The Lead December 12, 2024 - LeadingAge Illinois

Welcome to the Lead

From the Desk of Angela Schnepf, President and CEO

CCRC/Life Plan Communities
Meridian Village Hosts Senator

Nursing and Rehabilitation
Upcoming NHSN Webinars on Updated Reporting Requirements
Care Compare Guide Updated for Nursing Homes
Institute for Healthcare Innovation Recruiting Nursing Homes for Action Community
Advocacy Win! HICPAC Advances Draft Recommendations to Reduce Work Restrictions
ICYMI: CMS Revises Several Regulations in Appendix PP
New Resources from the Center of Excellence
OIG Releases Compliance Guide for Nursing Homes
New Member Resources on Revised Surveyor Guidance
Moving Forward Coalition Releases New Guide to Addressing Resident Preferences

Housing
HUD Publishes 2025 Annual Adjustment Factors

HCBS
CMS Proposes Changes to Home Health CAHPS Measures
Hospice Updates

Other
Ask the Expert

From the Desk of Angela Schnepf, President and CEO

We wanted to make sure our skilled nursing members are aware that the staffing ratio census reporting fines for non-compliance go into effect July 1, 2025 and are based on days starting January 1, 2025. We were successful in delaying the fine implementation two times in the legislative process. However, the current implementation time is July 1, 2025. It is imperative that the templates for reporting are submitted each quarter.

Kindest Regards,

Angela

LeadingAge Illinois Legislative Luncheon Set for January 10, 2025

We are excited to announce the return of the LeadingAge Illinois Legislative Awards Luncheon, a special occasion to honor the outstanding efforts and contributions of legislators who have championed our public policy priorities.

Friday, January 10, 2025

12:00 p.m. – 2:00 p.m.

Westminster Place

A Presbyterian Homes Community

3200 Grant St, Evanston

Fees: $30 PAC donation for Member Organizations

$125 PAC donation for Business Member

The Luncheon is a celebration of our 2024 advocacy successes. We look forward to celebrating with you.

Please register here for the Luncheon by January 3, 2025.

2025 Calendar for Celebrations & Activities

LeadingAge Illinois & Iowa is pleased to offer members a 2025 list of special celebrations that may be incorporated into activity programming and staff recognition. Click here to view.

The Time for Advocacy is Now: Tell Congress to Protect Medicaid in 2025

Medicaid is a critical component of how long-term services and supports are financed through nursing homes and home and community-based services. Because of its significant budget and concerns from incoming Congressional leadership and budget hawks about the program’s scope and cost, the Medicaid program will be a target for spending reductions in the coming months. We need to speak up about the importance of Medicaid to aging services providers and those we serve and ask that no cuts or changes that impede access to Medicaid benefits be included in any forthcoming budget resolutions or legislation. Take Action Now.

Prevention of Spousal Impoverishment Standards for 2025

Effective January 1, 2025, pursuant to Public Act 102-1037, the Community Spouse Resource Allowance (CSRA) and the Community Spouse Maintenance Needs Allowance (CSMNA) will increase annually.

The term “spousal impoverishment” includes the standards for the Community Spouse Resource Allowance (CSRA) and the Community Spouse Maintenance Needs Allowance (CSMNA). The prevention of spousal impoverishment standards should be included in the oral and written information that must be provided to residents and potential residents about how to apply for and use Medicaid benefits. Facilities are required by federal regulations (42 CFR 483.10) and State statute (210 ILCS 45/2-211) to give an explanation of resident rights at the time of admission and at least annually thereafter.

The CSRA standard will change from $129,084.00 to $135,648.00. This is the maximum amount of resources a resident may transfer to a community spouse or to another for the sole benefit of a community spouse. The actual amount a resident may transfer is determined by deducting non‑exempt resources of the community spouse from the standard of $135,648.00.

The CSMNA standard will change from $3,853.50 to $3,948.00. This is the maximum amount of monthly income a resident may give to a community spouse. The actual amount a resident may give is determined by deducting any gross income of the community spouse from the standard of $3,948.00.

The CSMNA and CSRA will increase every year based on the Federal Poverty Level (FPL) amounts posted annually by the Federal government.

Reminder: The CSRA determination only occurs once. If the CSRA was already determined at application or long term care determination, then the previously determined amount will not be updated.

LeadingAge Illinois Presents on Quality Care in Nursing Homes at ASA-Chicago Roundtable

LeadingAge Illinois served on a panel recently to give the provider perspective on safety and quality in nursing homes and discuss the impact of federal and state mandates.

Jason Speaks, director of government relations at LeadingAge Illinois, served on the panel alongside state regulators that included Kelly Richards, LTC Ombudsman for Illinois, Sheila Baker from the Illinois Department of Public Health, and Kelly Cunningham who leads Medicaid for the Illinois Department of Healthcare and Family Services.

Health Care Considerations for Highly Pathogenic Avian Influenza

Cambridge University developed an online article discussing highly pathogenic avian influenza (HPAI) and considerations for health care settings. While this information is likely more relevant to hospitals, long-term care services and centers may be at risk if staff are possibly caring for or had contact with infected animals. Similar to the COVID-19 pandemic, any individual that is suspected to have a respiratory illness should be removed from duty (staff) or placed in contact isolation (residents) with an airborne infection isolation room (AIIR) if available. Staff caring for residents in contact isolation should utilize PPE including an N95 or higher respirator, gloves, isolation gown, and eye protection. If HPAI is suspected, nursing home providers must reach out to local public health as there is no current testing readily available and samples must be sent to hygienic laboratories.

The article indicates that the risk of human-to-human transmission of HPAI is low, however, health care providers should have a containment strategy and an understanding of isolation duration for exposures and cases. You can find additional information on the Centers for Disease Control & Prevention’s Avian Influenza website.

IDPH Office of Health Care Regulation Monthly Educational Webinars

The Illinois Department of Public Health (IDPH) Office of Health Care Regulation (OHCR) will be hosting monthly educational webinars providing general information and topics of interest for long term care facilities. Updates will also be provided on new federal and state regulatory requirements and IDPH will also allow opportunities for questions and answers from the audience. Webinars will be announced several months in advance and registration will be required. Register Here.

Upcoming LTC HAI Webinars

The Illinois Department of Public Health (IDPH) Healthcare Associated Infection (HAI) team announced several upcoming webinar opportunities for infection prevention in long-term care settings. You can register for the series or individual webinars by clicking the links below. The webinars are held from 1 – 2 p.m. CT on the dates indicated.

To register for the entire series click here.

January 10 – Water Management with a focus on the Water Risk Assessment
January 24: Occupational Health

Attendance is limited, if you cannot register or get into the webinar, please contact Michael Moore at IDPH. The webinars will be recorded, and links can be sent out.

IDPH Offering Two-Day Emergency Preparedness Training

The Illinois Department of Public Health is offering a two-day training course in conjunction with Texas A&M Engineering Extension Service on EOC Operations and Planning for All-Hazards. This training focuses on the core functions, processes and best practices necessary to ensure effective and repeatable performance of an emergency operations center at any level. The processes are reviewed and demonstrated via facilitated discussion and classroom activities to gain practical experience via a series of interrelated activities and exercises which are supported by state-of-the-art computer simulation systems and coached by instructors with extensive emergency operations and management experience.

The training will be held on March 26 & 27 from 8 a.m. – 5 p.m. at 1 Natural Resources Way in Springfield. You can register for this event by creating an account and then registering for the program here.

QALC Releases Infection Control Guidelines for Assisted Living

The Quality in Assisted Living Collaborative (QALC) released Infection Prevention and Control Guidelines for Assisted Living Communities, a new resource outlining best practices for infection prevention and control (IPC) in assisted living settings. Developed collaboratively by QALC members, including LeadingAge, Argentum, and many other assisted living focused associations, the IPC guidelines provides a comprehensive framework for planning and implementing IPC strategies.

This is the first initiative from QALC, which was launched in June 2023 to identify, define, and develop model voluntary guidance for assisted living. Broad adoption of these guidelines across the assisted living sector will help ensure a consistent, effective approach to IPC nationwide. QALC convened a subject matter expert workgroup that met over the past year to develop the IPC guidelines including designating an IPC Leader, annual evaluation of the IPC program, staff training and preventative and control measures, along with policies and procedures.

The IPC guidelines are intended to support assisted living communities in developing and implementing a comprehensive approach to infection control practices to promote the health and safety of staff and residents, as well as quality care. The Collaborative’s resources will be available to aid and educate providers, regulators, policymakers, and other stakeholders. LeadingAge joined QALC to prioritize quality of care for our members and collaborate on pressing issues – one of the most critical being infection control in the post-pandemic environment.

Department of Justice Revises Antitrust Guidance to Incorporate Use of AI

The United States Department of Justice (DOJ) recently revised the Evaluation of Corporate Compliance Programs in Criminal Antitrust Investigations to incorporate Artificial Intelligence (AI) in technology platforms. The risk assessment section of the document outlines procedures for the company’s risk assessment to address the use of technology, particularly those including AI and algorithmic revenue management. Some important notes as you consider whether your antitrust practices are meeting compliance are outlined below.

The definition of AI as set forth by the Office of Management & Budget (OMB) states any artificial system that:

Performs tasks under varying and unpredictable circumstances without significant human oversight, or that can learn from experience and improvement performance when exposed to data sets.
Is developed in computer software, hardware, or other context that solves tasks requiring human like perception, cognition, planning, learning, communication, or physical action.
Is designed to think or act like a human, including cognitive architectures and neural networks.
A set of techniques, including machine learning, that is designed to approximate a cognitive task.
Is designed to act rationally, including an intelligent software agent or embodied robot that achieves goals using perception, planning, reasoning, learning, communicating, decision-making, and acting.

Additionally, this technical context should guide interpretation of the AI definition:

It encompasses, but is not limited to, AI technical subfields of machine learning including deep learning as well as supervised, unsupervised, and semi-supervised approaches, reinforcement learning, transfer learning, and generative AI.
It does not include robotic process automation or other systems who behavior is defined only by human-defined rules or that learn solely by repeating an observed practice exactly as it was conducted.
No system should be considered too simple to qualify as a covered AI system due to a lack of technical complexity.
Includes systems that are fully autonomous, partially autonomous, and not autonomous and that operate both with and without human oversight.

Considerations to include in your compliance program:

How does the organization’s risk assessment address the use of new technologies including AI and algorithmic revenue management that are used to conduct company business?
As new technology tools are deployed by the company, is antitrust risk assessed?
What steps are being taken to mitigate the risk associated with the use of the technology?
Are compliance personnel involved in the deployment of AI and other technologies to assess the risks they may pose?
Do compliance personnel have an understanding of the AI and other technology tools used?
How quickly can the company detect and correct decisions made by AI or other new technologies that are not consistent with the organization’s values?
How does training address permissible and nonpermissible uses of new technology including AI?
Does the compliance program monitor and detect decision-making by AI or other technology tools to ensure they are not violating antitrust laws?

New NOMNC and DENC Notices Effective January 1

The Office of Management and Budget (OMB) has renewed the Notice of Medicare Non-Coverage (NOMNC, CMS-10123) and the Detailed Explanation of Non-Coverage (DENC, CMS-10124). These renewed notices contain updates which are applicable only to Medicare Advantage enrollees. The new notices must be used beginning January 1, 2025.

Medicare Advantage Only:

The NOMNC has been modified to reflect regulations providing enrollees additional fast-track appeal rights when they untimely request an appeal to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or still wish to appeal after they end services on or before the planned termination date. (See: CMS-4205, p. 30827)

Additionally, DENC instructions have been updated to include a new element for health plans to complete for the DENC. Special instructions for repeat appeals within the same episode of care:

If the enrollee has previously received a favorable BFCC-QIO appeal decision during the current episode of care, detail the specific change(s) in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Hospices, and Outpatient Rehab Facilities are required to provide a NOMNC to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries on how to request an expedited determination from their BFCC-QIO and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO. A DENC is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered services.

Full instructions for the Original Medicare (also known as Fee for Service or FFS), expedited determination process are available in Section 260, of Chapter 30 of the Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual. Full instructions for the Medicare health plan expedited determination process, also known as the Medicare Advantage (MA) fast track appeals process, are available in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in Section 100.

Questions regarding the NOMNC and DENC can be submitted at https://appeals.lmi.org

Notice of Medicare Non-Coverage (NOMNC)
NOMNC Instructions
Detailed Explanation of Non-Coverage (DENC)
DENC Instructions

Meridian Village Hosts Senator

This week, Meridian Village, a Lutheran Senior Services community, hosted Senator Erica Harriss (R-56th District; Edwardsville). She is a member of the Senate Appropriations – Health and Human Services Committee. It was her first Partners in Quality visit since taking office in 2023.

During the visit, she had the opportunity to sit with a group of residents to give an update on her work for the district, legislative recaps, and answer questions. She committed to returning for another visit soon with an interest in learning more about their Alzheimer’s and Dementia care.

Upcoming NHSN Webinars on Updated Reporting Requirements

On December 11 at 12 p.m. C.T. the National Health Care Safety Network (NHSN) will host a webinar on NHSN Long-Term Care Facility (LTCF) Component: Respiratory Pathogens and Vaccination Updates. You can register in advance for this webinar here.

Care Compare Guide Updated for Nursing Homes

The updated Nursing Home Care Compare Technical Users’ Guide is now available on the Five Star Quality Rating System page. Starting with the January 2025 refresh, the Centers for Medicare & Medicaid Services (CMS) will unfreeze four quality measures (QMs) that were previously frozen as of the April 2024 refresh. The measures are:

Percentage of residents who made improvements in function (short stay)
Percent of residents whose need for help with activities of daily living has increased (long-stay)
Percent of residents whose ability to move independently worsened (long-stay)
Percent of high-risk residents with pressure ulcers (long-stay)

These measures have been revised to reflect recent updates to the Minimum Data Set (MDS). For further details on these updates, please refer to CMS Memorandum QSO-25-01-NH. The revised memo outlines the timeline for adjusting the quality measures so that all affected quality measures are updated at the same time.

Institute for Healthcare Innovation Recruiting Nursing Homes for Action Community

The Institute for Healthcare Innovation (IHI) is currently recruiting nursing homes for their “Action Community” which is a free virtual learning opportunity as part of the Age-Friendly Health Systems movement. The Action Community begins in March 2025 and offers a free, seven-month virtual learning program designed to help nursing homes and other healthcare systems accelerate adoption of the 4Ms Framework. The 4Ms (What Matters, Medication, Mentation, and Mobility) are a set of evidence-based practices intended to make the complex care of older adults manageable, consistent, and reliable. Nearly 750 nursing homes are already recognized as Age-Friendly and are beginning to report positive impacts on overall quality, residents, and staff. You can learn more here.

Advocacy Win! HICPAC Advances Draft Recommendations to Reduce Work Restrictions

The Healthcare Infection Control Advisory Committee (HICPAC) held a public meeting on November 14 & 15, 2024. During this meeting, updates were presented by the Infection Control in Healthcare Personnel Guideline Workgroup and the Isolation Precautions Guideline Workgroup. Committee discussion was held for topics presented by both workgroups, followed by public comment and committee vote, including approval of draft recommendations that would reduce healthcare personnel work restrictions following respiratory virus infection, for which LeadingAge Illinois and LeadingAge have been advocating. Draft recommendations have been sent to the Centers for Disease Control & Prevention (CDC) in preparation for public comment in the Federal Register. When the draft recommendations have been published, LeadingAge Illinois will communicate to members for further comment/advocacy. LeadingAge developed an article on additional details regarding the HICPAC meeting.

ICYMI: CMS Revises Several Regulations in Appendix PP

The Centers for Medicare & Medicaid (CMS) released a Quality, Safety & Oversight Group (QSO) Memo on November 18, 2024. QSO-20-07-NH incorporates revised Appendix PP regulations including Admission, Transfer & Discharge, Chemical Restraints/Unnecessary Psychotropic Medication, Resident Assessment, Quality of Life and Quality of Care, Administration, Quality Assurance Performance Improvement (QAPI), Infection Prevention and Control, and other areas including clarifications and technical corrections have also been made throughout Appendix PP. The memo lists an effective date of February 24, 2025, and surveyor resources will be finalized and released on that date as well. Advanced copies are currently available and included in the memo. The revised guidance is outlined below.

Admission, Transfer, and Discharge:

F-Tags 622 – 626 and F660 – F661 were removed with two new regulations being added under F627 – Inappropriate Transfers and Discharges and F628 – Transfer and Discharge Process.

The regulatory language under F627 combines the regulatory language from the former F622 – F626. Changes include revisions in the intent and interpretative guidance.

The intent of the regulation is to address inappropriate discharges by ensuring:

Policies are developed and implemented which allow residents to return to the nursing home following hospitalization or therapeutic leave.
Ensuring that the nursing home does not transfer or discharge a resident in an unsafe manner such as to a location that is unable to meet their needs, does not provide needed support and resources, or does not meet the resident’s preferences and therefore should not have occurred.
Ensuring the discharge planning process addresses each resident’s discharge goals and needs.

The interpretative guidance directs surveyors to begin determining compliance in offsite preparation and instructs the team coordinator (TC) to contact the local ombudsman and inquire if there are specific residents that they have received complaints about regarding potential inappropriate discharges. Evidence of noncompliance may include, but is not limited to:

Evidence does not support the basis for discharge such as:
- Discharge based on the inability to meet the resident’s need without evidence of attempts to meet the needs, or an assessment indicating what needs could not be met.
- Discharge based on improvement in the resident’s health such that services are no longer needed, however, documentation indicates the resident’s health did not improve or actually declined.
- Discharge based on the failure to pay, however, there is a lack of evidence that the nursing home offered the resident to pay privately or apply for medical assistance or that the resident refused to pay or have Medicare or Medicaid pay for services.
- The discharge occurred despite an appeal which is pending and a lack of documentation to support that the failure of discharge would endanger the health or safety of others in the nursing home.
When evidence in the medical record shows the resident was not allowed to return following hospitalization or leave without a valid basis for discharge.
When there is no evidence that the nursing home considered the care giver’s availability, capacity, or capability to perform necessary care following discharge.
The post-discharge care plan did not address the resident’s limitations in ability to provide care for themselves.

Nursing homes must ensure that if the resident is being discharged based on the nursing home’s inability to meet the resident’s needs an assessment of the resident’s status must be completed at the time of the proposed return to the nursing home or there cannot be a determination of the nursing home’s inability to meet the resident’s needs or that the health and safety of other individuals would be endangered.

If a resident has appealed their discharge and obtained a favorable ruling, the resident or their representative may choose to report the discharge as a compliant to the State Survey Agency (SSA). However, the SSA cannot take survey action, citing noncompliance exclusively based on the ruling of the hearing. Surveyors must identify in a compliant survey if other noncompliance was present, citing the appropriate tag and scope and severity. In addition, if the resident was discharged and it was determined that the discharge location was not to a location or setting that is able to meet their health or safety needs, the plan of correction should state that the nursing home will either, readmit the resident until a safe and compliant discharge can be completed or coordinate a transfer of the resident to another setting that will be safe.

Violations of F627 would generally be cited at the severity of a harm or immediate jeopardy level when using the reasonable person approach in considering psychosocial outcomes as well as the likelihood for serious physical harm resulting from an unsafe discharge. For citations at any level of scope and severity, if the discharged resident’s health and/or safety is threatened in the setting they are currently located, the plan of correction should state that either the nursing home will readmit the resident until a safe and compliant discharge can be completed or coordinate a transfer of the resident to another setting where they will be safe. Substantial compliance should not be achieved until one of these two items is complete (and all other noncompliance has been corrected).

F628 is a new regulation that includes information required for documentation of transfers and discharges. The regulatory language includes what information must be communicated to the receiving location, the notice before a transfer (including notifying the LTC Ombudsman of the transfer), timing of transfer and discharge notices, notice of closure, bed hold information, and discharge summaries. The regulatory language previously was incorporated into several regulations.

The intention of this regulation is to ensure that the nursing home adheres to all applicable components of the process for transferring or discharging a resident which include documentation and information conveyed to the receiving provider, the notice of the transfer or discharge, notice of bed-hold policy, and completing the discharge summary. The interpretative guidance included in this regulation only included minor technical and wording changes.

Chemical Restraints/Unnecessary Psychotropic Medications:

Previous regulations regarding chemical restraints were found under F605 and Unnecessary Psychotropic Medications under F758 while regulatory language for F758 applied to both F757 (Unnecessary Medications pertaining to all categories of medications except psychotropics) and F758. Regulatory language for F758 was moved to F605 under the Freedom from Abuse, Neglect, and Exploitation subsection. Despite the regulatory language appearing to be revised as indicated in red font, the language is the same as previously incorporated in F758.

The intent of this regulation was revised to indicate that the requirements are to ensure residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Also, residents must only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinical contraindicated. Additionally, medications should only be used to treat resident’s medical symptoms and not used for discipline or staff convenience, which would be deemed a chemical restraint. The regulations and guidance are not intended to supplant the judgment of a practitioner in consultation with staff, the resident and their representative. Rather, are intended to ensure psychotropic medications are used only when a practitioner determines that medication(s) are appropriate to treat a specific, diagnosed condition and they are beneficial to the resident based on monitoring and documentation of response.

Several definitions were merged into the one interpretative guidance, for example indication for use was previously just under F605 and not F758. Key changes in the interpretative guidance include:

If the surveyor identifies that a medication has caused symptoms consistent with prolonged sedation that is not addressed such as excessive sleeping, withdrawal, decreased activity participation, noncompliance is cited at a minimum of a harm level.
Convenience definition was revised and now states “the unnecessary administration of a medication that causes (intentionally or unintentionally) a change in a resident’s behavior such that the resident is subdued and/or requires less effort from staff. Therefore, if a medication causes symptoms consistent with sedation, it may take less effort to meet the resident’s behavioral needs, which meets the definition of convenience.”

A new section was added on the resident’s right to be informed. In accordance with regulations included in the resident’s rights subsection, residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. To demonstrate compliance, the record must include documentation that the resident or representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option they prefer. A written consent form may serve as evidence of a resident’s consent, but other types of documentation are also acceptable. If the resident/representative was not informed, noncompliance should be cited under F552.

Professional Standards and Medical Director:

Updates were made to both F658 (Professional Standards) and F841 (Medical Director) related to physicians and other practitioners adhering to policies on diagnosing and prescribing medications, the coordination of care, and implementation of resident care policies.

F658 includes new interpretative guidance outlining a proper diagnosis of mental disorders including the diagnosis that must be based on evidence-based criteria and professional standards such as using the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and are supported by documentation in the resident’s medical record. The supporting documentation should include, but is not limited to, the resident’s physical, behavioral, mental, psychosocial status, and comorbid conditions. The record should also rule out other physiological effects such as substance use, other medical conditions, indications of distress, changes in functional status, resident complaints, behaviors, symptoms. The documentation can also reference the Preadmission Screening and Resident Review (PASARR) evaluation.

The resident’s medical record must include:

Documentation indicating the resident had symptoms, disturbances, or behaviors and for the period of time consistent with the DSM criteria.
Documentation from the diagnosing provider indicating the diagnosis was given based on a comprehensive assessment such as a physician’s visit.
Documentation from the diagnosing provider indicating that symptoms, disturbances, or behaviors are not attributable to the effects of a substance or another medical condition.
Documentation regarding the effect the disturbance is having on the resident’s function including interpersonal relationships or self-care in comparison to their level of function prior to the onset.

Examples of insufficient documentation would include:

Schizophrenia or other diagnosis is only mentioned as an indication in medication orders without supporting documentation.
The addition of, or request to a practitioner of schizophrenia or other diagnosis without supporting documentation.
A practitioner’s note or transfer summary stating a history of schizophrenia or another diagnosis without supporting documentation confirming the diagnosis with a previous practitioner or family and the nursing home did not have evidence that a practitioner conducted a comprehensive evaluation.
A diagnosis list or practitioner’s note including schizophrenia or another diagnosis without supporting documentation.
A nurse documenting schizophrenia or other diagnosis in the medical record without supporting practitioner documentation.

F841 includes revisions of the medical director’s responsibilities for the nursing home. These updates include:

Implementation of resident care policies, such as ensuring that the nursing home staff and other practitioners adhere to policies on diagnosing and prescribing medications including intervening when care is inconsistent with current professional standards of care.
Addressing issues related to the coordination of medical care and implementation of resident care policies identified in the QAPI activities.
Active involvement in the process of conducting the facility assessment.
Administrative decisions including recommending, developing, and approving policies related to resident care which includes the resident’s physical, mental and psychosocial well-being.

Accuracy/Coordination/Certification:

F642 which relates to the coordination of the Minimum Data Set (MDS), certification, accuracy, and penalties for falsification of the MDS were moved to F641 and F642 was deleted.

F641 includes new information in the interpretative guidance outlining inaccurate MDS coding based on diagnoses that lack supporting documentation based on the criteria in the DSM. While several other regulations include language regarding inaccurate diagnoses, this regulation relates to the nursing home coding it in the MDS. The guidance also directs surveyors to report concerns identified that constitute a pattern of inaccurate MDS coding to the appropriate licensure board. There is also a statement included in the investigative procedures that direct survey staff to report concerns when they believe the individual coding the inaccurate information knew it was inaccurate to the Office of Inspector General (OIG) for investigating possible falsification of the MDS assessment.

An additional new section containing information on certifying accuracy and completion is included in the interpretative guidance including that each individual assessor is responsible for certifying the accuracy of responses relative to the resident’s condition and discharge or entry status. These assessments must be dated the day they complete their portion of the assessment. Information previously included in the interpretative guidance in F642 is now included in F64 such as the use of electronic signatures and backdating completion dates.

Significant Change in Condition:

The interpretative guidance for F637 was revised slightly to include current language from Section GG of the MDS when identifying a significant change in the resident’s performance in Activities of Daily Living (ADLs).

Quality Assurance:

F867 interpretive guidance was updated in the QAPI regulations to incorporate health equity reports for nursing home providers. The revised QAPI guidelines include incorporating indicators of health equity into the QAPI program. Examples are outlined in the interpretative guidance including considering feedback related to health equity concerns such as addressing needs of individuals with disabilities, limited English proficiency, or different cultural or ethnic preferences. In addition, data can be incorporated while monitoring various measures to identify if there are increased concerns with problem-prone areas as the relate to sub-populations including race, sexual orientation, socioeconomic status, or preferred language.

CPR:

The language included in the interpretative guidance of F678 was updated to reflect current standards of practice with CPR instruction. The guidance states that staff must maintain current CPR certification for a health care provider through a CPR provider whose training includes a hands-on session either physically or virtually instructor-led setting in accordance with accepted professional standards.

Pain Management:

The interpretative guidance included in F697 was updated to define acute, subacute, and chronic pain and that opioid treatment to address pain needs to be individualized for each resident . When starting Opioid therapy, clinicians may consider prescribing immediate release opioids instead of long-acting or extended release. The update also includes references to F552 and identifying the risks of opioid use whenever prescribed by the physician.

Physical Environment:

Interpretative guidance was updated at F918 to clarify when nursing homes must meet compliance with each resident having access to a bathing facility in their room. The requirement for having each resident bedroom with its own bathroom consisting of at least a sink and commode/toilet includes:

Approval for construction after November 28, 2016
Newly certified after November 28, 2016
A change of ownership that results in a new initial certification after November 28, 2016
A nursing home whose provider agreement was terminated by CMS and a new provider is working to reenroll in the Medicare program as a newly certified nursing home after November 28, 2016

Nursing homes that meet the above criteria must also meet the requirement that resident rooms accommodate no more than two individuals. This includes a clarification regarding Jack & Jill type bathrooms where two residents have individual living space but share a bathroom. Noncompliance would exist if one of those rooms had more than one resident in it though.

Infection Control:

F880 was updated to include language on Enhanced Barrier Precautions (EBP) as outlined in the QSO-24-08-NH memo issued on March 20, 2024.

COVID-19 Immunization:

F887 was also added to Appendix PP incorporating the requirements to screen, educate, offer, and assist with administering COVID-19 vaccination to residents and staff as previously outlined in QSO-21-19-NH on May 11, 2021.

LeadingAge Illinois will provide resources based on some of the significant changes made to the interpretative guidance and notify members when they are available.

New Resources from the Center of Excellence

The Center of Excellence for Behavioral Health in Nursing Facilities recently released new toolkits for providers. As a reminder, the Center of Excellence for Behavioral Health in Nursing Facilities is a free resource provided by the Centers for Medicare & Medicaid Services (CMS) to provide tools and resources on behavioral health.

De-Escalation Strategies In-Service Toolkit This toolkit aims to equip staff with the knowledge and techniques necessary to prevent escalating behaviors and enhance safety within nursing homes.
Substance Use Disorder In-Service Toolkit. The substance use disorder (SUD) toolkit is used to equip staff with knowledge and skills related to the disease concept of substance use, the impact substances have on brain chemicals, and the appropriate steps to take when supporting residents with SUD.
Major Depressive Disorder In-Service Toolkit. The major depressive disorder (MDD) toolkit is used to educate nursing home staff about MDD, including its risk factors and symptoms, as well as the appropriate steps to take when supporting a resident with MDD.

OIG Releases Compliance Guide for Nursing Homes

On November 20, the Department of Health and Human Services Office of Inspector General (OIG) released Industry Segment-Specific Compliance Program Guidance for Skilled Nursing Facilities and Nursing Facilities (Nursing Facility ICPG). Providers may use the ICPG to help identify their own risks and to implement effective compliance and quality programs to reduce those risks. Together with the OIG’s General Compliance Program Guidance (GCPG), the ICPG is a voluntary program that may guide nursing homes to reduce fraud, waste, and abuse; promote cost-effective and quality care; enhance the effectiveness of providers’ operations; and propel improvements in compliance, quality of care, and resident safety. The ICPG draws on insights and recommendations informed by:

Findings and observations from the OIG’s decades of work in nursing homes, including audits, evaluations, investigations, enforcement actions, and monitoring of Corporate Integrity Agreements (CIAs).
Legal actions initiated and investigated by the OIG in collaboration with its government partners.
Current enforcement priorities
Engagements and discussions with nursing home owners, operators, industry leaders, trade associations, resident advocacy groups, and other stakeholders.

Under the Centers for Medicare & Medicaid Services (CMS) Requirements of Participation (RoPs) Phase 3, implemented in 2019, nursing homes are required to maintain a compliance and ethics plan. The recommendations and practical guidance provided in the ICPG and GCPG can support nursing homes in meeting these compliance program requirements while also aiding adherence to other statutory and regulatory obligations.

New Member Resources on Revised Surveyor Guidance

As promised, LeadingAge Illinois has been busy preparing member resources for the revised surveyor guidance that will be effective February 24, 2025. These new resources include a checklist that outlines all of the changes with links to resources to aid members in compliance. The new 2025 Regulatory Revisions Resources are now available on our website!

Check out these new resources:

If there are additional resources that you think will be helpful as you navigate the changes, please let Kellie Van Ree know.

Additionally, registration has now open for the What You Need to Know Regarding the Updated Surveyor Guidance webinar on January 30, 2025.

Moving Forward Coalition Releases New Guide to Addressing Resident Preferences

The Moving Forward Nursing Home Quality Coalition recently released a Guide to Addressing Resident Goals, Preferences and Priorities. The guide is developed to support nursing home staff in addressing each resident’s goals, preferences and priorities (GPP) by offering resources and recommendations to implement standardized processes. The website includes several downloadable and printable tools including checklists, orientation templates, and checklists.

HUD Publishes 2025 Annual Adjustment Factors

On December 3, the Department of Housing and Urban Development (HUD) announced the Annual Adjustment Factors (AAFs) for 2025, which adjust rents for certain Section 8 housing assistance payment programs for the current fiscal year. HUD establishes the rent adjustment factors on the basis of Consumer Price Index (CPI) data relating to changes in residential rent and utility costs. AAFs are applied at the anniversary of certain Housing Assistance Payment (HAP) contracts; the amount that an owner is required to deposit to the Reserve for Replacement account is also adjusted annually by the most recently published AAF, at the HAP contract anniversary. The AAFs are distinct from, and do not apply to the same properties as, Operating Cost Adjustment Factors (OCAFs), which are used by many project-based Section 8 and Section 202/8 properties. HUD’s OCAF notice is still forthcoming for 2025. The 2023 AAFs are effective as of December 3, 2024.

CMS Proposes Changes to Home Health CAHPS Measures

On November 25, the Centers for Medicare and Medicaid Services (CMS) released the 2024 Measures Under Consideration (MUC) List in partnership with Battelle. This list includes all the quality and efficiency measures CMS will consider adopting, through the federal rulemaking process, in the next calendar year. Included in the 41 new measures are five measures for the Home Health Quality Reporting Program, specifically changes to five CAHPS composite measures. Two of the proposed measure changes, Care of Patients and Communications Between Providers and Patient, if adopted could have significant impacts on the Expanded Home Health Value Based Purchasing model. As part of this yearly process, CMS makes the measures publicly available and will seek input through public comments by the CMS Consensus Based-Entity (CBE), Battelle. Comments are due by December 30, 2024. LeadingAge is honored to have Jodi Eyigor representing the post-acute care and long-term care community as part of the Pre-Rulemaking Measure Review advisory groups.

Hospice Updates

Hospice Care Compare November 2024 Refresh Complete:

The November 2024 quarterly refresh for the Hospice Quality Reporting Program is now available on Care Compare. As a reminder, November is the one time a year when the claims-based hospice measures, Hospice Care Index and Hospice Visits in the Last Days of Life, are updated. LeadingAge is currently working on updating the members-only Hospice Trends Report and will issue notice to members when that update is complete and ready to be viewed.

CMS Hosts Hospice Quality Reporting Program Webinar December 12:

On December 12, 1 p.m. ET, the Centers for Medicare and Medicaid Services (CMS) will host a webinar on an Introduction to Hospice Outcomes and Patient Evaluation. Subject matter experts will answer questions as time permits. Click to register for this webinar.

Ask the Expert

A number of member questions come in daily to the association. In this article we will feature unique or recent questions of interest to members.

Q. Will NHSN Reporting Expire at the end of 2024?

A. No. The Home Health PPS final rule extended NHSN reporting on acute respiratory illnesses for nursing home residents indefinitely. However, there will be a reduction in frequency with reporting health care provider COVID-19 vaccinations. If you did not participate in the December 11 NHSN Webinar you will want to tune in to the replay webinar on January 7 by registering here. There are also new methods for credentialing new users of NHSN that are discussed in the training.

Have a question? Email yours now.