LeadingAge Illinois eNews

The Lead July 10 2025

LeadingAge Illinois Bi-Weekly Member Call
Upcoming IDPH Webinars
Send us your MCO Issues
Department of Homeland Security Terminates TPS for Honduras and Nicaragua
OSHA Issues Proposed Rule Revising the Respiratory Protection Program Requirements
OSHA Issues Proposed Rule to Remove COVID-19 Recordkeeping Requirements
Department of Homeland Security Terminates TPS for Haiti
Free & Non-Punitive Infection Control Assessment Opportunity
June IDPH Updates
Clinical Best Practice – Post Fall Physical Assessments
DOJ Submits Notice of Appeal in Staffing Mandate Lawsuit
July Training from the Center of Excellence for Behavioral Health in Nursing Facilities
Regulatory Review – F568 Accounting and Records of Resident’s Funds
PBJ Policy and FAQ Documents Updated
Impact Analysis of Medicaid Cuts on Nursing Homes Released by Senators
Reminder – SNF Off-Cycle Revalidations Due August 1
Greencastle of Barrington Hosts Senator
Greencastle of Kenwood Hosts House Speaker Pro Tempore
CMS Announces New Home Health and Hospice RAC Contract
LeadingAge Releases HOPE Implementation Guide
CMS Releases Home Health Proposed Rule
Ask the Expert

 LeadingAge Illinois Bi-Weekly Member Call

We are excited to invite you to our biweekly member meeting, open to all members! This is a great opportunity to stay informed on the latest legislative developments and education updates, as well as engage with our featured guest speakers.

Mark your calendars!
Every other Friday from 9:00 – 10:00 AM
Next Zoom is July 18

Meeting Highlights:

  • Legislative Updates: Learn about the most recent legislative changes that may impact our community from our Public Policy Team.
  • Education Updates: Stay up-to-date with the latest education offerings.
  • Featured Guests: Special guests will join us to share their expertise and insights on key topics.

This event is free and open to all members—we encourage you to join, participate, and connect with fellow members and LeadingAge Illinois staff.

RSVP Here.

We look forward to seeing you on Zoom!

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 Upcoming IDPH Webinars

The Illinois Department of Public Health announced the following upcoming webinars. Registration is required and attendance is limited. If you’re unable to attend, email Michael.moore@illinois.gov as the webinar will be recorded and can be distributed following the event.

Register for all offerings in July, August, and September here.

 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.

 Department of Homeland Security Terminates TPS for Honduras and Nicaragua

The U.S. Department of Homeland Security (DHS) has announced the termination of the Temporary Protected Status (TPS) designations for Honduras and Nicaragua. Each of these country-specific designations was set to expire on July 5, 2025. DHS formally published the Honduras and Nicaragua notifications in the Federal Register on July 8, 2025, and in both cases the notice states that the termination will be effective 60 days following the publication date. DHS estimates that there are approximately 72,000 Honduras nationals and 4,000 Nicaraguan nationals who hold TPS under the respective designations. DHS recognizes and notes that both TPS beneficiaries continue to be employment authorized during the 60-day transition period. LeadingAge will continue to compile and highlight information in their Pathways for Foreign-Born Workers serial post.

 OSHA Issues Proposed Rule Revising the Respiratory Protection Program Requirements

On July 1, 2025, the Occupational Safety and Health Administration (OSHA) filed a proposed rule in the Federal Register which seeks to revise the Respiratory Protection Program. Currently, the Respiratory Protection Program requires that employers complete medical evaluations and fit testing when employees are required to wear filtering facepiece respirators (FFR) or loose-fitting powered air-purifying respirators (PAPR). In the proposed rule, OSHA is seeking to remove the requirement for employers to complete the medical evaluation component of the respiratory protection program and is seeking feedback on all components of the program. OSHA indicated in the proposed rule, that the health effects are lacking and insufficient to establish that medical evaluations meaningfully reduce material impairment caused by wearing a FFR or loose fitting PAPR.

Comments are due to https://www.regulations.gov/document/OSHA-2025-0006-0013 no later than 10:59 p.m. CT on September 2, 2025.

 OSHA Issues Proposed Rule to Remove COVID-19 Recordkeeping Requirements

On July 1, 2025, The Occupational Safety and Health Administration (OSHA) filed a proposed rule in the Federal Register related to the Occupational Exposure to COVID-19 in Healthcare Settings. The proposed rule seeks to remove the remaining requirements of the OSHA Emergency Temporary Standard (ETS) issued in June 2021. While the majority of the ETS were not finalized in formal rulemaking, except for the requirements to maintain a log of and report COVID-19 hospitalizations and fatalities among staff. OSHA notes in the proposed rule that they are currently not enforcing the rule despite the text remaining in the Code of Federal Regulations (CFR) and therefore seek to remove the requirements.

You may submit written comments on the proposed rule electronically at https://www.regulations.gov/document/OSHA-2020-0004-2542 by 10:59 p.m. CT on September 2, 2025.

 Department of Homeland Security Terminates TPS for Haiti

On June 27, the Department of Homeland Security (DHS) announced the termination of Temporary Protected Status (TPS) for Haiti. The TPS designation for the country expires on August 3, 2025, and the termination will be effective on Tuesday, September 2, 2025. In February 2025, DHS issued a notice that it had shortened the existing TPS designation for Haiti by six months, with the effect that it would end August 3; that notice stated that the Department would conduct a review of current conditions in Haiti and then determine whether to newly-designate the country for an additional period of time. Most observers expect that DHS would not choose to redesignate, and the June 27 announcement confirms that it will not. Developments related to immigration can be found on the Pathways for Foreign Born Workers – serial post.

 Free & Non-Punitive Infection Control Assessment Opportunity

Did you know that the Illinois Department of Public Health’s Regional Infection Prevention Program (IDPH RIPP) within the Medical Services Division of IDPH can provide on-site Infection Control Assessment and Response (ICAR) evaluations? What is great about this opportunity?

1.     It is FREE!

2.     Unlike IDPH – OHCR this is non-punitive!

You can request an onsite ICAR by emailing DPH.IP@illinois.gov. Want to learn more? Join us on the member call July 18 as the RIPP team describes how they can help you improve your infection prevention and control program!

Haven’t registered for the bi-weekly member calls yet? Member calls are scheduled for every other Friday at 9 a.m. where you can learn the most recent updates from the LeadingAge Illinois team, ask your questions, and network with your peers! Register here to join us.

 June IDPH Updates

On June 26, LeadingAge Illinois staff met with the Illinois Department of Public Health (IDPH) Office of Health Care Regulation (OHCR). The department provided updates on the LLCS Portal, transition to iQIES, and then answered questions from the associations with updates are outlined below.

LLCS Portal:

LLCS Portal Training was offered by the department in June. You can access the recording of the training here. There are still approximately 200 of 1500+ providers that do not have a registered user established in the portal. The associations are seeking ways that they can assist the department in having these individuals register.

Important Note: If your email addresses for various individuals in your program are generic (such as administrator@…. Or directorofnursing@…..) there are extra steps required to change the user associated with that email which takes more time. If you reach out to the department and request this change and don’t receive a prompt response back, it may be because they have to submit multiple requests in these circumstances to complete the change.

Transition to iQIES:

Survey agencies will be transitioning from the ASPEN program (current software) to iQIES on July 14, 2025. Since Illinois currently uses the electronic plan of correction (ePOC) process, nursing home providers will be expected to register for iQIES ePOC access (which is different from MDS access – see separate article on how to complete this process).

Point Click Care (PCC) Multifactor Authentication Change:

During the call, one association expressed concern about the upcoming changes to PCC electronic health record access requiring multifactor authentication (MFA). IDPH confirmed that surveyors are currently completing MFA to access their computers and are confident that they will be able to duplicate the process to gain access to PCC. However, the department is going to reach out to their technology support staff to ensure this will be ok.

Misc:

The department indicated that they are in the process of printing new maps for the redistricting. These will be distributed soon so providers will know what region they are included in.

 Clinical Best Practice – Post Fall Physical Assessments

Nursing home regulations direct providers to “ascertain if there were injuries following a fall and provide treatment as necessary.” However, the guidelines don’t provide recommendations or best practices for the frequency or duration of follow-up assessments, which leaves providers wondering what the best practice is and what should staff assess for.

Root Cause:

When a fall occurs, providers should do their best to attempt to determine (or assist the tenant/patient depending on the level of care in determining) why the fall occurred or the root cause. This helps drive new fall interventions that can prevent similar falls from possibly occurring. If you’re unable to identify a root cause, you may consider implementing new interventions that would reduce the resident’s risk for injury. Typically, a post fall investigation into the possible contributing factors is completed once with a follow up to ensure that the implemented intervention is appropriate. For example, following a fall, you determined that Resident #1 stood up unassisted and attempted to walk to the bathroom which led to a fall. During investigation, it was determined that last assisted to the resident in the bathroom three hours prior and the resident was incontinent of urine at the time of the fall. Even if the resident is unable to tell you they needed to go to the bathroom, a reasonable assumption given the circumstances could be that the resident may have been attempting to go to the toilet and appropriate interventions could be assisting the resident to use the bathroom every two hours. During follow up review of the intervention it was determined that the resident still attempted to walk unassisted despite staff compliance with the toileting plan and fall intervention which means that the intervention may not have been appropriate and should be reevaluated to determine if the intervention is still necessary or if something different should be implemented.

Physical Assessments:

Additionally, nurses should assess the resident/patient to determine if an injury is apparent. Neurological assessments may also be indicated and are based on your individual policy. Some providers require that neurological assessments should be completed for all unwitnessed falls, which leaves your nurses sometimes scrambling to complete them without any clear signs of head trauma while others just complete neurological assessments if there is an indication or belief that the resident hit their head. This is nursing home and survey/deficiency specific as it may have been a plan of correction to a previous finding of noncompliance. There isn’t anything in guidance that states neurological assessments after each fall or unwitnessed falls are required. It is the standard of practice that if you have suspicion of a resident hitting their head, you complete neurological assessments.

According to references cited below, a resident should be assessed for physical injuries prior to moving them from the location of the fall because if the resident sustained an injury, moving them may cause further physical injury, such as a cervical or spinal injury. If a significant injury is suspected based on clinical assessment findings, the resident should not be moved, and the nurse should follow the procedures for transferring the resident/patient to a higher level of care for evaluation (such as to an ER). Allow the emergency medical personnel to complete splinting or bracing of potential injury areas prior to moving the resident/patient and then assisting the resident onto a cot for transport.

The nurse assessing the resident/patient following a fall should assess:

  • Vital signs include the resident’s pulse, blood pressure, respiratory rate, oxygen saturation. Some providers include orthostatic blood pressure and pulses to determine if orthostatic hypotension (when the blood pressure decreases as someone changes elevation) was a contributing factor to the fall. Vital sign abnormalities could indicate a potential injury as well as a possible indication of an underlying infection that could have contributed to the fall.
  • Cognition or a change in consciousness as an indication that the resident/patient may have suffered a head injury.
  • Muscle strength, sensation, and range of motion which could be indicators of possible injuries including sprains, strains, or fractures.
  • Deformities could be an indication of a physical injury such as external rotation of a leg or one leg is longer than the other in a possible hip fracture.
  • Skin integrity such as abrasions, skin tears, or bruises.

Frequency:

The resource documents referenced below vary in the recommendations of the frequency of follow-up assessments. Injuries from a fall may not always present immediately upon the incident such as a head injury that may take hours for the residents to display a change in consciousness. It is important for nurses to complete some type of follow-up assessment after the fall to ensure that any possible injuries are identified and treated as soon as possible.

The recommendations include anywhere from every four hours to every shift and for durations extending to 24 – 48 hours post fall. Some providers may extend this out to a 72 hour period, just to be on the safe side. Additionally, follow-up assessments may vary based on any suspected injuries. If a resident has signs that they hit their head during the fall, neurological assessments should be completed more frequently than general physical assessments without signs of head trauma. Whatever your policy is, ensure that your nurses have a clear process of completing the follow-up assessments including where and how they are documented for consistency.

Notification of State Survey Agency:

Some providers are required to notify the state survey agency of specific incidents. Staff should have knowledge of the specific requirements to report to the survey agency along with the method for expedited reporting. Illinois rules are outlined below:

Nursing Homes – 300.690 requires that the department is notified of any serious incident or accident. Serious is defined as any incident or accident that causes physical injury or harm to a resident. Notification should occur via the LLCS portal or by notifying the regional IDPH office within 24 hours. Additionally, law enforcement may need to be notified if the incident or accident results in death. Within seven days of the incident, the nursing home shall submit a narrative summary of the reportable accident or incident.

Assisted Living – 295.2050 also requires that the department is notified of any serious incident or accident. Serious is defined as causing physical or emotional harm or injury to the resident. Reporting shall be completed via the LLCS portal if the program has portal access or by emailing DPH.LTCAL@illinois.gov within 24 hours of the incident or accident. A copy of the report must be maintained for one year of the incident/accident. However, during the most recent legislative session, LeadingAge Illinois was successful in passing legislation that amends the definition of a reportable accident/incident to a significant physical harm or injury where a resident requires immediate medical attention, including admission to the hospital as a result of the incident or accident.

Policy & Procedure:

Finally, all steps in the fall process must be included in your policy and procedure. This includes pre-fall preparation such as completing a fall risk assessment, identifying preventative interventions to when a fall occurs and what the expectations are of your staff to monitor the individual ongoing for possible injuries or a change in condition. Whether the resident sustains an injury or not, ensure that the resident/patient’s responsible party and physician are notified timely of the incident and include findings from the assessment.

References:

HB3414 – Changes to Assisted Living & Shared Housing Establishments Act

AAPACN – Post-Fall Assessments

AHRQ – Falls Management Program: A Quality Improvement Initiative for Nursing Facilities – Chapter 1.

Preventing Falls in Hospitals – Tool 3N: Postfall Assessment, Clinical Review

Veteran’s Administration – Falls Policy Overview

CMS – Appendix PP for Nursing Homes

Nursing Home Code – Illinois Department of Public Health

 DOJ Submits Notice of Appeal in Staffing Mandate Lawsuit

On June 2, the Department of Justice (DOJ) submitted a notice of appeal in the United States District Court for the Northern District of Texas following the Court’s April 7 ruling in favor of the LeadingAge lawsuit to vacate the Centers for Medicare & Medicaid Services (CMS) federal staffing mandate for nursing homes. The lawsuit was filed by American Health Care Association, LeadingAge, the Texas Health Care Association, and several Texas providers. LeadingAge is awaiting the next step in the appeal process, which will entail the Court establishing a briefing schedule.

 July Training from the Center of Excellence for Behavioral Health in Nursing Facilities

The Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) is hosting several trainings in July for nursing home providers. You can register at the links below for these free training opportunities!

 Regulatory Review – F568 Accounting and Records of Resident’s Funds

F568 – Accounting and Records of Resident’s Funds

In the residents’ rights regulations, F568 requires specific accounting practices and maintaining records of funds deposited with the nursing home for the residents. Within this regulation, the nursing home must:

In the residents’ rights regulations, F568 requires specific accounting practices and maintaining records of funds deposited with the nursing home for the residents. Within this regulation, the nursing home must:

  • Establish methods of accounting of the resident’s funds based on generally accepted accounting principles.
  • Ensure the accounting of resident funds is separate from business funds as well as any other resident’s funds.
  • The record for the resident’s funds must be available to the residents via quarterly statements and upon request.

The interpretative guidance for this regulation includes that the accounting of the resident’s funds must include transactions that occurred for the specific resident such as when they occurred, what they were, and an ongoing balance. Additionally, the residents should be given a receipt of the transaction and the nursing home should retain a copy of the receipt. Finally, quarterly statements are considered timely if provided within 30 days of the end of a quarter and upon request.

This regulation is not frequently cited. However, Appendix PP includes some examples of noncompliance including that the nursing home did not assure the accounting of resident’s funds were separate from business funds and not providing the resident the quarterly statements.

 PBJ Policy and FAQ Documents Updated

The Payroll Based Journal (PBJ) Policy and FAQ documents were recently updated (dated June 2025) and include the following clarifications:

  1. If the employee takes less than a 30-minute meal break, is the full 30 minutes still deducted? Yes, even if the employee takes less than a minute break, the PBJ rules require that a 30-minute break is deducted for each eight-hour shift worked. If the provider were audited, the audit would be compliant if the PBJ report showed a 30-minute break, despite the payroll records indicated a shorter break.
  2. Can nurse consultant hours be reported? Only if the nurse consultant is on-site and available to provide direct care to the resident. If the nurse consultant is assisting with survey preparation or chart reviews, the hours cannot be reported.
  3. Can remote hours be reported?
  4. If a provider can prove that an RN was onsite for 8 consecutive hours but the PBJ report includes only 7.5 hours (due to the meal break policy), would the nursing home be in non-compliance? No, if the nursing home can provide evidence that the RN was onsite for 8 consecutive hours they should not receive a deficiency.
  5. What should nursing homes do if they have an RN waiver but wanted It to remain above a one-star? The nursing home should contact CMS to verify that an RN waiver is present. The RN waiver would be verified, and the nursing home can remain above a one star as long as the RN is onsite for a minimum of 40 hours per week.
  6. What if a person’s salary is based on more than 40 hours per week? Is there a cap that can be reported? The hours can be reported if the person receives some type of bonus that is directly correlated to the hours worked and is distinguishable from other payments. No, there is not a cap to the number of additional hours, but you must have evidence such as the person’s contract of what the person is being paid for (minus other applicable rules such as removal of the 30-minute meal break period).
  7. If a provider fails a PBJ audit and would like to appeal the decision, is there a way for them to do so? Yes, instructions on requesting a reconsideration are included in the audit results letter. However, there are some reasons when a provider fails an audit where no reconsideration would be available. For example, if an audit reveals that a nursing home grouped contract employees under one ID instead of creating unique IDs for each employee, the failure caused a significant variance because turnover cannot be calculated accurately. In this case, the results letter would not contain reconsideration instructions.
  8. The understanding is that a “significant variance between the hours reported and verified” would trigger a failed PBJ audit. Is that correct? Are there other conditions that would trigger a PBJ audit failure? Yes, a significant variance between the hours that were reported in PBJ and the hours that were verifiable back to payroll would result in an audit failure. A significant variance could also occur if a facility did not complete all MDS discharge assessments timely, resulting in an inaccurate census calculation. In addition, a failure to respond to an audit request or to submit all required documentation would trigger a failed PBJ audit.
  9. Can you clarify that all communication regarding the audit and appeal is through the auditors and not directly from CMS? The audit request and all subsequent communication regarding the audit would come directly from the current audit contractor and not from CMS. This includes the final results letter and, if reconsideration is requested, the results of that request. Note that all reconsiderations are sent to CMS for review and final decision, however, the final decision would be communicated by the audit contractor.

Additionally, the PBJ LTC Policy Manual included the following additional change:

  • In no case should a single employee ID or system ID include more than 22.5 hours for a single day entered (as this is in compliance with working 24 hours minus the meal break policy).

 Impact Analysis of Medicaid Cuts on Nursing Homes Released by Senators

Senate Finance Committee Ranking Member Ron Wyden (D-OR), member Mark Warner (D-VA), Budget Committee Ranking Member Jeff Merkley (D-OR), and Senate Minority Leader Chuck Schumer (D-NY) released a June 27, 2025, analysis regarding the potential impacts on nursing homes of Medicaid cuts contained in H.R.1, the One Big Beautiful Bill Act. This analysis, conducted by researchers from the Brown University School of Public Health, identifies 579 nursing homes across 45 states that would be at elevated risk of closure due to the more than $800 billion in proposed Medicaid cuts. The states with the highest numbers of at-risk nursing homes are Illinois (93) – (note: we don’t believe this includes the reserve funds allocated for anticipated Medicaid funding cuts), Texas (66), Ohio (41), Missouri (39), and Georgia (37). The analysis examines 10 years of nursing home data to determine the top indicators of financial risk for nursing home closures: facilities that have the highest level of residents enrolled in Medicaid (85% or more), facilities with the lowest occupancy rates (less than 80%), and those with the lowest quality ratings (a 1- or 2-star quality rating). The full analysis can be found here. A list of the 579 nursing homes at an elevated risk of closure is here.

 Reminder – SNF Off-Cycle Revalidations Due August 1

A friendly reminder that skilled nursing providers must submit their off-cycle revalidation information by August 1. LeadingAge Illinois and LeadingAge have resources available to aid in this process which are linked below.

 Greencastle of Barrington Hosts Senator

Greencaslte of Barrington, an Embrace Living community, recentlyt hosted Senator Darby Hills (R-Lake Zurich) for a visit. The staff discussed the need for more affordable housing in Illinois. The community has a three years plus waiting list. Embrace continues to look to expand and add more capacity and would like to reduce the waiting lists. The Senator was provided a tour of a unit and also got a chance to see the therapy room, which is full of state-of-the-art equipment. The tour was preceded by her address of a large gathering of staff and residents where she held a great discussion with several questions.

If you would like to host your legislator, contact Jason Speaks and he will do all the legwork to get the visit set and make it a success.

 Greencastle of Kenwood Hosts House Speaker Pro Tempore

Embrace Living continues to advocate for senior housing at the federal and state levels. In the last week weeks, they have hosted state and federal legislative visits at some of their communities. One of the most recent was a visit from State Representative Kam Buckner, Speaker Pro Tempore at Greencastle of Kenwood in Chicago. The visit included meeting with residents and taking a tour.

 CMS Announces New Home Health and Hospice RAC Contract

The Centers for Medicare & Medicaid Services (CMS) awarded Cotiviti GOV Services, LLC, the Recovery Audit Contract (RAC) Region 5 contract in addition to contracts for two other Medicare Part A and B RAC contracts. CMS’ previous contractor for home health and hospice, Performant, will remain under contract to support the RAC program from an administrative and appeals perspective for home and hospices, while Cotiviti GOV Services, LLC will begin reviews in the Summer of 2025.

 LeadingAge Releases HOPE Implementation Guide

LeadingAge released a new tool to help hospice providers navigate CMS’s new Hospice Outcomes and Patient Evaluation (HOPE) assessment. This resource walks through key information and timelines to help members prepare for a successful HOPE tool implementation on October 1, 2025. The content covers all sections of the HOPE along with considerations for staffing and information on submission and corrections. It also includes helpful downloadable materials and is free to all LeadingAge members.

 CMS Releases Home Health Proposed Rule

On June 30, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2026 Home Health Proposed Rule that will make an aggregate      -6.4% cut to the base payment. This reduction along with the -8.79% cut to the base payment since CY2023 threatens the existence of home health agencies. Between 2019 and 2023, the number of skilled home health agencies that treated more than 10 fee-for-service patients annually decreased or remained the same in 94.1% of counties which is concerning statistics considering the growth in the older adult population and the focus on receiving care in the home. The rule also includes removal of several measures in the home health quality reporting program, value based purchasing program, and changes to the conditions of participation regarding OASIS collection. LeadingAge completed a thorough analysis of the rule here.

 Ask the Expert

What is the requirement for testing a new staff member for TB?

According to the TB code (Title 77 Section 696), health care providers must complete an individual risk assessment, a symptom evaluation, and a tuberculin test which includes either a TB skin test or an interferon gamma release assay (IGRA) blood test. Did you know that LeadingAge Illinois has a website dedicated to TB resources where you can find a template policy and the forms required in the State Code?

Also, a member recently asked about the contradictory statement on the TB risk assessment form that indicates if a staff member answered no to all of the above questions, a test is not required. This is not accurate for new staff as they all require a test. LeadingAge Illinois reached out to the Illinois Department of Public Health (IDPH) Medical Services unit to seek clarification and discuss the contradictory statement in the form.