LeadingAge Illinois eNews

The Lead January 9, 2025

From the Desk of Angela Schnepf, President and CEO

Top Stories:
2025 Calendar for Celebrations & Activities
IDPH Office of Health Care Regulation Monthly Educational Webinars
HHS Proposes Modifications to HIPAA
LeadingAge Launches New 5-Star Report Portal
It’s Prime Time for Illnesses! What You Need to Know
Upcoming LTC HAI Webinars
Send us your MCO Issues

Nursing and Rehabilitation:
IDPH Proposes Rules on LTC Cost Reports
IDPH Implements TB Screening Rules
CMS Issues QSO on LTC Acute Respiratory Illness Reporting
NHSN Updated Resources
Center of Excellence for Behavioral Health Upcoming Training
CMS Launches New Nursing Home Careers and Staffing Campaign Websites
CMS Discontinues CMP Grants for Communication Technology and Visitation Aids
Regulatory Review Article – F558 Reasonable Accommodation & Resident Preference

Housing:
HUD Publishes 2025 Annual Adjustment Factors\

HCBS:
CMS Proposes Changes to Home Health CAHPS Measures
Revised HH Privacy Rights Statement
CMS Releases Final OASIS-E1 Time Points Instruments

Other:
Ask the Expert

From the Desk of Angela Schnepf, President and CEO

Tomorrow at Westminster Place in Evanston, we come together to celebrate our 2025 legislative successes and honor our Legislators of the Year. We will recognize House Majoruty Leader, Robyn Gabel, ansd Senator Sara Feigenholtz, our two sponsors of the Medication Aide legislation that passed last session, creating the first ever permanent Medication Aide program in lllinois.

Please join us tomorrow at noon to take part in this celebratory luncheon. You can reserve your seat here.

Kindest Regards,

Angela

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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.

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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.

·      January 22 from 1 – 2 p.m. Developing Corrective Action Plans for Long-Term Care Facilities

·      February 26 from 1 – 2 p.m. Fall Risk Planning

·      March 19 from 1 – 2 p.m. Identifying and Reporting Abuse

Register Here.

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HHS Proposes Modifications to HIPAA

A proposed rule was published in the Federal Register on January 6 outlining revisions to the Health Information Portability and Accountability Act of 1996 (HIPAA) Security rule. The HIPAA Security Rule to Strengthen the Cybersecurity of Electronic Protected Health Information proposed rule has a 60-day comment period ending March 7, 2025. Comments may be submitted electronically at https://www.regulations.gov by searching for the Docket ID number HHS-OCR-0945-AA22 or via mail to:

U.S. Department of Health and Human Services Office of Civil Rights

Attention: HIPAA Security Rule NPRM

Hubert H. Humphrey Building, Room 509F

200 Independence Avenue SW

Washington DC, 20201

A Fact Sheet was also released on December 27, 2024 which outlines the new proposals and clarifications included in the proposed rule. The proposed changes include:

  • Removing the distinction between “required” and “addressable” implementation specifications and make all implementation specifications required with specific, limited exceptions.
  • Require written documentation of all Security Rule policies, procedures, plans, and analyses.
  • Update definitions and revise implementation specifications to reflect changes in technology and terminology.
  • Add specific compliance time periods for many existing requirements.
  • Require the development and revision of a technology asset inventory and a network map that illustrates the movement of electronic protected health information (ePHI) throughout the regulated entity’s electronic information system(s) on an ongoing basis, but at least once every 12 months and in response to a change in the regulated entity’s environment or operations that may impact ePHI.
  • Require greater specificity for conducting a risk analysis. New requirements would include a written assessment that contains:
    • A review of the technology asset inventory and network map.
    • Identification of all reasonably anticipated threats to the confidentiality, integrity, and availability of ePHI.
    • Identification of potential vulnerabilities and predisposing conditions to the regulated entity’s relevant electronic information systems.
    • An assessment of the risk level for each identified threat and vulnerability, based on the likelihood that each identified threat will exploit the identified vulnerabilities.
  • Require notification of certain regulated entities within 24 hours when a workforce member’s access to ePHI or certain electronic information systems is changed or terminated.
  • Strengthen requirements for planning for contingencies and responding to security incidents. Specifically, regulated entities would be required to:
    • Establish written procedures to restore the loss of certain relevant electronic information systems and technology assets to determine the priority for restoration.
    • Establish written security incident response plans and procedures documenting how workforce members are to report suspected or known security incidents and how the regulated entity will respond to suspected or known security incidents.
    • Implement written procedures for testing and revising written security incident response plans.
  • Require regulated entities to conduct a compliance audit at least once every 12 months to ensure their compliance with the Security Rule requirements.
  • Require that business associates verify at least once every 12 months for covered entities (and that business associate contractors verify at least once every 12 months for business associates) that they have deployed technical safeguards required by the Security Rule to protect ePHI through a written analysis of the business associate’s relevant electronic information systems by a subject matter expert and a written certification that the analysis has been performed and is accurate.
  • Require encryption of ePHI at rest and in transit, with limited exceptions.
  • Require regulated entities to establish and deploy technical controls for configuring relevant electronic information systems, including workstations, in a consistent manner. New requirements would include:
    • Deploying anti-malware protection.
    • Removing extraneous software from relevant electronic information systems.
    • Disabling network ports in accordance with the risk analysis.
  • Require the use of multi-factor authentication, with limited exceptions.
  • Require vulnerability screening at least every six months and penetration testing at least once every 12 months.
  • Require network segmentation.
  • Require separate technical controls for backup and recovery of ePHI and relevant electronic information systems.
  • Require regulated entities to review and test the effectiveness of certain security measures at least once every 12 months, in place of the current general requirement to maintain security measures.
  • Require business associates to notify covered entities (and subcontractors to notify business associates) upon activation of their contingency plans without unreasonable delay, but no later than 24 hours after activation.
  • Require group health plans to include in their plan documents requirements for their group health plan sponsors to comply with the administrative, physical, and technical safeguards of the Security Rule; ensure that any agent to whom they provide ePHI agrees to implement the administrative, physical, and technical safeguards of the Security Rule; and notify their group health plans upon activation of their contingency plans without unreasonable delay, but no later than 24 hours after activation.

LeadingAge Illinois/Iowa has scheduled a Feedback Session on the Proposed HIPAA Revisions to understand how these revisions will impact the Information Technology (IT) services to your organization. The feedback session is scheduled for February 11, 2025, at 10:30 a.m., advanced registration is required.

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LeadingAge Launches New 5-Star Report Portal

In partnership with LeadingAge New York, a new Report Portal Landing Page for Nursing Home and Hospice members is available on the LeadingAge website. Previously, these reports were available through the Quality Metrics website. This exclusive tool gives providers direct access to their quality metric reports through the LeadingAge website. By leveraging these reports, organizations can adopt a data-driven approach to enhance quality care and inform strategic decisions. With use of the Centers for Medicare & Medicaid (CMS) Care Compare data, providers can analyze provider-specific quality metrics for benchmarking, identifying strengths and weaknesses, and supporting continuous improvement. The report portal will be updated quarterly with CMS data refresh.

LeadingAge Illinois plans to continue sending these reports quarterly to members via email.

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It’s Prime Time for Illnesses! What You Need to Know

Respiratory illnesses and cases of norovirus are increasing across the country. Here are some friendly reminders and resources.

Respiratory Illness:

All residents should be placed in contact isolation when they develop symptoms of a respiratory illness. Once placed in contact isolation, you should take steps to determine if the resident has COVID-19 or Influenza. It may be advised to obtain standing orders from your physician’s or medical director to obtain these tests to prevent delays in testing.

A staff member should be excluded from work until they have been tested also. Providers should follow their return to work policies if COVID-19 and Influenza are negative. This should include being fever-free without the use of fever reducing medication and noted improvement in symptoms. If the employee tests positive for COVID-19 or influenza, you should follow the CDC guidance below on return-to-work procedures. **Note, the COVID-19 guidance has not been revised since May 2023 and still requires prolonged durations for employee work exclusion and isolation for residents. This is something that we continue to advocate on from both State and Federal perspectives.

Norovirus:

Norovirus is easily transmitted in health care settings. Any resident with nausea, vomiting, and diarrhea should be placed in contact isolation until at least 48 hours after symptoms have subsided. Ideally, residents should be placed in individual rooms to prevent transmission to other residents. However, if necessary, residents should be placed in rooms with other residents that have the same condition for isolation.

Any employee with similar symptoms should be excluded from work until at least 48 hours after symptoms have subsided.

Staff responsible for cleaning up diarrhea or vomitus should wear gloves, isolation gown, a facemask, and eye protection. According to public health officials, the norovirus is easily transmitted in this situation.

Any outbreak, regardless of cause, is reportable to public health officials. You can report outbreaks to your HAI nurse clinician once during the outbreak and continue communication with them on an ongoing basis until the outbreak resolves. Outbreaks can be reported by contacting your local health department.

Highly Pathogenic Avian Influenza (HPAI)

While there are increasing numbers of cases of HPAI in humans across the country, this is not a public health threat at this time. HPAI has only been transmitted from infected birds to humans without any human-to-human transmission identified.

Individuals with exposures to flocks of birds or poultry are at a higher risk of exposure as birds will not necessarily show signs of illness until they suddenly pass. If you need to touch a dead bird for any reason, PPE is recommended including gloves, isolation gown, surgical facemask, and eye protection followed by good handwashing.

There is no exposure risk from walking by dead birds or consuming cooked poultry or eggs. If you have a large flock of birds that die, please report to the Department of Natural Resources as they may do additional testing on the birds.

Human Metapneumovirus (HMPV)

There has been increased media attention regarding outbreaks of HMPV in China, which has people worried based on the COVID-19 pandemic. HMPV is a common seasonal illness that is present in the United States, as well as around the world. According to an article published by CBS News, the cases of HMPV are not new and there is not an unusually high spike in cases identified.

Regardless of the reason, providers should establish universal practices that protect both the residents and the staff. These include frequent handwashing or hand hygiene, cleaning and disinfecting high-touch surfaces, staying home when they are ill or isolating symptomatic residents, and limiting contact between your hands and mucous membranes.

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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.

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.

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Send us your MCO Issues

LeadingAge Illinois is working with the Illinois Department of Healthcare and Family Services (HFS) and the MCOs to resolve MCO billing issues. If you have a pattern of claims issues (not single claims) that you have not been able to resolve using the normal channels, such as working with your provider relations representative or through the use of the complaint portal, we can help by raising attention to these issues.

If you have issues, please contact Jason Speaks.

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IDPH Proposes Rules on LTC Cost Reports

The Illinois Department of Public Health (IDPH) recently issued proposed rules concerning the annual filing deadlines for Long Term Care (LTC) facility financial and statistical reports (cost reports).

  • The rulemaking extends the cost report due date for facilities whose fiscal year ends on or before June 30 to November 30 of the applicable year.
  • For facilities whose fiscal year ends after June 30, the report is due 5 months after the fiscal year end date. (Currently, all reports are due within 90 days after the end of the facility’s fiscal year.)
  • A 30-day extension of the due date that is provided for in current rule will only be granted for extraordinary circumstances over which the provider has no control.
  • The rulemaking also provides that cost reports filed prior to July 1 (currently, prior to April 1) of the applicable year will be used to calculate the facility’s rates for the upcoming July 1 rate.

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IDPH Implements TB Screening Rules

The Illinois Department of Public Health (IDPH) recently introduced rule amendments to Control of

Tuberculosis Code (77 IAC 696; proposed at 48 Ill Reg 437) that are now effective that incorporate recommendations from the federal Centers for Disease Control and Prevention and include symptom evaluation in the screening process for newly hired health care workers. Since

1st Notice, in response to public comment, IDPH removed proposed new testing and reporting requirements for suspected or confirmed cases of latent tuberculosis infection (LTBI).

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CMS Issues QSO on LTC Acute Respiratory Illness Reporting

On December 31, the Centers for Medicare and Medicaid Services (CMS) issued QSO-25-11-NH related to nursing homes reporting acute respiratory illnesses. The memo outlines the requirements included in the Calendar Year 2025 Home Health Prospective Payment System Rate Update final rule including reporting on census, resident vaccination status for COVID-19, influenza, and RSV, cases and hospitalizations related to each of the respiratory illnesses.

The new information included in the QSO memo indicates that CMS is in the process of establishing surveyor guidance to evaluate compliance with nursing homes reporting as required in the final rule. However, this guidance has not yet been developed or released. CMS indicated in the memo that once guidance is established, new requirements will be included in the survey process. While the survey process has not been revised at this time, CMS reiterates the requirements for nursing homes to report on the required elements by the effective date (January 1, 2025) and ongoing to maintain compliance.

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NHSN Updated Resources

The Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) has posted several revised resources recently which are linked below for your ease of access.

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Center of Excellence for Behavioral Health Upcoming Training

The Center of Excellence for Behavioral Health has several training opportunities upcoming, which are free to nursing home providers. The upcoming trainings are linked below.

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CMS Launches New Nursing Home Careers and Staffing Campaign Websites

The Centers for Medicare & Medicaid Services (CMS) launched two new websites geared towards improving staffing in nursing homes on December 16, 2024.

The Explore Nursing Home Careers website includes information on how to become a CNA for free with links to state’s resources, exploring nursing home career pathways in nursing, and outlining why working in nursing homes is beneficial to the individual.

The Nursing Home Staffing Campaign website appears to be a work-in-progress as there are several headlined areas which include information about the different campaigns. However, the different sections lack resources available to assist with the established goal. The nursing home staffing campaign outlines financial incentives for registered nurses (RNs), promoting on-the-job training opportunities for individuals to become CNAs, a future nurse recruitment webpage, collaborating with states to bolster CMS’ campaign, partnerships with various stakeholders, and the commitment to improving the quality of life for nursing home residents while enhancing the quality of work for nursing home staff. CMS notes at the bottom of the page that the campaign will be implemented in phases and encourages individuals to check the page for periodic updates on the progress.

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CMS Discontinues CMP Grants for Communication Technology and Visitation Aids

In a memo released on December 20, 2024, the Centers for Medicare & Medicaid Services (CMS) announced that they are discontinuing the category of communication technology and visitation aid for use of Civil Monetary Penalty (CMP) reinvestment funds effective January 1, 2025.

During the COVID-19 Public Health Emergency (PHE), CMS allowed use of CMP reinvestment funds for nursing homes to purchase technology which would enhance communication between residents and their families along with devises to assist with safe visitation. CMS notes that since the PHE ended in May 2023, they intend to discontinue this category and no longer accept applications for new requests after the first of the year.

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Regulatory Review Article – F558 Reasonable Accommodation & Resident Preference

F558 is included in the resident rights section of Appendix PP and relates to the resident’s rights to have reasonable accommodation of their needs and preferences unless it would endanger the health or safety of the resident and other residents. The interpretive guidance defines reasonable accommodation as the nursing home’s efforts to individualize the resident’s physical environment. However, this regulation is often cited for more than the physical environment and can include routines and schedules.

When reviewing this regulation, you want to ensure that you are doing the most you can to meet the residents’ requests for personal items and equipment they may desire. Examples of noncompliance are included in Appendix PP including storing items where the resident may not be able to reach it when they are otherwise ambulatory, not having accessible areas for the residents in the building, and providing equipment necessary to maintain independence.

If the nursing home cannot meet the resident’s preference and requested accommodation documentation in the record should include what the resident requested, how it would interfere with the other resident’s rights, health or safety, and what you did to attempt to accommodate a similar request or modify the original request. An example of this could include when the resident reports not being able to hear their TV because the noise in the hallway. In this example perhaps the resident turns up the volume on the TV to be able to hear it but then other residents complain about the noise level and want it turned down. You should meet with the resident and determine if there are steps that can be taken to both allow the resident to hear the TV while other resident’s rights are being protected with the accommodation such as the use of headphones.

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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.

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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

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Revised HH Privacy Rights Statement

The Centers for Medicare & Medicaid Services (CMS) issued updates to providing OASIS Privacy Notices for home health (HH) providers. Due to the transition to collection of OASIS Data on all patients, regardless of payer, HH providers must issue all patients with the CMS Privacy Act Statement and Attachment A – Statement of Patient Privacy Rights. These forms are available here (zip file) with both English and Spanish options available. Effective January 1, the Notice About Privacy for Patients Who Don’t Have Medicare or Medicaid should not be provided (Attachment C).

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CMS Releases Final OASIS-E1 Time Points Instruments

On December 16, the Centers for Medicare and Medicaid Services announced the final Office of Management and Budget (OMB) approved OASIS-E1 time points instruments that will be effective January 1, 2025 which are now available in the downloads section of the OASIS Data Sets webpage. A change table OASIS-E1 Instruments March 2024-December 2024 Changes is also available.

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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.

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