sc-letter-ltc-reform/) - Last week, the Centers for Medicare & Medicaid Services (CMS) proposed sweeping regulations to modernize the long term care industry. We announced the changes on our blog since the comment period for these proposed regulations opened on July 16, 2015 and comments must be received by September 14, 2015. View “Publication of Medicare and Medicaid - [Proposed LTC Regs: Competency-Based Staffing](https://cmscompliancegroup.com/news/24-competency-based-staffing/) - One proposed regulation for nursing facilities addresses “sufficient” staffing requirements. In an effort to create an environment where the focus is person-centered care, CMS is trying to create a flexible model that would ensure residents receive with the highest level of care. In our post on the Facility Assessment, we noted how that assessment data - [New Focused Survey for Nursing Facilities - Adverse Drug Events](https://cmscompliancegroup.com/news/23-focused-survey-adverse-drug/) - In a new S&C letter, the Centers for Medicare & Medicaid services (CMS) announced a new focused survey type. Earlier this year, CMS began rolling out MDS-focused surveys that focus on accuracy of MDS 3.0 coding and nursing requirements. The Agency also piloted a focused dementia care survey and has asked states to participate on - [“Building Respect for LGBT Older Adults” Training Available Now](https://cmscompliancegroup.com/news/23-lgbt-older-adults-ltc/) - In August 2014, the Centers for Medicare & Medicaid (CMS) released a learning tool, “Building Respect for LGBT Older Adults.” The online tool consists of six training modules to increase awareness of the issues faced by LGBT individuals living in LTC facilities. CMS has issued an update to the web link for the learning tool. - [Home Health Care Agencies seeing stars](https://cmscompliancegroup.com/news/21-home-health-star-ratings/) - Last week, CMS announced the launch of Home Health Compare Quality of Patient Care Star Ratings. The Affordable Care Act required that consumers be able to review provider data for healthcare providers, and this new rating system is part of the Agency’s plan to roll out star ratings on all of the “Compare” websites. Earlier this - [Proposed LTC Regs: The Facility Assessment](https://cmscompliancegroup.com/news/21-ltc-regs-facility-assess/) - In the newly proposed “Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities,” there is one element that so many other regulations depend on – the facility assessment. Under the new regulations, nursing facilities would be required to conduct a facility assessment, which would review the capabilities of the facility and the resident - [Proposed LTC Regs: The Overview](https://cmscompliancegroup.com/news/17-proposed-ltc-regs-overview/) - So far, it’s been pretty quiet in terms of explanations of the newly released CMS document that seeks to modernize long term care regulations. That’s because the 403 pages are chock full of changes, rearranging of existing statutes, and lots of evidence on why these changes should be made. The document, published in the July - [CMS proposes overhaul of long term care regulations](https://cmscompliancegroup.com/news/14-long-term-care-regulations/) - While we all knew that regulatory changes were probably underway, the release of a 400+ page proposal of sweeping changes to long term care regulations was probably not anticipated. On Monday, July 13, 2015, the Obama administration released a document that takes into account the quality of care being provided to nursing home residents and - [OSHA provides guidance on nursing home inspections](https://cmscompliancegroup.com/news/07-osha-nursing-homes/) - The Occupational Safety & Health Administration (OSHA) has released guidance on the inspections that will be conducted for nursing homes – both planned and unplanned. The inspections will cover five hazard areas including musculoskeletal disorders (related to resident handling), workplace violence, blood borne pathogens, tuberculosis and slips/trips/falls. Any of these hazards may be the subject - [“Two Midnight” rule is here to stay – partially](https://cmscompliancegroup.com/news/06-two-midnight-rule-update/) - Last week, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to the highly controversial “Two Midnight” rule that governs inpatient vs observation stays at hospitals and has resulted in many patients not qualifying for skilled nursing care. As part of the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment - [Happy 4th of July from CMS Compliance Group!](https://cmscompliancegroup.com/blog/04-happy-4th-of-july-2015/) - [AHRQ to collect data on nursing home safety culture](https://cmscompliancegroup.com/news/02-nursing-home-safety-culture/) - The Agency for Healthcare Research and Quality (AHRQ) has requested approval for a project, “Nursing Home Survey on Patient Safety Culture Comparative Database,” which will allow the Agency to assess patient safety culture across the country. The survey utilizes data voluntarily provided by nursing homes to renew the Nursing Home SOPS Comparative database, which allows - [Person-centered care & staff-buy in in dementia care](https://cmscompliancegroup.com/news/23-dementia-care-articles/) - Last week’s MLN Connects call featured the results of the OPTIMISTIC study for training nursing home staff to better address dementia-related behaviors and a case study on person-centered care. The contents of this call really struck home to us because two of our CMSCG Bulletin articles in 2015 have focused on these critical topics. In - [MedPAC recommends “Two Midnight Rule” be withdrawn](https://cmscompliancegroup.com/news/18-medpac-2-midnight-rule/) - In its June 2015 Report to Congress, MedPAC reviewed hospital short-stay policy issues and provided several recommendations to reduce these issues. Hospital short stays have caused significant issues for beneficiaries who need to qualify for post-acute care at a skilled nursing facility and were widely reported on in 2015. In response to this problem, this - [OIG: NJ did not ensure home health agencies quality of care](https://cmscompliancegroup.com/news/16-oig-nj-home-health-agencies/) - A newly published OIG report reviewed a sample of claims for New Jersey Medicaid beneficiaries receiving home health services during 2007-2008 and found the State’s qualification requirements to be unsatisfactory. The OIG found that New Jersey’s qualification requirements for home health agencies did not ensure the appropriate quality of care had been provided. Issues around - [OIG: Home Health Agencies need more consistent background checks](https://cmscompliancegroup.com/news/12-oig-home-health-background/) - The OIG released a new report, “Home Health Agencies Conducted Background Checks of Varying Types,” which reviewed the types and amount of background checks performed by Home Health Agencies on their employees. Since there are no Federal regulations that require HHAs to conduct a background check before hiring (or periodically after hiring), or prevent HHAs - [HHS outlines results of falls reduction study and LTC impact](https://cmscompliancegroup.com/news/12-hhs-of-falls-reduction/) - The US Department of Health and Human Services (HHS) issued a press release on a comprehensive falls prevention program that was developed by the Agency. The program, which is meant to reduce the use of long-term care services, examines risk factors for falls of older adults and includes clinical in-home assessments of health, physical function, - [PACE Programs can now be run by for-profit organizations](https://cmscompliancegroup.com/news/6-for-profit-pace-programs/) - A May report to Congress provides the foundation for for-profit organizations to run PACE Programs. The US Department of Health & Human Services report titled “Report to Congress: The Centers for Medicare & Medicaid Services’ Evaluation of For-Profit PACE Programs under Section 4804(b) of the Balanced Budget Act of 1997” reviews a sample of non-profit - [Texas Begins Focused Dementia Care Surveys in May](https://cmscompliancegroup.com/news/27-texas-dementia-care-surveys/) - In 2014, CMS announced that it was piloting two new survey types, including a focused dementia care survey. Texas DADs announced that it will be implementing these surveys beginning in May as a stand-alone survey type which will not be attached to a standard or complaint survey. As part of its changes to Nursing Home - [CMS provides update on Traditional & QIS Survey formats](https://cmscompliancegroup.com/news/27-cms-qis-traditional-survey/) - In a new informational letter, CMS reviews the two recertification survey types used in the US, the Traditional Survey and the Quality Indicator Survey (QIS). The Agency describes how it has been evaluating the effectiveness of both survey processes over the past few years, and has found that both survey types have their merits. The - [MDS Focused Surveys to be rolled out in May](https://cmscompliancegroup.com/news/21-mds-focused-surveys/) - As CMS announced in a 2014 S&C letter, MDS-focused surveys are set to be rolled out nationwide in 2015. New York DOH, Texas DADs and the Maryland DHMH have announced that they will begin conducting these surveys starting in the next fiscal year. The surveys are expected to take approximately 2 days. Other information provided - [OSHA Updates Workplace Violence Prevention Guidelines](https://cmscompliancegroup.com/news/11-osha-workplace-violence/) - OSHA has updated its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, which updates the 1996 and 2004 voluntary guidelines for preventing this type of violence in residential treatment centers and other care settings. The document provides information on essential components of a workplace violence prevention program, a tool for analysis and - [GAO Report on Advance Directives in Healthcare Settings](https://cmscompliancegroup.com/news/08-gao-advance-directives/) - The GAO issued a report on Advance Directives in April to examine how CMS oversees PSDA requirements across healthcare settings, including nursing homes, the challenges providers face, and the prevalence of Advance Directives across the different settings. The Patient Self Determination ACT (PSDA) was put into effect in 1990, which required nursing homes to maintain - [Study Examines NYS Nursing Home Survey Findings & Enforcement](https://cmscompliancegroup.com/news/07-ltccc-nysdoh-survey/) - The results of a new study from the Long Term Care Community Coalition, “Safeguarding Residents & Program Integrity in New York State Nursing Homes: An Assessment of Government Agency Performance,” find that nursing home survey results may not be as accurate as they could be. New York has the largest number of nursing home residents - [National Partnership to Improve Dementia Care Update](https://cmscompliancegroup.com/news/07-dementia-initiative/) - The National Partnership to Improve Dementia Care in Nursing Homes has released a new update on the prevalence of long-stay nursing home residents who received antipsychotic medications. Antipsychotic drug use in nursing homes has decreased nationally to 19.1% as of Q4 2014. The GAO released a report in March that detailed how HHS has made - [OPTIMISTIC researchers receive grant to expand model nationally](https://cmscompliancegroup.com/news/28-optimistic-ltc-grant/) - OPTIMISTIC, a long term care model that stands for “Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care,” has received a grant from the Hartford Foundation. This grant money will help with evaluating the program, developing training materials and will provide the support to help scale the model to a national model. - [Administrative Law Judge requests to be submitted electronically](https://cmscompliancegroup.com/news/27-admin-law-judge-requests/) - CMS released an S&C letter on April 24, 2015 for all providers regarding requests for Administrative Law Judge hearings. Reiterating a prior requirement, the letter states that starting October 1, 2014, electronic submissions must be used when providers are requesting a hearing regarding civil remedies. To file a DAB E-File, providers must include a signed - [CMS issues S&C letter on Payroll-Based Journal for LTC facilities](https://cmscompliancegroup.com/news/21-cms-pbj-letter/) - Earlier this month, CMS announced the release of its staffing data submission system, Payroll-Based Journal (PBJ). Payroll-Based Journal use will begin on a voluntary basis starting October 1, 2015, and will be mandatory for all long term care facilities beginning July 1, 2016. Read CMS S&C Letter “Implementation of Section 6106 of the Affordable Care - [CMS announces Payroll-Based Journal system to be implemented](https://cmscompliancegroup.com/news/09-payroll-based-journal/) - February’s announcement of adjustments to the Five Star Rating included the announcement that payroll-based staffing would be implemented in the next year or two for nursing homes, and CMS announced yesterday the release of its staffing submission data Payroll-Based Journal (PBJ) system. Section 6106 of the ACA mandated that nursing facilities electronically submit direct care - [CMS releases dementia care survey pilot final report](https://cmscompliancegroup.com/news/01-dementia-care-survey/) - Last year, CMS announced that it was piloting two new survey types, one that focused on dementia care and the other on the accuracy of MDS coding. The recently announced Nursing Home Compare 3.0 included notice that both of these survey types will be rolled out in 2015 after the pilots were completed in 2014. - [New York State e-prescribing delayed to 2016](https://cmscompliancegroup.com/news/30-ny-e-prescribing/) - New York State’s e-prescribing mandate has been postponed. The regulation, which went into effect in March 2013, allowed two years for prescribers to implement the regulations. NYS Governor Cuomo signed legislation in March that postponed the implementation date to March 27, 2016, providing an extension of one year. This is due largely in part to - [NOTICE Act to inform about observation status passes House](https://cmscompliancegroup.com/news/27-notice-act/) - On March 16, 2015, The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act passed the House of Representatives. H.R. 897, if it becomes legislation, would require hospitals to provide both written and oral notification to patients who are under observation status. Specifically, it would require that any patient in observation status at - [CMS provides update on QAPI implementation](https://cmscompliancegroup.com/news/16-cms-qapi-implementation/) - On a March 10th MLN Connects call, CMS provided an updated on the Quality Assurance and Performance Improvement (QAPI) initiative that was created as a requirement of the Affordable Care Act. In June 2013, CMS released QAPI materials, including tools to assist nursing facilities with getting started. At that point, CMS announced that there was - [GAO Report Finds Efforts to Reduce Antipsychotics Still Needed](https://cmscompliancegroup.com/news/6-gao-report-antipsychotics/) - A newly released GAO report, “Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings,” reviewed the prevalence of psychotropic drug prescriptions in older adults with dementia who were nursing home residents as well as those who live in settings with a lower - [Nursing Home Compare 3.0 being rolled out](https://cmscompliancegroup.com/news/18-nursing-home-compare-3-0/) - At a CMS Open Door Forum call last week, highly anticipated changes to the Five Star Rating were announced as a sneak peek for providers. The official release to the public will be on February 20th, 2015 and the revisions appear to have created a shakeup in many facilities’ ratings. CMS issued an S&C letter - [MDS focused surveys to be implemented in 2015](https://cmscompliancegroup.com/news/18-mds-focused-surveys/) - In a February 13, 2015 S&C letter, “MDS / Staffing Focused Survey Updates,” CMS provided the results of its pilot study of the MDS focused survey which assessed the accuracy of MDS coding practices and how this coding affects the quality of care provided in nursing homes. Using a sample of 25 nursing homes from - [Staffing's Impact on the Five Star Rating (Long Term Living)](https://cmscompliancegroup.com/news/12-staffing-five-star-rating/) - Please join CMS Compliance Group President Linda Elizaitis for a complimentary Long Term Living webinar, "Staffing's Impact on the Five Star Rating" on March 5, 2015. The Five Star Rating System continues to evolve as more revisions to determine quality ratings for skilled nursing facilities are developed. The Centers for Medicare & Medicaid Services (CMS) - [State Long-Term Care Ombudsman Program Rule Finalized](https://cmscompliancegroup.com/news/12-state-ltc-ombudsman/) - The Administration of Aging (AoA) of the Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) announced a final rule has been issued regarding the State Long-Term Care Ombudsman Program. The final rule implements part of the Older Americans Act, which governs grants for the operation of LTC Ombudsman Programs. - [FQC Advanced Administrator Leadership Program](https://cmscompliancegroup.com/news/10-fqc-advanced-administrator/) - The Foundation for Quality Care (FQC), an affiliate of NYSHFA, will be offerings its Advanced Administrator leadership program in April and May. This program is open to Nursing Home Administrators who have successfully completed the basic Nursing Home Administrator Leadership course and/or those with 2+ years of administration experience. CMS Compliance Group's Linda Elizaitis is - [FQC OASIS Train-the-Trainer Program](https://cmscompliancegroup.com/news/10-oasis-train-the-trainer/) - The Foundation for Quality Care has developed a 2-day Train-the-Trainer program for nursing home and assisted living leadership teams to implement OASIS in their facilities. This curriculum provides alternatives to prescribing antipsychotic drugs to adults with dementia by using person-centered approaches to addressing behaviors that may be a communication of unmet needs. Linda Elizaitis, President - [State Operations Manual updated to include CPR requirements](https://cmscompliancegroup.com/news/26-som-cpr-f155/) - In a recent revision to an S&C letter Ref: 14-01-NH which mandated that nursing homes may not establish or implement facility-wide no CPR policies, CMS has revised Guidance to Surveyors in Appendix PP at F-155 to clarify information on this policy. Facility-wide no CPR policies violate the rights of residents to formulate an Advance Directive - [OIG report: Medicare hospices have incentive to provide ALF care](https://cmscompliancegroup.com/news/oig-hospice-alf-report/) - The Office of the Inspector General (OIG) released a report on January 13, 2015, “Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities.” OIG found that in assisted living facilities, hospices provide longer periods of care than in other settings, and that beneficiaries in ALFs often required less complex care. This means - [MedPAC report finds no improvements to SNF reimbursement](https://cmscompliancegroup.com/news/19-medpac-reimbursement/) - A new MedPAC report has found that Medicare reimbursements for skilled nursing facilities have actually deteriorated under changes made by CMS in the years 2006-2014. The report, “The Need to Reform Medicare’s Payments to Skilled Nursing Facilities is as Strong as Ever,” notes that in 2014, Medicare payments for SNF services were estimated to be - [OPTIMISTIC care model to help reduce hospitalizations](https://cmscompliancegroup.com/news/16-optimistic-care-model/) - A new study published in the Journal of the American Geriatrics Society highlights a new care model that is being sponsored by an award from CMS called OPTIMISTIC. OPTIMISTIC, which stands for Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care is a program developed by Indiana University and the Regenstrief Institute - [INTERACT Version 4.0 Tools for Nursing Homes Released](https://cmscompliancegroup.com/news/9-interact-tools-4/) - INTERACT (Interventions to Reduce Acute Care Transfers) tools have been updated to version 4.0. INTERACT is a quality improvement initiative that is geared towards reducing hospital transfers, and includes communication tools, care paths/clinical tools and advance care planning tools. The new tools include the following changes: Revision to the SBAR Communication Form and Progress Note - [Resident-to-Resident Altercations in the Spotlight](https://cmscompliancegroup.com/news/8-resident-abuse-study/) - In late 2014, research from Weill Cornell found that nearly 20% of residents in a sample of ten nursing homes in New York were involved in aggressive behavior incidents within the past four weeks. These incidents involved resident to resident aggressive behaviors including: Verbal incidents (16%) Physical incidents (5.7%) Sexual incidents (1.3%) Unwelcome entry into - [AALNC Webinar: The Downside to Falls in a Nursing Home](https://cmscompliancegroup.com/news/06-aalnc-falls-webinar/) - CMS Compliance Group President Linda Elizaitis will be presenting for the American Association of Legal Nurse Consultants on January 7, 2014. The topic - one that's always an issue in nursing homes - is "The Downside to Falls in a Nursing Home." Members of the AALNC can register here. - [Five Star Rating Coming for Home Health Compare in 2015](https://cmscompliancegroup.com/news/22-home-health-star-rating/) - Last week, CMS released a fact sheet on Home Health Compare Star Ratings with the intent to implement the Five Star Rating system for home health agencies in 2015. Star ratings are currently being used on the Medicare.gov Compare websites, including Nursing Home Compare. This type of reporting is provided to assist consumers with selecting - [HHS Releases Active Shooter Guidance for healthcare facilities](https://cmscompliancegroup.com/blog/19-active-shooter-guidance/) - Last week, the Department of Health and Human Services (HHS) released guidance for healthcare facilities on how to prepare for an active shooter event. While regulatory compliance requirements for skilled nursing facility disaster planning have been lax, this guidance is meant to help these facilities prepare for a potential incident that may not be included - [CMS Clarifies Spousal Relationship Terms for Long Term Care](https://cmscompliancegroup.com/news/19-spousal-relationships/) - In an S&C letter issued Friday, December 12th by CMS, “Clarification of Terms Implicating the Spousal Relationship in Regulations and Guidance for Medicare- and Medicaid-certified Providers and Suppliers,” the agency states its intent to clarify several terms used in regulatory language and guidance. The terms, “spouse,” “marriage,” “family,” and “relative” have all be updated to - [CMS Releases Updated SOM Appendix PP Guidance to Surveyors](https://cmscompliancegroup.com/news/04-som-appendixpp-update/) - This week, the Centers for Medicare & Medicaid Services (CMS) released the update version of the State Operations Manual. Revisions to Appendix PP – Guidance to Surveyors for Long Term Care Facilities have been updated to reflect CMS S&C letters that have been issued from 2003-2014. Regulations that have been updated include F-tags with major - [Skilled nursing staffing levels under fire](https://cmscompliancegroup.com/news/21-snf-staffing-levels/) - Staffing levels seems to be the hot button topic in the back half of 2014. Skilled nursing facilities have been seeing a lot of pressure in recent months to provide more accurate staffing data, with everyone from CMS to the Center for Public Integrity calling out administration for “staffing up” ahead of survey. In an - [November 20th, 2014 is Pressure Ulcer Prevention Day](https://cmscompliancegroup.com/news/16-pressure-ulcer-prevention/) - The National Pressure Ulcer Advisory Panel has set November 20th, 2014 as World Wide Pressure Ulcer Prevention Day. This initiative seeks to increase awareness for pressure ulcer prevention and to provide education to the public on pressure ulcers. Nursing homes that wish to participate in this important initiative can find more information and media - [OIG releases FY 2015 Work Plan](https://cmscompliancegroup.com/news/14-oig-2015-work-plan/) - Well, the Office of the Inspector General (OIG) has released its FY 2015 Work Plan, not even a year after its 2014 Work Plan was released in February of 2014. The reports, generally issued in November, highlight the initiatives the agency will undertake. For nursing homes, this means additional scrutiny while the OIG reviews data, - [Honoring our Veterans](https://cmscompliancegroup.com/news/11-honoring-our-veterans/) - The team at CMS Compliance Group wanted to take a moment to honor and thank our country's veterans. - [MDS and Focused Staffing Surveys Starting in 2015](https://cmscompliancegroup.com/news/06-mds-focused-survey/) - In a recent S&C letter, “Nationwide Expansion of Minimum Data Set (MDS) Focused Survey,” CMS provided the results of its pilots on focused surveys for MDS coding practices. The 2014 pilot program consisted of testing the MDS-focused survey in 5 states, and provided a wealth of insights to the surveyors. The new survey type provided - [Happy Halloween from CMS Compliance Group!](https://cmscompliancegroup.com/news/31-happy-halloween/) - [Survey Trends & Tips (ChemRx)](https://cmscompliancegroup.com/news/survey-trends-tips-chemrx/) - Join CMS Compliance Group at the ChemRx Winter Seminar! CMSCG's Linda Elizaitis will be presenting "Survey Trends & Tips." December 4, 2014 10AM - 11AM Register now on the ChemRx website - [Extensions Available for CMS National Background Check Program Grants](https://cmscompliancegroup.com/news/31-nbcp-grant-extensions/) - States that are participating in the National Background Check Program (NBCP) may be eligible for grant extensions that will be approved by CMS on a case by case basis. In an October 24, 2014 S&C letter, CMS notes that grants may be extended in 12 month increments. Written requests for extensions must be submitted no - [Managing Behaviors and Unnecessary Drugs (PHCA)](https://cmscompliancegroup.com/news/30-managing-behaviors-phca/) - Are you attending the Pennsylvania Healthcare Association Annual Convention and Trade Show? Join CMS Compliance Group for the following session: Managing Behaviors and Unnecessary Drugs Presenter: Linda Elizaitis, President of CMS Compliance Group November 13, 2014 8AM - 9AM View the program agenda on the PHCA website. - [The Administrator, The Lawyer & the Regulator (HCANJ)](https://cmscompliancegroup.com/news/24-hcanj-linda-elizaitis/) - Are you attending the 2014 HCANJ Annual Convention? CMS Compliance Group's President Linda Elizaitis will be leading a discussion on survey trends in New Jersey with a panel comprised of a nursing home administrator, an attorney and two representatives from the NJDOH. Session: The Administrator, the Lawyer and the Regulator Moderator: Linda Elizaitis, CMS Compliance - [CMS Approves Use of Power Strips in Long Term Care Facilities](https://cmscompliancegroup.com/news/06-power-strips-long-term-care/) - In a September 26, 2014 S&C Letter, “Categorical Waiver for Power Strips in Patient Care Areas” (Ref: S&C: 14-46-LSC), CMS notes that power strips may be used in certain long term care facility resident rooms. The letter states, “Resident rooms in long term care or other residential care facilities that do not use line-operated electrical - [CMS Announces Changes to Nursing Home Compare Coming in 2015](https://cmscompliancegroup.com/news/08-nursing-home-compare/) - On October 6, 2014, the IMPACT Act was signed into law by the President, and along with it came an announcement from the Centers for Medicare and Medicaid Services (CMS) that is will be making changes to Nursing Home Compare for 2015 that will have a strong impact on the current reporting measures. Since August, - [New Goal Set to Reduce Unnecessary Antipsychotic Medications in LTC](https://cmscompliancegroup.com/news/23-new-antipsychotics-goal/) - On Friday, the National Partnership to Improve Dementia Care issued a press release announcing that it met its goal of reducing the national prevalence of antipsychotic drug use in nursing home residents by 15.1%. Every state showed a reduction in long-stay resident unnecessary medications. Since this goal has been achieved, a new goal has been - [Updates to MDS 3.0 Manual Released](https://cmscompliancegroup.com/news/17-mds-manual-update/) - The MDS 3.0 Manual was updated on September 15, 2014. RAI Manual v1.12 is now available on the CMS website Earlier this month CMS issued an S&C letter about the requirements for completing MDS discharge assessments that you may have missed. View the information in this CSMCG blog post. McKnight’s Long Term Care News recently - [Linda Elizaitis quoted in McKnight's "Success without Silos"](https://cmscompliancegroup.com/news/08-linda-elizaitis-mcknights/) - McKnight's Long Term Care News feature article for September takes a look at the MDS 3.0 and upcoming changes due every year. CMS Compliance Group President Linda Elizaitis was asked to weigh in. Read the article on the McKnight's website. - [Congress Urges CMS to Ensure LTC Staffing Information Correct](https://cmscompliancegroup.com/news/08-ltc-staffing-information/) - In late August, members of the Congressional Seniors Task Force sent a letter to CMS requesting that staffing information for long term care facilities be provided through the payroll system, not through the current self-reporting measures. This calls into question the common practice of staffing-up during a facility’s survey window and tries to ensure that - [FQC OASIS Master Training Program on NBC Tonight!](https://cmscompliancegroup.com/cmscg-updates/05-fqc-oasis-master-training/) - The Foundation for Quality Care (FQC) has been invited to NBC 4 in New York City for a live interview at tonight at 7:00 PM EST regarding its OASIS (Dementia Care) Master Trainer Program. Dr. Susan Wehry, who is the Commissioner of the Department of Disabilities, Aging and Independent Living in Vermont and the Author - [CMS Reminder on MDS 3.0 Discharge Assessments for Resident Transfers](https://cmscompliancegroup.com/news/29-mds-discharge-assessments/) - CMS has issued an S&C letter reinforcing the requirements for completing MDS discharge assessments when a resident is transferred from a certified bed to a non-certified bed in a skilled nursing facility (SNF). The letter states that discharge assessments are required for residents that are transferred to non-certified beds housed under the same certified facility. - [New LTC Tool: Building Respect for LGBT Older Adults in Long Term Care](https://cmscompliancegroup.com/news/26-ltc-building-respect-lgbt/) - In an August 22 S&C letter, “Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults,” CMS announced that a new learning tool is available to educate long term care providers about the rights and needs of this population. The learning tool consists of 6 training modules and can be - [OIG Report Finds Only 53% of Abuse or Neglect Violations Reported](https://cmscompliancegroup.com/news/22-oig-report-abuse/) - The Office of the Inspector General (OIG) reviewed nursing facilities’ compliance with federal regulations for reporting allegations of neglect or abuse in its August report. The report reviewed a sample of over 100 nursing homes and found: 85% of nursing facilities reported at least one allegation of abuse or neglect in 2012 76% of nursing - [Update from the National Partnership to Improve Dementia Care](https://cmscompliancegroup.com/news/20-dementia-care-call-update/) - MLN Connects hosted its monthly call on August 19th, 2014. Here are some of the highlights that post-acute and long term care providers should be aware of: Focus dementia care survey pilot – As we mentioned previously, this small pilot is underway across the country. Five states that have volunteered to participate are each conducting - [Join CMS Compliance Group at these LTC Education Sessions!](https://cmscompliancegroup.com/news/15-linda-elizaitis-education/) - Looking to learn more about the most important topics and trends in the long term care industry? Well, CMS Compliance Group President Linda Elizaitis will be presenting the following sessions - let us know if you will be attending! Achieving Good Clinical Outcomes (LeadingAge New York) - Audio Conference September 23, 10:30AM - 11:30AM 2014 - [Proposed nursing home rule in Texas: 3 strikes & you’re out](https://cmscompliancegroup.com/news/15-texas-nursing-homes-rule/) - Members of the Texas Sunset Advisory Commission are putting the heat on poorly performing nursing homes in Texas. The Sunset Advisory Commission is a legislative commission that oversees the identification and elimination of waste/duplication/inefficiency of Texas state agencies, including the Department of Aging and Disability Services (DADs). At an August 13, 2014 meeting, the Commission - [2 Proposed Bills Could Affect Long Term Care & Skilled Nursing Facilities](https://cmscompliancegroup.com/news/12-rn-bill-notice-act/) - Congress has been busy the past few weeks and a number of new healthcare related bills have been introduced, including the following two pieces of legislation that could directly impact nursing homes. Put a Registered Nurse in the Nursing Home Act A new bill introduced on July 31, 2014 would require all nursing homes and - [ICD-10 delay impacts implementation of OASIS-C1](https://cmscompliancegroup.com/news/28-oasis-c1-dataset-icd-10/) - In a new S&C letter, “Outcome and Assessment Information Set (OASIS)-CI / International Classification of Diseases (ICD-)9 Webinar: September 3, 2014,” (Ref: S&C: 14-40-HHA), CMS notes that is has determined that the ICD-10 delay will have an impact on the Home Health Quality Reporting Program, especially the implementation of OASIS-CI. The new version of OASIS - [Next phase of new CMS Quality Improvement Program Underway](https://cmscompliancegroup.com/news/24-qio-program-awards/) - On July 18th, the Centers for Medicare & Medicaid Services (CMS) added fourteen new organizations to its list of contracts awarded to restructure the Quality Improvement Organization (QIO) Program. Earlier this year, CMS announced that it was looking to improve the QIO program to make it more efficient, reduce perceived conflicts of interest and do - [Is your facility on the updated Special Focus Facility list?](https://cmscompliancegroup.com/news/23-special-focus-facility-list/) - An update to the CMS Special Focus Facility list was made last week, with a total of 17 new nursing homes added to the list. CMSCG is taking a deep dive into SFFs with our 3-part series. Part 2 is scheduled for release next week - have you signed up to receive our articles? Check - [Struggle to Balance Improper Payments & Medicare Appeals Claims Continues](https://cmscompliancegroup.com/news/11-settlement-conference/) - On Wednesday, the Government Accountability Office provided testimony to Congress regarding improper payments. The report found that Medicare and Medicaid were two of the top five programs with the highest reported amounts of improper payments in 2013. Recent reports about improper payments had led to an increase in auditing by the government to recover funds, - [SNF 30-Day All-Cause Readmission Measure Part of New Proposed Rule](https://cmscompliancegroup.com/news/11-hospital-snf-readmission/) - In a proposed rule published in the July 11 Federal Register, CMS recommended that Accountable Care Organizations (ACOs) be assessed on the number of people who return to their hospitals within 30 days of discharge. The measure, Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM), reviews the rate of “all cause, unplanned hospital readmissions for - [New Elder Justice Roadmap to Combat Abuse of Elderly](https://cmscompliancegroup.com/blog/09-elder-justice-roadmap/) - Today the Department of Justice (DOJ) and Department of Health and Human Services (HHS) released the Elder Justice Roadmap, which outlines the most important priorities for preventing elder abuse in America. DOJ has created a free online curriculum for attorneys to help them identify and respond to elder abuse. HHS will be creating a voluntary - [Advance Guidance: Updates to SOM Appendix PP for LTC and Chapter 4](https://cmscompliancegroup.com/news/8-som-appendixpp-chap-4-update/) - On July 3, 2014, CMS published an S&C letter that contains advance copy of multiple updates made to Appendix PP of the SOM and SOM Chapter 4. The letter, “Advance Guidance – Revisions to State Operations Manual (SOM), and Appendix PP – Guidance to Surveyors for Long Term Care (LTC) Facilities and Chapter 4,” (Ref: - [New York Focused Dementia Care Survey Pilot Update](https://cmscompliancegroup.com/news/07-ny-dementia-survey-pilot/) - We mentioned in an April 23, 2014 blog post that CMS is piloting two new survey types, with one focusing on dementia care practices and the other on MDS accuracy. The Agency noted that it planned to conduct two short-term focused reviews of the survey processes in these areas and that five State Agencies had - [Happy 4th of July from CMS Compliance Group!](https://cmscompliancegroup.com/cmscg-updates/04-happy-4th-of-july-2/) - The team at CMS Compliance Group would like to wish all our colleagues and clients a Happy 4th of July! - [RAND’s Blueprint for Improving Dementia Care Stresses Training, Better Transitions](https://cmscompliancegroup.com/news/25-rand-dementia-blueprint/) - The RAND Corporation recently released a research report, ‘Improving Dementia Long Term Care: A Policy Blueprint,” which provides a framework for stakeholders to look at how dementia and long-term services and supports (LTSS) intersect. The authors focused on five objectives for the dementia LTSS system: Increase public awareness of dementia to reduce stigma and promote - [CFPB Releases Guide to Protecting Nursing Home Residents from Financial Exploit](https://cmscompliancegroup.com/news/24-finance-exploit-prevention/) - #183409498 / gettyimages.com The Consumer Financial Protection Bureau has created a guide for nursing homes and assisted living facilities to help protect their residents from financial exploitation. It includes information on relevant laws, potential warning signs, prevention techniques and resources to assist facilities. The guide also includes relevant topics for in-service training or staff orientation. - [MedPac Report Explores Site-Neutral Payments for SNFs and IRFs](https://cmscompliancegroup.com/news/17-medpac-snfs-irfs/) - MedPac’s June 2014 Report to Congress includes a chapter on site-neutral payments between inpatient rehab facilities (IRFs) and skilled nursing facilities (SNFs). The Commission notes that there may be an opportunity to develop site-neutral policies that could eliminate unwarranted payment differences since although the services provided in IRFs and SNFs differ, the outcomes achieved may - [New Guidance on Infection Control Breaches Found on Survey](https://cmscompliancegroup.com/news/03-infection-control-breaches/) - CMS issued a memorandum on May 30, 2014 regarding infection control findings on surveys that must be referred to Public Health Authorities. The letter, “Infection Control Breaches Which Warrant Referral to Public Health Authorities,” outlines breaches that must be reported to State public health authorities so they are aware of the deficient practice. These breaches - [CMS Reiterates Sprinkler Requirement in S&C Informational Memo](https://cmscompliancegroup.com/news/23-cms-sprinkler-requirement/) - In a letter sent to all State Survey Agency Directors on May 20, 2014, “Final Rule – Promoting Program Efficiency, Transparency, and Burden Reduction, Part II – Informational Only,” CMS provided a recap of key parts of CMS-3267-F. One of these includes the limited circumstances where an extension may be granted for nursing homes that - [CMS Revises Guidance to F-371 about Preparation of Eggs](https://cmscompliancegroup.com/news/22-f371-egg-preparation/) - After last year’s landmark case about runny eggs, Elgin, CMS has finally issued guidance on the appropriate preparation of eggs in nursing homes in a S&C letter dated May 20, 2014, “Advance Copy of Revised F371; Interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes.” The guidance notes: Nursing homes should - [CMP Funds Available for Improving Dementia Care in Nursing Homes](https://cmscompliancegroup.com/news/21-cmp-funds-dementia/) - CMS is soliciting grants for using available Federal Civil Monetary Funds (CMPs) to expand the National Partnership to Improve Dementia Care in Nursing Homes. A S&C letter issued May 16, 2014, “Grant Solicitation for the Reinvestment of Federal Civil Monetary Penalty (CMP) Funds to Benefit Nursing Home Residents,” notes that $500,000 in CMP funds will - [CMS LTC Facility Survey Process Related to Sprinkler Extension](https://cmscompliancegroup.com/news/20-sprinkler-survey-process/) - On May 16 2014, CMS issued an S&C letter, “Information on Applications to Extend the Due Date for the Installation of Automatic Sprinkler Systems in Existing Nursing Homes” (Ref: S&C: 14-29-LSC). This letter serves as a follow up to a final rule issued in the May 12, 2014 Federal Register on this Life Safety Code - [Long Term Care Sprinkler Deadline Extended (Federal Register)](https://cmscompliancegroup.com/news/16-ltc-sprinkler-extension/) - August 13, 2013 – the date that all LTC facilities were required to have fully automated sprinkler systems – came and went with many facilities unable to meet the deadline. On November 15, CMS issued a memo where the agency maintained its position that it could not grant extensions and that enforcement actions would be - [CMS Revises Guidance at F-441 for Single Use Devices](https://cmscompliancegroup.com/news/13-f441-single-use-devices/) - On May 9, 2014, CMS issued advance copy of a change to interpretive guidance in the SOM regarding the requirements for single use devices. The S&C letter, “Advance Copy – Single Use Device Reprocessing under Tag F-441, Revisions to Interpretive Guidance in Appendix PP, State Operations Manual (SOM) on Infection Control” (Ref: S&C: 14-25-NH) states - [US News: 5 Traits of the Worst Nursing Homes – Familiar?](https://cmscompliancegroup.com/news/13-worst-nursing-home-traits/) - A recent US News & World Report article examined the five worst traits that can be found when evaluating a nursing home. If someone looked at your facility, would you be crossed off the list? Check out these five “red flags” from the article: A history of violations A number of severe violations High staff - [CMS to Restructure Quality Improvement Organizations (QIOs)](https://cmscompliancegroup.com/news/12-cms-to-restructure-qios/) - The Centers for Medicare & Medicaid Services (CMS) issued a press release on Friday outline the details of the launch of its improved Quality Improvement Program. CMS is looking to adapt the QIO program to make it more efficient, eliminate perceived conflicts of interest and better address the needs of Medicare beneficiaries. The first phase - [Happy Nurses' Week from CMS Compliance Group!](https://cmscompliancegroup.com/cmscg-updates/06-happy-nurses-week/) - Thank you to all nurses in the long term care industry and our nurses on staff at CMSCG - you all make a difference! - [Addressing Quality of Death (McKnight's Long Term Care News)](https://cmscompliancegroup.com/news/06-addressing-quality-of-death/) - CMS Compliance Group's President, Linda Elizaitis, wrote a guest column for McKnight's Long Term Care News - "Addressing Quality of Death." What do you do when a resident crosses the threshold and your organization needs to address quality of death? We all know that there is a great emphasis, appropriately so, on a resident's quality - [Changes Proposed to SNF Reimbursement Rates](https://cmscompliancegroup.com/news/02-snf-reimbursement-rates/) - CMS has issued a proposed rule to update PPS payment rates for skilled nursing facilities starting in 2015. The proposed rule also includes the following: Proposal to adopt the most recent OMB statistical definitions for urban/rural facility status Discussion of CMS’ current SNF therapy research Revision to policies related to Change of Therapy (COT) Other - [It’s a Preparathon! How’s Your Facility’s Disaster Plan?](https://cmscompliancegroup.com/news/29-preparathon/) - April 30, 2014 marks the first ever Preparathon, a national day of action for increasing emergency preparedness and resilience. It’s a great reminder to take the time to review your facility’s disaster plan to identify gaps. As you know, the Centers for Medicare & Medicaid Services (CMS) recently proposed a rule that enhances emergency planning - [CMS to Pilot New Focused Dementia Care Survey and MDS Survey for Nursing Homes](https://cmscompliancegroup.com/cmscg-updates/22-dementia-survey-mds-survey/) - As part of its initiative to increase Survey & Certification efforts, CMS outlined two new survey practices in an S&C letter released on April 18, 2014, “Focused Minimum Data Set (MDS) and Dementia Care Surveys.” The Agency notes that it is planning to conduct two short-term focused reviews of the survey processes surrounding dementia care, - [CMS Proposed Rule for Fire Safety Requirements (Federal Register)](https://cmscompliancegroup.com/news/23-proposed-rule-fire-safety/) - On April 16, 2014, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to revise the edition of the Life Safety Code (LSC) that is mentioned in the Requirements for long term care facilities and other providers. In an S&C Letter, “Publication of Notice of Proposed Rulemaking (MPRM) for Fire Safety Requirements - [CMS Adjusts Special Focus Facilities Program, Includes State Minimums](https://cmscompliancegroup.com/news/22-special-focus-facilities/) - Effective April 2014, the Centers for Medicare & Medicaid Services (CMS) has adjusted the number of required slots and candidates for the Special Focus Facilities program. Due to sequestration issues, CMS had required that State Agencies (SAs) schedule a final “last chance” onsite survey with nursing homes that were designated SFFs for more than 18 - [“Two Midnight” Rule on its Way to Court](https://cmscompliancegroup.com/news/16-aha-2-midnight-lawsuit/) - The American Hospital Association (AHA) issued a press release that it has filed two lawsuits challenging the controversial “two midnight” stay requirement on inpatient admissions at hospitals. CMS has issued a guidance letter in early March to provide clarification to providers about information that may have affected their rejected claims. The President & CEO of - [CMS Proposes Update to NFPA 2012 Edition of Life Safety Code](https://cmscompliancegroup.com/news/16-nfpa-2012-lsc/) - On April 14, 2014, the Centers for Medicare & Medicaid Services (CMS) proposed that the National Fire Protection Association’s (NFPA) 2012 editions of the Life Safety Code (LSC) and Health Care Facilities Code (HCFC) be used. The current edition being used is the 2000 edition. The key changes that would go into place with the - [CMS Dementia Care in Nursing Homes Report Shows Positive Trends](https://cmscompliancegroup.com/news/15-cms-antipsychotics-dementia/) - In an April 11, 2014 S&C Letter, “Interim report on the CMS National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011 – Q1 2014” (Ref: S&C 14-19-NH), CMS summarizes its initiative to reduce the off-label use of antipsychotic medications in nursing homes. An OIG report in 2011 spurred this initiative when it found - [Senators Add to Pressure for Increased Survey & Certification Activity](https://cmscompliancegroup.com/news/10-snf-survey-certification/) - Last week, our friends at McKnight’s posted a letter that Senators Bill Nelson and Charles Grassley wrote to Marilyn Tavenner to express their concern about the quality of care being provided in skilled nursing facilities (SNFs). For readers of the CMSCG Blog, this should not be that surprising. A series of reports by various agencies - [CMS Emphasizes CMPs and Immediate Jeopardies in New S&C Letter](https://cmscompliancegroup.com/news/01-som-chapter-7-cmps-ijs/) - The Centers for Medicare & Medicaid Services (CMS) issued an S&C letter, “Advance Copy: Update of State Operations Manual (SOM) Chapter 7 and Survey Process Timeframe Reminder” on March 28th. The memo emphasizes changes to Civil Monetary Penalties that are related to provisions of the Affordable Care Act (ACA). Last August, CMS issued an S&C - [CMS Compliance Group LTC News Recap (Week of 3/24/14)](https://cmscompliancegroup.com/news/28-cmscg-ltc-news-recap-32814/) - It's the end of another week - did you have a busy one? If you aren't subscribed to our blog, you may have missed these recent important posts: CMS Releases New MDS 3.0 Training Videos (Sections I, G, M & O) and OIG Nudges CMS with Compendium of Priority Recommendations (3/14). Here are some key recent - [OIG Nudges CMS with Compendium of Priority Recommendations (3/14)](https://cmscompliancegroup.com/news/26-oig-compendium-2014/) - The Office of the Inspector General (OIG) released its March 2014 Compendium of Priority Recommendations, outlining some of the key initiatives that it has provided recommendations for that have not yet been satisfactorily addressed. There are many recommendations that will impact skilled nursing facilities, particularly around the survey process. Here’s a recap of the OIG’s - [CMS Releases New MDS 3.0 Training Videos (Sections I, G, M & O)](https://cmscompliancegroup.com/news/25-cms-mds-training-videos/) - The Centers for Medicare & Medicaid Services (CMS) released new MDS 3.0 training videos on its YouTube channel yesterday. The four videos are on the following topics: Section O – Special Treatments Procedures and Programs Section G - Functional status Section M – Skin Conditions Section I – MDS 3.0 Active Diagnoses More information on - [New South Carolina Bill Would Allow Electronic Monitoring in LTC Facilities](https://cmscompliancegroup.com/news/19-electronic-monitoring-ltc/) - “Granny cams” are back in the spotlight with a recently proposed South Carolina bill, “Electronic Monitoring of a Resident’s Room in a Long-Term Care Facility.” Texas was the first state to pass a “granny cam” law, and its provisions are the basis for most other state regulations. 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[PEPPER reports](https://cmscompliancegroup.com/tag/pepper-reports/) - [Electronic Health Records](https://cmscompliancegroup.com/tag/electronic-health-records/) - [Hand-washing](https://cmscompliancegroup.com/tag/hand-washing/) - [Sprinkler System](https://cmscompliancegroup.com/tag/sprinkler-system/) - [September 11th](https://cmscompliancegroup.com/tag/september-11th/) - [Antibiotic Resistance Threats](https://cmscompliancegroup.com/tag/antibiotic-resistance-threats/) - [CDC](https://cmscompliancegroup.com/tag/cdc/) - [Painkiller guidelines](https://cmscompliancegroup.com/tag/painkiller-guidelines/) - [regulations](https://cmscompliancegroup.com/tag/regulations/) - [SNF occupancy](https://cmscompliancegroup.com/tag/snf-occupancy/) - [Bagnell v. Sebelius](https://cmscompliancegroup.com/tag/bagnell-v-sebelius/) - [Observation Stay](https://cmscompliancegroup.com/tag/observation-stay/) - [Skilled Nursing Services](https://cmscompliancegroup.com/tag/skilled-nursing-services/) - [CMS-1599-F](https://cmscompliancegroup.com/tag/cms-1599-f/) - [Complex Medical Judgment](https://cmscompliancegroup.com/tag/complex-medical-judgment/) - [SNF Coverage](https://cmscompliancegroup.com/tag/snf-coverage/) - [incentive programs](https://cmscompliancegroup.com/tag/incentive-programs/) - [Inpatient requirement](https://cmscompliancegroup.com/tag/inpatient-requirement/) - [preventing falls](https://cmscompliancegroup.com/tag/preventing-falls/) - [MDS 3.0 RAI Manual v1.11](https://cmscompliancegroup.com/tag/mds-3-0-rai-manual-v1-11/) - [October 1](https://cmscompliancegroup.com/tag/october-1/) - [government shutdown](https://cmscompliancegroup.com/tag/government-shutdown/) - [long term care costs](https://cmscompliancegroup.com/tag/long-term-care-costs/) - [sprinkler systems](https://cmscompliancegroup.com/tag/sprinkler-systems/) - [Impact of shutdown on nursing home survey & certification](https://cmscompliancegroup.com/tag/impact-of-shutdown-on-nursing-home-survey-certification/) - [Fall investigation](https://cmscompliancegroup.com/tag/fall-investigation/) - [Five-star rating](https://cmscompliancegroup.com/tag/five-star-rating/) - [Meal delivery](https://cmscompliancegroup.com/tag/meal-delivery/) - [Resident Rights](https://cmscompliancegroup.com/tag/resident-rights/) - [Survey and Certification](https://cmscompliancegroup.com/tag/survey-and-certification/) - [Dual Eligibles](https://cmscompliancegroup.com/tag/dual-eligibles/) - [LTC physician competencies](https://cmscompliancegroup.com/tag/ltc-physician-competencies/) - [Nursing home trust funds](https://cmscompliancegroup.com/tag/nursing-home-trust-funds/) - [DIsaster Plan](https://cmscompliancegroup.com/tag/disaster-plan/) - [Disaster Preparation](https://cmscompliancegroup.com/tag/disaster-preparation/) - [ASPEN](https://cmscompliancegroup.com/tag/aspen/) - [F-454](https://cmscompliancegroup.com/tag/f-454/) - [Survey & Certification](https://cmscompliancegroup.com/tag/survey-certification/) - [CPR Policy](https://cmscompliancegroup.com/tag/cpr-policy/) - [Hospital-SNF Partnerships](https://cmscompliancegroup.com/tag/hospital-snf-partnerships/) - [Nursing Home Abuse](https://cmscompliancegroup.com/tag/nursing-home-abuse/) - [Sandy](https://cmscompliancegroup.com/tag/sandy/) - [Wound Care](https://cmscompliancegroup.com/tag/wound-care/) - [RAI Manual](https://cmscompliancegroup.com/tag/rai-manual/) - [Resident Preferences](https://cmscompliancegroup.com/tag/resident-preferences/) - [Resident Sleep](https://cmscompliancegroup.com/tag/resident-sleep/) - [RAI Manual Update](https://cmscompliancegroup.com/tag/rai-manual-update/) - [SNF to SNF Ambulance Transfers](https://cmscompliancegroup.com/tag/snf-to-snf-ambulance-transfers/) - [Survey Trends](https://cmscompliancegroup.com/tag/survey-trends/) - [Obese Seniors](https://cmscompliancegroup.com/tag/obese-seniors/) - [Oral Care](https://cmscompliancegroup.com/tag/oral-care/) - [Senior Housing](https://cmscompliancegroup.com/tag/senior-housing/) - [turn schedule](https://cmscompliancegroup.com/tag/turn-schedule/) - [Enforcement Actions](https://cmscompliancegroup.com/tag/enforcement-actions/) - [Nursing Home Automatic Sprinklers](https://cmscompliancegroup.com/tag/nursing-home-automatic-sprinklers/) - [F329](https://cmscompliancegroup.com/tag/f329/) - [unnecessary medications](https://cmscompliancegroup.com/tag/unnecessary-medications/) - [OIG Report. Nursing Home Hospitalizations](https://cmscompliancegroup.com/tag/oig-report-nursing-home-hospitalizations/) - [Assisted Living Program](https://cmscompliancegroup.com/tag/assisted-living-program/) - [Audit Protocols](https://cmscompliancegroup.com/tag/audit-protocols/) - [New York](https://cmscompliancegroup.com/tag/new-york/) - [OMIG](https://cmscompliancegroup.com/tag/omig/) - [Antipychotics](https://cmscompliancegroup.com/tag/antipychotics/) - [Medication Management](https://cmscompliancegroup.com/tag/medication-management/) - [OIG Strategic Plan](https://cmscompliancegroup.com/tag/oig-strategic-plan/) - [Misappropriation](https://cmscompliancegroup.com/tag/misappropriation/) - [Quality Strategy](https://cmscompliancegroup.com/tag/quality-strategy/) - [Jimmo v. Sebelius](https://cmscompliancegroup.com/tag/jimmo-v-sebelius/) - [Medicare Program Manual](https://cmscompliancegroup.com/tag/medicare-program-manual/) - [No Improvement Standard](https://cmscompliancegroup.com/tag/no-improvement-standard/) - [dining](https://cmscompliancegroup.com/tag/dining/) - [EHR fraud](https://cmscompliancegroup.com/tag/ehr-fraud/) - [hospice claims](https://cmscompliancegroup.com/tag/hospice-claims/) - [Emergency Plan](https://cmscompliancegroup.com/tag/emergency-plan/) - [Emergency Planning Requirements](https://cmscompliancegroup.com/tag/emergency-planning-requirements/) - [Long Term Care Facilities](https://cmscompliancegroup.com/tag/long-term-care-facilities/) - [Falls](https://cmscompliancegroup.com/tag/falls/) - [HSBC Transition](https://cmscompliancegroup.com/tag/hsbc-transition/) - [Recovery Audits](https://cmscompliancegroup.com/tag/recovery-audits/) - [VA Program to Redure MRSA](https://cmscompliancegroup.com/tag/va-program-to-redure-mrsa/) - [Long Term Care Compliance](https://cmscompliancegroup.com/tag/long-term-care-compliance/) - [Post-Acute Compliance](https://cmscompliancegroup.com/tag/post-acute-compliance/) - [Home and Community Based Services](https://cmscompliancegroup.com/tag/home-and-community-based-services/) - [2 Midnight Rule](https://cmscompliancegroup.com/tag/2-midnight-rule/) - [home health reimbursements](https://cmscompliancegroup.com/tag/home-health-reimbursements/) - [Nursing home ratings](https://cmscompliancegroup.com/tag/nursing-home-ratings/) - [telemedicine](https://cmscompliancegroup.com/tag/telemedicine/) - [MLN Matters](https://cmscompliancegroup.com/tag/mln-matters/) - [Rehospitalizations](https://cmscompliancegroup.com/tag/rehospitalizations/) - [Transition nurses](https://cmscompliancegroup.com/tag/transition-nurses/) - [Nursing Home Residents](https://cmscompliancegroup.com/tag/nursing-home-residents/) - [Medicare appeals](https://cmscompliancegroup.com/tag/medicare-appeals/) - [Review Process Period](https://cmscompliancegroup.com/tag/review-process-period/) - [Fraud Detection](https://cmscompliancegroup.com/tag/fraud-detection/) - [LTC background checks](https://cmscompliancegroup.com/tag/ltc-background-checks/) - [Nursing home billing practices](https://cmscompliancegroup.com/tag/nursing-home-billing-practices/) - [OIG 2014 Work Plan](https://cmscompliancegroup.com/tag/oig-2014-work-plan/) - [POC verification](https://cmscompliancegroup.com/tag/poc-verification/) - [Nursing Home Staff Turnover](https://cmscompliancegroup.com/tag/nursing-home-staff-turnover/) - [Civil Monetary Penalities](https://cmscompliancegroup.com/tag/civil-monetary-penalities/) - [NHRRRA](https://cmscompliancegroup.com/tag/nhrrra/) - [Nursing home law](https://cmscompliancegroup.com/tag/nursing-home-law/) - [Dementia Home Care Program](https://cmscompliancegroup.com/tag/dementia-home-care-program/) - [Medicaid Managed Care](https://cmscompliancegroup.com/tag/medicaid-managed-care/) - [Dementia Village](https://cmscompliancegroup.com/tag/dementia-village/) - [MDS Assessments](https://cmscompliancegroup.com/tag/mds-assessments/) - [RAC Audits](https://cmscompliancegroup.com/tag/rac-audits/) - [2014 Top Nursing Homes](https://cmscompliancegroup.com/tag/2014-top-nursing-homes/) - [Emergency Preparedness Checklist Revision; S&C Letter](https://cmscompliancegroup.com/tag/emergency-preparedness-checklist-revision-sc-letter/) - [adverse events in nursing homes](https://cmscompliancegroup.com/tag/adverse-events-in-nursing-homes/) - [Probe and Educate](https://cmscompliancegroup.com/tag/probe-and-educate/) - [Diabetes](https://cmscompliancegroup.com/tag/diabetes/) - [EHR](https://cmscompliancegroup.com/tag/ehr/) - [Rehospitalization Rates](https://cmscompliancegroup.com/tag/rehospitalization-rates/) - [SNF Discharge](https://cmscompliancegroup.com/tag/snf-discharge/) - [Assisted Living Bill](https://cmscompliancegroup.com/tag/assisted-living-bill/) - [Florida](https://cmscompliancegroup.com/tag/florida/) - [dementia in nursing homes](https://cmscompliancegroup.com/tag/dementia-in-nursing-homes/) - [Massachusetts](https://cmscompliancegroup.com/tag/massachusetts/) - [CMSCG](https://cmscompliancegroup.com/tag/cmscg/) - [medicaid fraud](https://cmscompliancegroup.com/tag/medicaid-fraud/) - [nursing home inspection](https://cmscompliancegroup.com/tag/nursing-home-inspection/) - [Background Checks](https://cmscompliancegroup.com/tag/background-checks/) - [electronic monitoring](https://cmscompliancegroup.com/tag/electronic-monitoring/) - [Granny cams](https://cmscompliancegroup.com/tag/granny-cams/) - [South Carolina bill](https://cmscompliancegroup.com/tag/south-carolina-bill/) - [MDS 3.0 Training Videos](https://cmscompliancegroup.com/tag/mds-3-0-training-videos/) - [emergency planning](https://cmscompliancegroup.com/tag/emergency-planning/) - [Nursing Homes. OIG](https://cmscompliancegroup.com/tag/nursing-homes-oig/) - [CCRC](https://cmscompliancegroup.com/tag/ccrc/) - [Lawsuits](https://cmscompliancegroup.com/tag/lawsuits/) - [Independent IDR](https://cmscompliancegroup.com/tag/independent-idr/) - [SOM Chapter 7](https://cmscompliancegroup.com/tag/som-chapter-7/) - [Interim report](https://cmscompliancegroup.com/tag/interim-report/) - [Partnership to Improve Dementia Care](https://cmscompliancegroup.com/tag/partnership-to-improve-dementia-care/) - [NFPA 2012](https://cmscompliancegroup.com/tag/nfpa-2012/) - [American Hospital Association](https://cmscompliancegroup.com/tag/american-hospital-association/) - [Nursing Home Survey](https://cmscompliancegroup.com/tag/nursing-home-survey/) - [Special Focus Facilities List](https://cmscompliancegroup.com/tag/special-focus-facilities-list/) - [Federal Register](https://cmscompliancegroup.com/tag/federal-register/) - [Proposed Rule](https://cmscompliancegroup.com/tag/proposed-rule/) - [Dementia Care](https://cmscompliancegroup.com/tag/dementia-care/) - [Preparathon](https://cmscompliancegroup.com/tag/preparathon/) - [reimbursement rates](https://cmscompliancegroup.com/tag/reimbursement-rates/) - [Quality of death](https://cmscompliancegroup.com/tag/quality-of-death/) - [Nurses' Week](https://cmscompliancegroup.com/tag/nurses-week/) - [QIO](https://cmscompliancegroup.com/tag/qio/) - [Quality Improvement Organizations](https://cmscompliancegroup.com/tag/quality-improvement-organizations/) - [Resident Choice](https://cmscompliancegroup.com/tag/resident-choice/) - [Staff Turnover](https://cmscompliancegroup.com/tag/staff-turnover/) - [Survey History](https://cmscompliancegroup.com/tag/survey-history/) - [US News & World Report](https://cmscompliancegroup.com/tag/us-news-world-report/) - [Worst Nursing Homes](https://cmscompliancegroup.com/tag/worst-nursing-homes/) - [F-441](https://cmscompliancegroup.com/tag/f-441/) - [Sprinklers](https://cmscompliancegroup.com/tag/sprinklers/) - [Music & Memory](https://cmscompliancegroup.com/tag/music-memory/) - [National Partnership to Improve Dementia Care in Nursing Homes](https://cmscompliancegroup.com/tag/national-partnership-to-improve-dementia-care-in-nursing-homes/) - [S&C Letter](https://cmscompliancegroup.com/tag/sc-letter/) - [Eggs](https://cmscompliancegroup.com/tag/eggs/) - [Elgin](https://cmscompliancegroup.com/tag/elgin/) - [F-371](https://cmscompliancegroup.com/tag/f-371/) - [State Public Health authorities](https://cmscompliancegroup.com/tag/state-public-health-authorities/) - [Inpatient Rehab Facilities](https://cmscompliancegroup.com/tag/inpatient-rehab-facilities/) - [MedPac](https://cmscompliancegroup.com/tag/medpac/) - [Site-Neutral Payments](https://cmscompliancegroup.com/tag/site-neutral-payments/) - [CFPB](https://cmscompliancegroup.com/tag/cfpb/) - [InService Training](https://cmscompliancegroup.com/tag/inservice-training/) - [Resident Financial Exploitation Prevention Guide](https://cmscompliancegroup.com/tag/resident-financial-exploitation-prevention-guide/) - [Care Transitions](https://cmscompliancegroup.com/tag/care-transitions/) - [Improving Dementia](https://cmscompliancegroup.com/tag/improving-dementia/) - [LTSS](https://cmscompliancegroup.com/tag/ltss/) - [Rand](https://cmscompliancegroup.com/tag/rand/) - [Staff Training](https://cmscompliancegroup.com/tag/staff-training/) - [SFF](https://cmscompliancegroup.com/tag/sff/) - [Survey Results](https://cmscompliancegroup.com/tag/survey-results/) - [Dementia Focused Survey](https://cmscompliancegroup.com/tag/dementia-focused-survey/) - [SOM Chapter 4](https://cmscompliancegroup.com/tag/som-chapter-4/) - [Elder Abuse](https://cmscompliancegroup.com/tag/elder-abuse/) - [Elder Justice Roadmap](https://cmscompliancegroup.com/tag/elder-justice-roadmap/) - [ACOs](https://cmscompliancegroup.com/tag/acos/) - [Hospital Quality Measures](https://cmscompliancegroup.com/tag/hospital-quality-measures/) - [Readmissions](https://cmscompliancegroup.com/tag/readmissions/) - [Settlement Conference Facilitation Pilot](https://cmscompliancegroup.com/tag/settlement-conference-facilitation-pilot/) - [Quality Improvement Organization Program](https://cmscompliancegroup.com/tag/quality-improvement-organization-program/) - [ICD-10 implementation](https://cmscompliancegroup.com/tag/icd-10-implementation/) - [OASIS-C1](https://cmscompliancegroup.com/tag/oasis-c1/) - [Legislation](https://cmscompliancegroup.com/tag/legislation/) - [NOTICE Act](https://cmscompliancegroup.com/tag/notice-act/) - [Put a Registered Nurse in the Nursing Home Act](https://cmscompliancegroup.com/tag/put-a-registered-nurse-in-the-nursing-home-act/) - [3 strikes rule](https://cmscompliancegroup.com/tag/3-strikes-rule/) - [repeat deficiencies](https://cmscompliancegroup.com/tag/repeat-deficiencies/) - [Texas Nursing Homes](https://cmscompliancegroup.com/tag/texas-nursing-homes/) - [Texas Sunset Advisory Commission](https://cmscompliancegroup.com/tag/texas-sunset-advisory-commission/) - [ChemRX](https://cmscompliancegroup.com/tag/chemrx/) - [Healthcare Association of New Jersey](https://cmscompliancegroup.com/tag/healthcare-association-of-new-jersey/) - [LeadingAge New Yorkk](https://cmscompliancegroup.com/tag/leadingage-new-yorkk/) - [Pennsylvania Healthcare Association](https://cmscompliancegroup.com/tag/pennsylvania-healthcare-association/) - [Focused Dementia Care Survey Pilot](https://cmscompliancegroup.com/tag/focused-dementia-care-survey-pilot/) - [National Partnership to Improve Dementia Care](https://cmscompliancegroup.com/tag/national-partnership-to-improve-dementia-care/) - [Abuse Reporting in Nursing Homes](https://cmscompliancegroup.com/tag/abuse-reporting-in-nursing-homes/) - [Investigations](https://cmscompliancegroup.com/tag/investigations/) - [Neglect Reporting in Nursing Homes](https://cmscompliancegroup.com/tag/neglect-reporting-in-nursing-homes/) - [Learning Tool on Building Respect for LGBT Older Adults](https://cmscompliancegroup.com/tag/learning-tool-on-building-respect-for-lgbt-older-adults/) - [long term care providers](https://cmscompliancegroup.com/tag/long-term-care-providers/) - [Certified Beds](https://cmscompliancegroup.com/tag/certified-beds/) - [OASIS Master Training Program](https://cmscompliancegroup.com/tag/oasis-master-training-program/) - [Affordable Care Act Mandate](https://cmscompliancegroup.com/tag/affordable-care-act-mandate/) - [Jan Schakowsky](https://cmscompliancegroup.com/tag/jan-schakowsky/) - [Long term care staffing](https://cmscompliancegroup.com/tag/long-term-care-staffing/) - [MDS 3.0 Manual](https://cmscompliancegroup.com/tag/mds-3-0-manual/) - [OASIS](https://cmscompliancegroup.com/tag/oasis/) - [Focused Surveys](https://cmscompliancegroup.com/tag/focused-surveys/) - [IMPACT Act](https://cmscompliancegroup.com/tag/impact-act/) - [Power Strips](https://cmscompliancegroup.com/tag/power-strips/) - [HCANJ](https://cmscompliancegroup.com/tag/hcanj/) - [Grants](https://cmscompliancegroup.com/tag/grants/) - [National Background Check Program](https://cmscompliancegroup.com/tag/national-background-check-program/) - [Happy Halloween](https://cmscompliancegroup.com/tag/happy-halloween/) - [CMS S&C letter](https://cmscompliancegroup.com/tag/cms-sc-letter/) - [MDS focused survey](https://cmscompliancegroup.com/tag/mds-focused-survey/) - [staffing levels](https://cmscompliancegroup.com/tag/staffing-levels/) - [Veterans Day](https://cmscompliancegroup.com/tag/veterans-day/) - [OIG FY 2015 Work Plan](https://cmscompliancegroup.com/tag/oig-fy-2015-work-plan/) - [World Wide Pressure Ulcer Prevention Day](https://cmscompliancegroup.com/tag/world-wide-pressure-ulcer-prevention-day/) - [Skilled nursing staffing levels](https://cmscompliancegroup.com/tag/skilled-nursing-staffing-levels/) - [SNF Open Door Forum](https://cmscompliancegroup.com/tag/snf-open-door-forum/) - [Appendix PP](https://cmscompliancegroup.com/tag/appendix-pp/) - [Guidance to Surveyors](https://cmscompliancegroup.com/tag/guidance-to-surveyors/) - [Spousal relationship terms](https://cmscompliancegroup.com/tag/spousal-relationship-terms/) - [Active Shooter Guidance](https://cmscompliancegroup.com/tag/active-shooter-guidance/) - [Home Health Compare](https://cmscompliancegroup.com/tag/home-health-compare/) - [AALNC](https://cmscompliancegroup.com/tag/aalnc/) - [legal nurse consultant](https://cmscompliancegroup.com/tag/legal-nurse-consultant/) - [Resident to Resident Mistreatment](https://cmscompliancegroup.com/tag/resident-to-resident-mistreatment/) - [INTERACT version 4.0](https://cmscompliancegroup.com/tag/interact-version-4-0/) - [OPTIMISTIC care model](https://cmscompliancegroup.com/tag/optimistic-care-model/) - [SNF reimbursement](https://cmscompliancegroup.com/tag/snf-reimbursement/) - [Medicare hospices](https://cmscompliancegroup.com/tag/medicare-hospices/) - [CPR requirements](https://cmscompliancegroup.com/tag/cpr-requirements/) - [OASIS Train-the-Trainer](https://cmscompliancegroup.com/tag/oasis-train-the-trainer/) - [Advanced Administrator Leadership Program](https://cmscompliancegroup.com/tag/advanced-administrator-leadership-program/) - [State Long Term Care Ombudsman Program](https://cmscompliancegroup.com/tag/state-long-term-care-ombudsman-program/) - [Five Star Rating system](https://cmscompliancegroup.com/tag/five-star-rating-system/) - [Long Term Living](https://cmscompliancegroup.com/tag/long-term-living/) - [F803](https://cmscompliancegroup.com/tag/f803/) - [Ftag of the Week](https://cmscompliancegroup.com/tag/ftag-of-the-week/) - [Ftag Renumbering](https://cmscompliancegroup.com/tag/ftag-renumbering/) - [Nursing Home Compare 3.0](https://cmscompliancegroup.com/tag/nursing-home-compare-3-0/) - [Targeted Surveys](https://cmscompliancegroup.com/tag/targeted-surveys/) - [GAO Report](https://cmscompliancegroup.com/tag/gao-report/) - [QAPI rollout](https://cmscompliancegroup.com/tag/qapi-rollout/) - [Quality Assurance and Performance Improvement](https://cmscompliancegroup.com/tag/quality-assurance-and-performance-improvement/) - [observation status](https://cmscompliancegroup.com/tag/observation-status/) - [e-prescribing](https://cmscompliancegroup.com/tag/e-prescribing/) - [dementia care survey](https://cmscompliancegroup.com/tag/dementia-care-survey/) - [Payroll-based Journal](https://cmscompliancegroup.com/tag/payroll-based-journal/) - [Departmental Appeals Board](https://cmscompliancegroup.com/tag/departmental-appeals-board/) - [OPTIMISTIC](https://cmscompliancegroup.com/tag/optimistic/) - [Long Term Care Community Coalition](https://cmscompliancegroup.com/tag/long-term-care-community-coalition/) - [CPR in nursing homes](https://cmscompliancegroup.com/tag/cpr-in-nursing-homes/) - [F-155](https://cmscompliancegroup.com/tag/f-155/) - [OSHA](https://cmscompliancegroup.com/tag/osha/) - [Workplace Violence Prevention Guidelines](https://cmscompliancegroup.com/tag/workplace-violence-prevention-guidelines/) - [MDS Focused Surveys](https://cmscompliancegroup.com/tag/mds-focused-surveys/) - [long term care facility](https://cmscompliancegroup.com/tag/long-term-care-facility/) - [Texas DADs. dementia-focused survey](https://cmscompliancegroup.com/tag/texas-dads-dementia-focused-survey/) - [Falls Prevention Program](https://cmscompliancegroup.com/tag/falls-prevention-program/) - [background check](https://cmscompliancegroup.com/tag/background-check/) - [Home health agencies](https://cmscompliancegroup.com/tag/home-health-agencies/) - [New Jersey home health agencies](https://cmscompliancegroup.com/tag/new-jersey-home-health-agencies/) - [Hospital Short-Stays](https://cmscompliancegroup.com/tag/hospital-short-stays/) - [Focused dementia care surveys](https://cmscompliancegroup.com/tag/focused-dementia-care-surveys/) - [MLN Connects](https://cmscompliancegroup.com/tag/mln-connects/) - [OPTIMISTIC study](https://cmscompliancegroup.com/tag/optimistic-study/) - [AHRQ](https://cmscompliancegroup.com/tag/ahrq/) - [Nursing Home Safety Culture](https://cmscompliancegroup.com/tag/nursing-home-safety-culture/) - [nursing home inspections](https://cmscompliancegroup.com/tag/nursing-home-inspections/) - [Long Term Care regulations](https://cmscompliancegroup.com/tag/long-term-care-regulations/) - [#LTCRegs](https://cmscompliancegroup.com/tag/ltcregs/) - [Nursing Facility Regulations](https://cmscompliancegroup.com/tag/nursing-facility-regulations/) - [Facility Assessment](https://cmscompliancegroup.com/tag/facility-assessment/) - [Star ratings](https://cmscompliancegroup.com/tag/star-ratings/) - [LGBT Older Adults](https://cmscompliancegroup.com/tag/lgbt-older-adults/) - [Adverse Drug Events](https://cmscompliancegroup.com/tag/adverse-drug-events/) - [Focused Survey](https://cmscompliancegroup.com/tag/focused-survey/) - [Focused Survey on Medication Safety Systems](https://cmscompliancegroup.com/tag/focused-survey-on-medication-safety-systems/) - [LTC regulations](https://cmscompliancegroup.com/tag/ltc-regulations/) - [Competency-based Staffing](https://cmscompliancegroup.com/tag/competency-based-staffing/) - [GAO](https://cmscompliancegroup.com/tag/gao/) - [Quality Reporting Program](https://cmscompliancegroup.com/tag/quality-reporting-program/) - [SNF Staffing](https://cmscompliancegroup.com/tag/snf-staffing/) - [SNF Value-Based Purchasing Program](https://cmscompliancegroup.com/tag/snf-value-based-purchasing-program/) - [Staffing requirements](https://cmscompliancegroup.com/tag/staffing-requirements/) - [nursing home staffing requirements](https://cmscompliancegroup.com/tag/nursing-home-staffing-requirements/) - [Antibiotic Stewardship](https://cmscompliancegroup.com/tag/antibiotic-stewardship/) - [Antibiotics in nursing homes](https://cmscompliancegroup.com/tag/antibiotics-in-nursing-homes/) - [CDC Core Elements of Antibiotic Stewardship for Nursing Homes](https://cmscompliancegroup.com/tag/cdc-core-elements-of-antibiotic-stewardship-for-nursing-homes/) - [Speak up on Antibiotics](https://cmscompliancegroup.com/tag/speak-up-on-antibiotics/) - [Long term care electronic monitoring devices](https://cmscompliancegroup.com/tag/long-term-care-electronic-monitoring-devices/) - [CNAs](https://cmscompliancegroup.com/tag/cnas/) - [New Jersey Nursing Homes](https://cmscompliancegroup.com/tag/new-jersey-nursing-homes/) - [MDS 3.0 QM User’s Manual 9.0](https://cmscompliancegroup.com/tag/mds-3-0-qm-users-manual-9-0/) - [OIG Report SNF therapy levels](https://cmscompliancegroup.com/tag/oig-report-snf-therapy-levels/) - [Happy Holidays](https://cmscompliancegroup.com/tag/happy-holidays/) - [Care transition strategies](https://cmscompliancegroup.com/tag/care-transition-strategies/) - [compliance programs](https://cmscompliancegroup.com/tag/compliance-programs/) - [NYS OMIG](https://cmscompliancegroup.com/tag/nys-omig/) - [webinar](https://cmscompliancegroup.com/tag/webinar/) - [end-of-life planning](https://cmscompliancegroup.com/tag/end-of-life-planning/) - [adult day health services](https://cmscompliancegroup.com/tag/adult-day-health-services/) - [OIG FY 2016 Work Plan](https://cmscompliancegroup.com/tag/oig-fy-2016-work-plan/) - [Nursing Home Quality Improvement](https://cmscompliancegroup.com/tag/nursing-home-quality-improvement/) - [Emergency Generators](https://cmscompliancegroup.com/tag/emergency-generators/) - [New Jersey healthcare facilities](https://cmscompliancegroup.com/tag/new-jersey-healthcare-facilities/) - [Infection Control Pilot Project](https://cmscompliancegroup.com/tag/infection-control-pilot-project/) - [Focused Dementia Care Survey](https://cmscompliancegroup.com/tag/focused-dementia-care-survey/) - [Memory Care Forum](https://cmscompliancegroup.com/tag/memory-care-forum/) - [Patient Star Ratings](https://cmscompliancegroup.com/tag/patient-star-ratings/) - [Nursing Home Data Compendium](https://cmscompliancegroup.com/tag/nursing-home-data-compendium/) - [Exit conference](https://cmscompliancegroup.com/tag/exit-conference/) - [Long-Term Services and Supports](https://cmscompliancegroup.com/tag/long-term-services-and-supports/) - [White House Conference on Aging](https://cmscompliancegroup.com/tag/white-house-conference-on-aging/) - [Dementia Care Focused Survey](https://cmscompliancegroup.com/tag/dementia-care-focused-survey/) - [Medication Accuracy Focused Survey](https://cmscompliancegroup.com/tag/medication-accuracy-focused-survey/) - [Michigan Focused Surveys](https://cmscompliancegroup.com/tag/michigan-focused-surveys/) - [Illinois Focused Surveys](https://cmscompliancegroup.com/tag/illinois-focused-surveys/) - [Massachusetts Focused Surveys](https://cmscompliancegroup.com/tag/massachusetts-focused-surveys/) - [Med Errors](https://cmscompliancegroup.com/tag/med-errors/) - [CMS Focused Surveys](https://cmscompliancegroup.com/tag/cms-focused-surveys/) - [Connecticut](https://cmscompliancegroup.com/tag/connecticut/) - [Illinois](https://cmscompliancegroup.com/tag/illinois/) - [Michigan](https://cmscompliancegroup.com/tag/michigan/) - [New York Nursing Homes](https://cmscompliancegroup.com/tag/new-york-nursing-homes/) - [CMS Open Door Forum](https://cmscompliancegroup.com/tag/cms-open-door-forum/) - [Abuse Prevention](https://cmscompliancegroup.com/tag/abuse-prevention/) - [Resident Dignity](https://cmscompliancegroup.com/tag/resident-dignity/) - [Social Media Policy](https://cmscompliancegroup.com/tag/social-media-policy/) - [Oregon](https://cmscompliancegroup.com/tag/oregon/) - [F329 Unnecessary Drugs](https://cmscompliancegroup.com/tag/f329-unnecessary-drugs/) - [Psychosocial harm](https://cmscompliancegroup.com/tag/psychosocial-harm/) - [DOJ Elder Justice Task Forces](https://cmscompliancegroup.com/tag/doj-elder-justice-task-forces/) - [SNF 30-Day Potentially Preventable Readmission Measure](https://cmscompliancegroup.com/tag/snf-30-day-potentially-preventable-readmission-measure/) - [SNF Value Based Purchasing](https://cmscompliancegroup.com/tag/snf-value-based-purchasing/) - [justice-involved individuals](https://cmscompliancegroup.com/tag/justice-involved-individuals/) - [nursing facility resident rights](https://cmscompliancegroup.com/tag/nursing-facility-resident-rights/) - [Nursing home adverse events](https://cmscompliancegroup.com/tag/nursing-home-adverse-events/) - [Medicare Payment System](https://cmscompliancegroup.com/tag/medicare-payment-system/) - [therapy billing](https://cmscompliancegroup.com/tag/therapy-billing/) - [Drug Regimen Review](https://cmscompliancegroup.com/tag/drug-regimen-review/) - [Environmental Consulting](https://cmscompliancegroup.com/tag/environmental-consulting/) - [Home-like environment](https://cmscompliancegroup.com/tag/home-like-environment/) - 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[Termination Notices](https://cmscompliancegroup.com/tag/termination-notices/) - [F557](https://cmscompliancegroup.com/tag/f557/) - [Critical Element Pathways](https://cmscompliancegroup.com/tag/critical-element-pathways/) - [Entrance Conference Form](https://cmscompliancegroup.com/tag/entrance-conference-form/) - [LTC Survey](https://cmscompliancegroup.com/tag/ltc-survey/) - [LTC survey process](https://cmscompliancegroup.com/tag/ltc-survey-process/) - [Emergency Preparedness Plan](https://cmscompliancegroup.com/tag/emergency-preparedness-plan/) - [Hurricane Harvey](https://cmscompliancegroup.com/tag/hurricane-harvey/) - [Abuse and Neglect](https://cmscompliancegroup.com/tag/abuse-and-neglect/) - [Surveyor training](https://cmscompliancegroup.com/tag/surveyor-training/) - [F678](https://cmscompliancegroup.com/tag/f678/) - [F561 Self-Determination](https://cmscompliancegroup.com/tag/f561-self-determination/) - [F851](https://cmscompliancegroup.com/tag/f851/) - [Falls Prevention Awareness Day](https://cmscompliancegroup.com/tag/falls-prevention-awareness-day/) - [F758](https://cmscompliancegroup.com/tag/f758/) - [Unnecessary psychotropic meds](https://cmscompliancegroup.com/tag/unnecessary-psychotropic-meds/) - [F574 Notices and Communication](https://cmscompliancegroup.com/tag/f574-notices-and-communication/) - [New Ftag list](https://cmscompliancegroup.com/tag/new-ftag-list/) - [F825 Specialized Rehab Services](https://cmscompliancegroup.com/tag/f825-specialized-rehab-services/) - [F584](https://cmscompliancegroup.com/tag/f584/) - [F744](https://cmscompliancegroup.com/tag/f744/) - [Treatment/Service for Dementia](https://cmscompliancegroup.com/tag/treatmentservice-for-dementia/) - [CDC US Antbiotic Awareness Week](https://cmscompliancegroup.com/tag/cdc-us-antbiotic-awareness-week/) - [F881 Antibiotic Stewardship Program](https://cmscompliancegroup.com/tag/f881-antibiotic-stewardship-program/) - [F803 Menus Meet Resident Needs/ Prepared in Advance/ Followed](https://cmscompliancegroup.com/tag/f803-menus-meet-resident-needs-prepared-in-advance-followed/) - [LTCSP](https://cmscompliancegroup.com/tag/ltcsp/) - [Phase 2 RoPs](https://cmscompliancegroup.com/tag/phase-2-rops/) - [F553 Right to Participate in Planning Care](https://cmscompliancegroup.com/tag/f553-right-to-participate-in-planning-care/) - [F624 Orientation for Transfer or Discharge](https://cmscompliancegroup.com/tag/f624-orientation-for-transfer-or-discharge/) - [CMS Surveyor Training](https://cmscompliancegroup.com/tag/cms-surveyor-training/) - [Facility initiated discharges](https://cmscompliancegroup.com/tag/facility-initiated-discharges/) - [Text message orders](https://cmscompliancegroup.com/tag/text-message-orders/) - [F835 Administration](https://cmscompliancegroup.com/tag/f835-administration/) - [F639 Maintain 15 Months of Assessments](https://cmscompliancegroup.com/tag/f639-maintain-15-months-of-assessments/) - [F730 Nurse Aide Performance Review – 12Hr/Yr In-Service](https://cmscompliancegroup.com/tag/f730-nurse-aide-performance-review-12hryr-in-service/) - [HHA Survey Protocol](https://cmscompliancegroup.com/tag/hha-survey-protocol/) - [State Operations Manual Appendix B](https://cmscompliancegroup.com/tag/state-operations-manual-appendix-b/) - [CMS QSO memo](https://cmscompliancegroup.com/tag/cms-qso-memo/) - [Federal Oversight Support Survey (FOSS)](https://cmscompliancegroup.com/tag/federal-oversight-support-survey-foss/) - [FOSS National Pilot](https://cmscompliancegroup.com/tag/foss-national-pilot/) - [Appropriate transfers and discharges](https://cmscompliancegroup.com/tag/appropriate-transfers-and-discharges/) - [Review and Correct Reports](https://cmscompliancegroup.com/tag/review-and-correct-reports/) - [F554 Resident Self-Administer Meds – Clinically Appropriate](https://cmscompliancegroup.com/tag/f554-resident-self-administer-meds-clinically-appropriate/) - [Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN)](https://cmscompliancegroup.com/tag/skilled-nursing-facility-advance-beneficiary-notice-of-non-coverage-snfabn/) - [SNFABN](https://cmscompliancegroup.com/tag/snfabn/) - [F696 Prostheses](https://cmscompliancegroup.com/tag/f696-prostheses/) - [F809 Frequency of Meals/ Snacks at Bedtime](https://cmscompliancegroup.com/tag/f809-frequency-of-meals-snacks-at-bedtime/) - [Food and Nutrition Services](https://cmscompliancegroup.com/tag/food-and-nutrition-services/) - [§483.10 Resident Rights](https://cmscompliancegroup.com/tag/§483-10-resident-rights/) - [F552 Right to be Informed/ Make Treatment Decisions](https://cmscompliancegroup.com/tag/f552-right-to-be-informed-make-treatment-decisions/) - [Five-Star Quality Rating System Technical Users’ Guide](https://cmscompliancegroup.com/tag/five-star-quality-rating-system-technical-users-guide/) - [Health Inspection](https://cmscompliancegroup.com/tag/health-inspection/) - [Treatment/Devices to Maintain Hearing/Vision](https://cmscompliancegroup.com/tag/treatmentdevices-to-maintain-hearingvision/) - [F761 Label/Store Drugs & Biologicals](https://cmscompliancegroup.com/tag/f761-labelstore-drugs-biologicals/) - [Long Term Care Administrator's Week](https://cmscompliancegroup.com/tag/long-term-care-administrators-week/) - [F573 Right to Access/ Purchase Copies of Records](https://cmscompliancegroup.com/tag/f573-right-to-access-purchase-copies-of-records/) - [Infection Prevention and Control](https://cmscompliancegroup.com/tag/infection-prevention-and-control/) - [F908 Essential Equipment](https://cmscompliancegroup.com/tag/f908-essential-equipment/) - [Safe Operating Condition](https://cmscompliancegroup.com/tag/safe-operating-condition/) - [F710 Resident’s Care Supervised by a Physician](https://cmscompliancegroup.com/tag/f710-residents-care-supervised-by-a-physician/) - [F606 Not Employ/Engage Staff with Adverse Actions](https://cmscompliancegroup.com/tag/f606-not-employengage-staff-with-adverse-actions/) - [Freedom from Abuse](https://cmscompliancegroup.com/tag/freedom-from-abuse/) - [Neglect and Exploitation](https://cmscompliancegroup.com/tag/neglect-and-exploitation/) - [F727 RN 8 Hrs/7 days/Wk](https://cmscompliancegroup.com/tag/f727-rn-8-hrs7-dayswk/) - [Full Time DON](https://cmscompliancegroup.com/tag/full-time-don/) - [Nursing Services](https://cmscompliancegroup.com/tag/nursing-services/) - [(§)483.20 Resident Assessments](https://cmscompliancegroup.com/tag/§483-20-resident-assessments/) - [F645 PASARR Screening for Mental Disorder/ Intellectual Disability](https://cmscompliancegroup.com/tag/f645-pasarr-screening-for-mental-disorder-intellectual-disability/) - [(§)483.50 Laboratory/Radiology/Other Diagnostic Services](https://cmscompliancegroup.com/tag/§483-50-laboratoryradiologyother-diagnostic-services/) - [F777 Radiology/Diag. Svcs Ordered/Notify Results](https://cmscompliancegroup.com/tag/f777-radiologydiag-svcs-orderednotify-results/) - [F943 Abuse Neglect and Exploitation Training](https://cmscompliancegroup.com/tag/f943-abuse-neglect-and-exploitation-training/) - [F563 Right to Receive/Deny Visitors](https://cmscompliancegroup.com/tag/f563-right-to-receivedeny-visitors/) - [Residents Rights](https://cmscompliancegroup.com/tag/residents-rights/) - [LTCSP Procedure Guide](https://cmscompliancegroup.com/tag/ltcsp-procedure-guide/) - [F800 Provided Diet Meets Needs of Each Resident](https://cmscompliancegroup.com/tag/f800-provided-diet-meets-needs-of-each-resident/) - [Behavioral Health Services](https://cmscompliancegroup.com/tag/behavioral-health-services/) - [F745 Provision of Medically Related Social Services](https://cmscompliancegroup.com/tag/f745-provision-of-medically-related-social-services/) - [F675 Quality of Life](https://cmscompliancegroup.com/tag/f675-quality-of-life/) - [Texas](https://cmscompliancegroup.com/tag/texas/) - [F658 Services Provided Meet Professional Standards](https://cmscompliancegroup.com/tag/f658-services-provided-meet-professional-standards/) - [Understanding Appropriate Transfers and Discharges](https://cmscompliancegroup.com/tag/understanding-appropriate-transfers-and-discharges/) - [F610 Investigate/Prevent/Correct Alleged Violation](https://cmscompliancegroup.com/tag/f610-investigatepreventcorrect-alleged-violation/) - [adult care facilities](https://cmscompliancegroup.com/tag/adult-care-facilities/) - [DAL](https://cmscompliancegroup.com/tag/dal/) - [Dental Services](https://cmscompliancegroup.com/tag/dental-services/) - [F790](https://cmscompliancegroup.com/tag/f790/) - [F791](https://cmscompliancegroup.com/tag/f791/) - [Legionella](https://cmscompliancegroup.com/tag/legionella/) - [Home health care](https://cmscompliancegroup.com/tag/home-health-care/) - [Patient-Driven Groupings Model](https://cmscompliancegroup.com/tag/patient-driven-groupings-model/) - [Remote monitoring](https://cmscompliancegroup.com/tag/remote-monitoring/) - [Centers for Medicare & Medicaid Services (CMS)](https://cmscompliancegroup.com/tag/centers-for-medicare-medicaid-services-cms/) - [Nursing Facility Staffing Levels](https://cmscompliancegroup.com/tag/nursing-facility-staffing-levels/) - [Interpretive Guidelines](https://cmscompliancegroup.com/tag/interpretive-guidelines/) - [F559 Choose/ Be Notified of Room/ Roommate Change](https://cmscompliancegroup.com/tag/f559-choose-be-notified-of-room-roommate-change/) - [F679 Activities Meet Interest/ Needs of Each Resident](https://cmscompliancegroup.com/tag/f679-activities-meet-interest-needs-of-each-resident/) - [F659 Qualified Persons](https://cmscompliancegroup.com/tag/f659-qualified-persons/) - [F684 Quality of Care](https://cmscompliancegroup.com/tag/f684-quality-of-care/) - [CMS FY 2019 Mission & Priorities](https://cmscompliancegroup.com/tag/cms-fy-2019-mission-priorities/) - [Skilled Nursing Facility Quality Reporting Program](https://cmscompliancegroup.com/tag/skilled-nursing-facility-quality-reporting-program/) - [F743 No Pattern of Behavioral Difficulties Unless Unavoidable](https://cmscompliancegroup.com/tag/f743-no-pattern-of-behavioral-difficulties-unless-unavoidable/) - [US Antibiotics Awareness Week](https://cmscompliancegroup.com/tag/us-antibiotics-awareness-week/) - [Grievances](https://cmscompliancegroup.com/tag/grievances/) - [F641 Accuracy of Assessments](https://cmscompliancegroup.com/tag/f641-accuracy-of-assessments/) - [F948 Training for Feeding Assistants](https://cmscompliancegroup.com/tag/f948-training-for-feeding-assistants/) - [CMPRP Nursing Home Staff Competency Assessment Tools](https://cmscompliancegroup.com/tag/cmprp-nursing-home-staff-competency-assessment-tools/) - [Patient Driven Payment Model](https://cmscompliancegroup.com/tag/patient-driven-payment-model/) - [F811 Feeding Asst – Training/Supervision/Resident](https://cmscompliancegroup.com/tag/f811-feeding-asst-training-supervision-resident/) - [Involuntary Transfers and Discharges](https://cmscompliancegroup.com/tag/involuntary-transfers-and-discharges/) - [F567 – Protection / Management of Personal Funds](https://cmscompliancegroup.com/tag/f567-protection-management-of-personal-funds/) - [F687 Foot Care](https://cmscompliancegroup.com/tag/f687-foot-care/) - [F837 Governing Body](https://cmscompliancegroup.com/tag/f837-governing-body/) - [F947 Required Inservice Training for Nurse Aides](https://cmscompliancegroup.com/tag/f947-required-inservice-training-for-nurse-aides/) - [Inservice](https://cmscompliancegroup.com/tag/inservice/) - [Adverse Events](https://cmscompliancegroup.com/tag/adverse-events/) - [All-Cause Harm Prevention](https://cmscompliancegroup.com/tag/all-cause-harm-prevention/) - [F558 Reasonable Accomodation of Needs/Preferences](https://cmscompliancegroup.com/tag/f558-reasonable-accomodation-of-needs-preferences/) - [Home Health Conditions of Participation](https://cmscompliancegroup.com/tag/home-health-conditions-of-participation/) - [QSO Memo](https://cmscompliancegroup.com/tag/qso-memo/) - [F880 Infection Prevention & Control](https://cmscompliancegroup.com/tag/f880-infection-prevention-control/) - [Legionnaires' Disease](https://cmscompliancegroup.com/tag/legionnaires-disease/) - [Water Management Programs](https://cmscompliancegroup.com/tag/water-management-programs/) - [Appendix Z](https://cmscompliancegroup.com/tag/appendix-z/) - [F880 Infection Prevention and Control](https://cmscompliancegroup.com/tag/f880-infection-prevention-and-control/) - [MDS 3.0 Data specifications](https://cmscompliancegroup.com/tag/mds-3-0-data-specifications/) - [PDPM](https://cmscompliancegroup.com/tag/pdpm/) - [F883 Influenza and Pneumococcal Vaccinations](https://cmscompliancegroup.com/tag/f883-influenza-and-pneumococcal-vaccinations/) - [MDS 3.0 QM User's Manual Version 12.0](https://cmscompliancegroup.com/tag/mds-3-0-qm-users-manual-version-12-0/) - [F882 Infection Preventionist](https://cmscompliancegroup.com/tag/f882-infection-preventionist/) - [Nursing home staffing](https://cmscompliancegroup.com/tag/nursing-home-staffing/) - [Five-Star Quality Rating System Techical Users' Guide April 2019](https://cmscompliancegroup.com/tag/five-star-quality-rating-system-techical-users-guide-april-2019/) - [Health Inspection Star Rating](https://cmscompliancegroup.com/tag/health-inspection-star-rating/) - [Quality Measure Star Rating](https://cmscompliancegroup.com/tag/quality-measure-star-rating/) - [Staffing Star Rating](https://cmscompliancegroup.com/tag/staffing-star-rating/) - [Appendix Q](https://cmscompliancegroup.com/tag/appendix-q/) - [Phase 3 Competencies & Training - Not Just for Nursing](https://cmscompliancegroup.com/tag/phase-3-competencies-training-not-just-for-nursing/) - [F940 Training Requirements](https://cmscompliancegroup.com/tag/f940-training-requirements/) - [F941 Communication Training](https://cmscompliancegroup.com/tag/f941-communication-training/) - [F942 Resident's Rights Training](https://cmscompliancegroup.com/tag/f942-residents-rights-training/) - [CDC Training](https://cmscompliancegroup.com/tag/cdc-training/) - [F550 Resident's Rights/Exercise of Rights](https://cmscompliancegroup.com/tag/f550-residents-rights-exercise-of-rights/) - [F801 Qualified Dietary Staff](https://cmscompliancegroup.com/tag/f801-qualified-dietary-staff/) - [F770 Laboratory Services](https://cmscompliancegroup.com/tag/f770-laboratory-services/) - [F583 Personal Privacy/ Confidentiality of Records](https://cmscompliancegroup.com/tag/f583-personal-privacy-confidentiality-of-records/) - [Disclosure/Good Faith Attempt](https://cmscompliancegroup.com/tag/disclosure-good-faith-attempt/) - [CMS Blog](https://cmscompliancegroup.com/tag/cms-blog/) - [866 QAPI/QAA Data Collection and Monitoring](https://cmscompliancegroup.com/tag/866-qapi-qaa-data-collection-and-monitoring/) - [F867 QAPI/QAA Improvement Activities](https://cmscompliancegroup.com/tag/f867-qapi-qaa-improvement-activities/) - [Ftag review](https://cmscompliancegroup.com/tag/ftag-review/) - [F868 QAA Committee](https://cmscompliancegroup.com/tag/f868-qaa-committee/) - [Nursing Home Survey Deficiencies](https://cmscompliancegroup.com/tag/nursing-home-survey-deficiencies/) - [F841 Responsibilities of Medical Director](https://cmscompliancegroup.com/tag/f841-responsibilities-of-medical-director/) - [F600 Free from Abuse and Neglect](https://cmscompliancegroup.com/tag/f600-free-from-abuse-and-neglect/) - [Seema Verma](https://cmscompliancegroup.com/tag/seema-verma/) - [Medicare data](https://cmscompliancegroup.com/tag/medicare-data/) - [F580 Notify of Changes](https://cmscompliancegroup.com/tag/f580-notify-of-changes/) - [PHCA Convention](https://cmscompliancegroup.com/tag/phca-convention/) - [What to Expect on Your Next DOH Survey](https://cmscompliancegroup.com/tag/what-to-expect-on-your-next-doh-survey/) - [F925 Maintains Effective Pest Control Program](https://cmscompliancegroup.com/tag/f925-maintains-effective-pest-control-program/) - [F911 Bedroom Number of Residents](https://cmscompliancegroup.com/tag/f911-bedroom-number-of-residents/) - [F912 Bedrooms Measure at Least 80 Square Ft/Resident](https://cmscompliancegroup.com/tag/f912-bedrooms-measure-at-least-80-square-ft-resident/) - [F913 Bedrooms Have Direct Access to Exit Corridor](https://cmscompliancegroup.com/tag/f913-bedrooms-have-direct-access-to-exit-corridor/) - [F914 Bedrooms Assure Full Visual Privacy](https://cmscompliancegroup.com/tag/f914-bedrooms-assure-full-visual-privacy/) - [Physical Environment](https://cmscompliancegroup.com/tag/physical-environment/) - [Admission Transfer Discharge](https://cmscompliancegroup.com/tag/admission-transfer-discharge/) - [CMS Proposed Rule](https://cmscompliancegroup.com/tag/cms-proposed-rule/) - [Phase 3 Delay](https://cmscompliancegroup.com/tag/phase-3-delay/) - [Pharmacy Services](https://cmscompliancegroup.com/tag/pharmacy-services/) - [Infection Preventionist](https://cmscompliancegroup.com/tag/infection-preventionist/) - [F915 Resident Room Window](https://cmscompliancegroup.com/tag/f915-resident-room-window/) - [F916 Resident Room Floor Above Grade](https://cmscompliancegroup.com/tag/f916-resident-room-floor-above-grade/) - [F917 Resident Room Bed/Furniture/Closet](https://cmscompliancegroup.com/tag/f917-resident-room-bed-furniture-closet/) - [F918 Bedrooms Equipped/Near Lavatory/Toilet](https://cmscompliancegroup.com/tag/f918-bedrooms-equipped-near-lavatory-toilet/) - [Measles](https://cmscompliancegroup.com/tag/measles/) - [F919 Resident Call System](https://cmscompliancegroup.com/tag/f919-resident-call-system/) - [Phase 3 RoPs](https://cmscompliancegroup.com/tag/phase-3-rops/) - [F907 Space and Equipment](https://cmscompliancegroup.com/tag/f907-space-and-equipment/) - [CMS Beyond the Policy podcast](https://cmscompliancegroup.com/tag/cms-beyond-the-policy-podcast/) - [Dr. Kate Goodrich](https://cmscompliancegroup.com/tag/dr-kate-goodrich/) - [Nursing Home oversight](https://cmscompliancegroup.com/tag/nursing-home-oversight/) - [Nursing home surveys](https://cmscompliancegroup.com/tag/nursing-home-surveys/) - [Law Enforcement Referrals](https://cmscompliancegroup.com/tag/law-enforcement-referrals/) - [F923 Ventilation](https://cmscompliancegroup.com/tag/f923-ventilation/) - [F924 Corridors Have Firmly Secured Handrails](https://cmscompliancegroup.com/tag/f924-corridors-have-firmly-secured-handrails/) - [F910 Resident Room](https://cmscompliancegroup.com/tag/f910-resident-room/) - [F920 Requirements for Dining and Activity Rooms](https://cmscompliancegroup.com/tag/f920-requirements-for-dining-and-activity-rooms/) - [Ensuring Safety and Quality in Nursing Homes](https://cmscompliancegroup.com/tag/ensuring-safety-and-quality-in-nursing-homes/) - [F922 Procedures to Ensure Water Availability](https://cmscompliancegroup.com/tag/f922-procedures-to-ensure-water-availability/) - [F909 Resident Bed](https://cmscompliancegroup.com/tag/f909-resident-bed/) - [F926 Smoking Policies](https://cmscompliancegroup.com/tag/f926-smoking-policies/) - [F921 Safe/Functional/Sanitary/Comfortable Environment](https://cmscompliancegroup.com/tag/f921-safe-functional-sanitary-comfortable-environment/) - [F810 Assistive Devices - Eating Equipment/Utensils](https://cmscompliancegroup.com/tag/f810-assistive-devices-eating-equipment-utensils/) - [F602 Free from Misappropriation/Exploitation](https://cmscompliancegroup.com/tag/f602-free-from-misappropriation-exploitation/) - [F551 Rights Exercised by Representative](https://cmscompliancegroup.com/tag/f551-rights-exercised-by-representative/) - [F812 Kitchen Sanitation](https://cmscompliancegroup.com/tag/f812-kitchen-sanitation/) - [Food Safety](https://cmscompliancegroup.com/tag/food-safety/) - [F635 Admission Physician Orders for Immediate Care](https://cmscompliancegroup.com/tag/f635-admission-physician-orders-for-immediate-care/) - [Intepretive Guidance](https://cmscompliancegroup.com/tag/intepretive-guidance/) - [F840 Use of Outside Resources](https://cmscompliancegroup.com/tag/f840-use-of-outside-resources/) - [F560 Right to Refuse Certain Transfers](https://cmscompliancegroup.com/tag/f560-right-to-refuse-certain-transfers/) - [F603 Free from Involuntary Seclusion](https://cmscompliancegroup.com/tag/f603-free-from-involuntary-seclusion/) - [Freedom from Abuse Neglect and Exploitation](https://cmscompliancegroup.com/tag/freedom-from-abuse-neglect-and-exploitation/) - [American College of Healthcare Administrators](https://cmscompliancegroup.com/tag/american-college-of-healthcare-administrators/) - [What to Expect on Your Next Survey](https://cmscompliancegroup.com/tag/what-to-expect-on-your-next-survey/) - [F842 Resident Records - Identifiable Information](https://cmscompliancegroup.com/tag/f842-resident-records-identifiable-information/) - [October 2020 MDS](https://cmscompliancegroup.com/tag/october-2020-mds/) - [F713 Physician for Emergency Care Available 24 Hours](https://cmscompliancegroup.com/tag/f713-physician-for-emergency-care-available-24-hours/) - [Centers for Disease Control](https://cmscompliancegroup.com/tag/centers-for-disease-control/) - [Coronavirus](https://cmscompliancegroup.com/tag/coronavirus/) - [F807 Drinks Avail to Meet Needs/ Preferences/ Hydration](https://cmscompliancegroup.com/tag/f807-drinks-avail-to-meet-needs-preferences-hydration/) - [F838 Facility Assessment](https://cmscompliancegroup.com/tag/f838-facility-assessment/) - [F576 Right to Forms of Communication with Privacy](https://cmscompliancegroup.com/tag/f576-right-to-forms-of-communication-with-privacy/) - [COVID-19](https://cmscompliancegroup.com/tag/covid-19/) - [F586 Resident Contact with External Entities](https://cmscompliancegroup.com/tag/f586-resident-contact-with-external-entities/) - [Post-Acute Care Quality Reporting Programs](https://cmscompliancegroup.com/tag/post-acute-care-quality-reporting-programs/) - [Infection Control Focused Survey](https://cmscompliancegroup.com/tag/infection-control-focused-survey/) - [COVID-19 Focused Survey](https://cmscompliancegroup.com/tag/covid-19-focused-survey/) - [Coronavirus Waivers and Flexibilities](https://cmscompliancegroup.com/tag/coronavirus-waivers-and-flexibilities/) - [COVID-19 Long-Term Care Facility Guidance](https://cmscompliancegroup.com/tag/covid-19-long-term-care-facility-guidance/) - [COVID-19 cohorting](https://cmscompliancegroup.com/tag/covid-19-cohorting/) - [Transfer and Discharge](https://cmscompliancegroup.com/tag/transfer-and-discharge/) - [Infection Prevention & Control](https://cmscompliancegroup.com/tag/infection-prevention-control/) - [FIve Star Quality Rating System](https://cmscompliancegroup.com/tag/five-star-quality-rating-system-2/) - [Coronavirus Commission for Safety and Quality in Nursing Homes](https://cmscompliancegroup.com/tag/coronavirus-commission-for-safety-and-quality-in-nursing-homes/) - [Coronavirus Symptoms](https://cmscompliancegroup.com/tag/coronavirus-symptoms/) - [ISDA](https://cmscompliancegroup.com/tag/isda/) - [Personal Protective Equipment](https://cmscompliancegroup.com/tag/personal-protective-equipment/) - [Abuse & Neglect](https://cmscompliancegroup.com/tag/abuse-neglect/) - [CDC NHSN LTCF COVID-19 Module](https://cmscompliancegroup.com/tag/cdc-nhsn-ltcf-covid-19-module/) - [CMS Interim Final Rule](https://cmscompliancegroup.com/tag/cms-interim-final-rule/) - [In-Service Training](https://cmscompliancegroup.com/tag/in-service-training/) - [Resident Records](https://cmscompliancegroup.com/tag/resident-records/) - [F884 COVID-19 Reporting to CDC](https://cmscompliancegroup.com/tag/f884-covid-19-reporting-to-cdc/) - [F885 COVID-19 Reporting to Residents their Representatives and Families](https://cmscompliancegroup.com/tag/f885-covid-19-reporting-to-residents-their-representatives-and-families/) - [COVID-19 Reporting](https://cmscompliancegroup.com/tag/covid-19-reporting/) - [Skilled Nursing QRP](https://cmscompliancegroup.com/tag/skilled-nursing-qrp/) - [CMS Nursing Home Best Practices Toolkit](https://cmscompliancegroup.com/tag/cms-nursing-home-best-practices-toolkit/) - [Nursing Home Reopening Recommendations](https://cmscompliancegroup.com/tag/nursing-home-reopening-recommendations/) - [Focused Infection Control Survey](https://cmscompliancegroup.com/tag/focused-infection-control-survey/) - [Infection Control Compliance](https://cmscompliancegroup.com/tag/infection-control-compliance/) - [CMS COVID-19 Nursing Home Data](https://cmscompliancegroup.com/tag/cms-covid-19-nursing-home-data/) - [CMS News Alert](https://cmscompliancegroup.com/tag/cms-news-alert/) - [Free from Abuse Neglect and Exploitation](https://cmscompliancegroup.com/tag/free-from-abuse-neglect-and-exploitation/) - [Nursing Home Visitation](https://cmscompliancegroup.com/tag/nursing-home-visitation/) - [Point-of-Care testing](https://cmscompliancegroup.com/tag/point-of-care-testing/) - [Home Health Quality Reporting Program](https://cmscompliancegroup.com/tag/home-health-quality-reporting-program/) - [F886 COVID-19 Testing](https://cmscompliancegroup.com/tag/f886-covid-19-testing/) - [F886 COVID-19 Testing Residents & Staff](https://cmscompliancegroup.com/tag/f886-covid-19-testing-residents-staff/) - [F886 COVID-19 Testing – Residents & Staff](https://cmscompliancegroup.com/tag/f886-covid-19-testing-residents-staff-2/) - [Healthcare-Associated Infections (HAI)](https://cmscompliancegroup.com/tag/healthcare-associated-infections-hai/) - [Public Comment Period](https://cmscompliancegroup.com/tag/public-comment-period/) - [CMP Funds](https://cmscompliancegroup.com/tag/cmp-funds/) - [Core Principles of COVID-19 Infection Control](https://cmscompliancegroup.com/tag/core-principles-of-covid-19-infection-control/) - [COVID-19 PHE](https://cmscompliancegroup.com/tag/covid-19-phe/) - [Emergency Preparedness Testing Exercise Exemption](https://cmscompliancegroup.com/tag/emergency-preparedness-testing-exercise-exemption/) - [SOM Appendix Z](https://cmscompliancegroup.com/tag/som-appendix-z/) - [F572 Notes of Rights and Rules](https://cmscompliancegroup.com/tag/f572-notes-of-rights-and-rules/) - [State Survey Agency](https://cmscompliancegroup.com/tag/state-survey-agency/) - [F676 Activities of Daily Living (ADLs)/ Maintain Abilities](https://cmscompliancegroup.com/tag/f676-activities-of-daily-living-adls-maintain-abilities/) - [Interim Infection Prevention and Control Recommendations for Healthcare Personnel](https://cmscompliancegroup.com/tag/interim-infection-prevention-and-control-recommendations-for-healthcare-personnel/) - [Survey Tips & Trends 2020](https://cmscompliancegroup.com/tag/survey-tips-trends-2020/) - [CMS Toolkit](https://cmscompliancegroup.com/tag/cms-toolkit/) - [Targeted COVID-19 Training for Frontline Nursing Home Staff & Management](https://cmscompliancegroup.com/tag/targeted-covid-19-training-for-frontline-nursing-home-staff-management/) - [Long-Term Care Survey Process](https://cmscompliancegroup.com/tag/long-term-care-survey-process-2/) - [COVID-19 Vaccine](https://cmscompliancegroup.com/tag/covid-19-vaccine/) - [Healthcare workers](https://cmscompliancegroup.com/tag/healthcare-workers/) - [Long-Term Care](https://cmscompliancegroup.com/tag/long-term-care-2/) - [Care Compare](https://cmscompliancegroup.com/tag/care-compare/) - [Quality Measures Domain](https://cmscompliancegroup.com/tag/quality-measures-domain/) - [CMS Nursing Home COVID-19 Testing FAQ](https://cmscompliancegroup.com/tag/cms-nursing-home-covid-19-testing-faq/) - [Survey Resources](https://cmscompliancegroup.com/tag/survey-resources/) - [Clinical](https://cmscompliancegroup.com/tag/clinical/) - [F697 Pain Management](https://cmscompliancegroup.com/tag/f697-pain-management/) - [1135 Waiver](https://cmscompliancegroup.com/tag/1135-waiver/) - [CDC Guidance](https://cmscompliancegroup.com/tag/cdc-guidance/) - [Long-Term Care Facilities](https://cmscompliancegroup.com/tag/long-term-care-facilities-2/)