The Lead May 1, 2025 - LeadingAge Illinois

From the Desk of Angela Schnepf, President and CEO

Nursing and Rehabilitation:
Off-Cycle Medicare Revalidations Delayed
Reminder – Annual Healthcare Personnel Influenza Vaccination Reporting Due Soon
Regulatory Review – F699 Trauma Informed Care
Upcoming COE-NF Behavioral Health Training

HCBS:
CMS Releases HOPE Manual Version 1.01

Other:
Ask the Expert

From the Desk of Angela Schnepf, President and CEO

We wanted to make sure you were aware that the Nursing Home Medicare Revalidation Deadline Extended to August 1. CMS has announced it on April 17, extending the deadline, from May 1 to August 1, for off-cycle revalidation for all Medicare-certified nursing homes to be completed.

Kindest Regards,

Angela

SNF Staffing Ratio Census Reports Due June 1

Census data for the 2^nd quarter (January 1 – March 31, 2025) is due to IDPH no later than the close of business on June 1, 2025.

Census data must be submitted to the Department on the attached Excel spreadsheet and sent to DPH.LTCDailyCensus@illinois.gov.

Failure to submit a required daily census report by the close of business on June 1, 2025, will result in the Department calculating staffing requirements utilizing the facility’s number of licensed beds and the skilled direct care staffing ratio.

Questions and technical difficulties may be directed to DPH.LTCDailyCensus@illinois.gov.

LeadingAge Illinois Continues Push for ADS Rate Increase

At 8:30 p.m. last night, Jason Speaks, director of government relations at LeadingAge Illinois testified alongside Cynthia Cunningham, advocacy chair of the Illinois Adult Day Services Association (IADSA) in a hearing of the Senate Appropriations-Human Services Committee. They urged the legislature to include an increase in the Adult Day Services rates in the State Budget.

LeadingAge Illinois is collaborating with IADSA on the effort to increase the rates. We were successful in getting an increase in the 2023 State Budget. Two years later, with inflation and other financial challenges, there is a clear need and justification to increase the rates again.

Advocacy Continues on SNF Staffing Ratio Issues and Funding Proposals

LeadingAge Illinois continues to discuss with legislators, state agencies, and stakeholders issues involving the staffing ratio census requirements and funding proposals before the Illinois General Assembly.

As we alerted you to recently, the Illinois Department of Public Health (IDPH) sent out, in error, non-compliance letters to providers indicating they did not reporting staffing numbers when they indeed had. We have discussed this issue with IDPH several times and as of today they report they are still finalizing a statewide alert to clear up the issue.

We also are working on legislative language this last month of session to remove the requirement of posting a notice of violation due to staffing requirement if staffing was at 90% of the minimum requirement as well as add infection preventionists and MDS nurses to he list of direct care staff used to compute staff to resident ratios.

There is also a proposal that surfaced over the last couple of weeks that would add an additional provider tax to skilled nursing facilities. We strongly oppose this effort, as our review of the proposal shows it as negatively impacting our members. We testified against this proposal last night in the Senate Appropriations-Human Services Committee.

New Executive Order to Expand Registered Apprenticeships

On April 23, President Trump signed an executive order improving and expanding apprenticeships. The Preparing Americans for High-Paying, Skilled Trade Jobs of the Future aims to improve and expand job training for skilled trades and directs the Departments of Labor, Education, and Commerce to streamline and consolidate federal workforce programs by expanding registered apprenticeships to over one million annually. This EO aligns with the administration’s goal to revive U.S. manufacturing, however, could also hold potential for direct care workers in health care including nursing assistants and home care aides and we are hopeful this could play a positive role in addressing critical workforce shortages in the aging services sector.

CMS Shares “Essential Survey Information” Toolkit

The Centers for Medicare & Medicaid Services (CMS) has developed an informational resource for providers on the survey process. The toolkit, available on the Quality, Safety, and Education Portal (QSEP) in the public training catalogue, provides tips on the survey process and common requests providers may receive during survey. Key topics include the purpose, the surveyors role, and cooperation during surveys.

Reminder on Section 1557 and 504 Implementation Dates

The Nondiscrimination in Health Programs and Activities final rule, published on May 6, 2024, includes provisions to implement several written policies and procedures prohibiting discrimination in health programs and activities. As a reminder, this includes all entities that accept any type of Federal financial assistance (directly or indirectly), participate in health programs (including Medicare and Medicaid), and programs or activities administered by a title I entity. Members likely have these policies and procedures already established but should review them to ensure that they include specifications included in the Nondiscrimination in Health Programs and Activities.

On or before November 2, 2024, health program providers were required to post a nondiscrimination notice, provide a form describing nondiscrimination practices, and designate a section 1557 coordinator. LeadingAge Illinois/Iowa provided templates for members to use to aid in compliance with the final rule. These templates were updated to reflect the Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government Executive Order issued on January 20, 2025.

You can find a list of required policies and procedures along with specific requirements in each policy in the original article here.

Sepsis Tool Call for Interest

The Centers for Disease Control & Prevention (CDC) is looking for long-term care partners to provide feedback on a tool currently under development. The Sepsis Prevention Assessment Tool in Nursing Homes (SPAT) seeks to facilitate further discovery of sepsis knowledge, attitudes, and practices and to outline best practices for approaching sepsis in nursing homes. CDC has drafted a preliminary tool and is seeking feedback from external partners with an interest in contributing to sepsis policies and practices. Interested? Email Jodi Eyigor jeyigor@leadingage.org for more information and to connect with CDC.

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 Monday from 10:00 – 11:00 AM
Starting March 31st Next one May 5th

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.

We look forward to seeing you on Zoom!

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.

Identified Offenders Program on April 23 from 1-2 p.m.
Tuberculosis Infection Control in LTC Facilities on May 16 from 1 – 2 p.m.
Intermediate and Skilled Nursing Staffing Rules on May 21 from 1 – 2 p.m.
Antimicrobial Stewardship on May 30 from 1 – 2 p.m.
NHSN Requirements for LTCFs on June 13 from 1 – 2 p.m.
LLCS Network Training on June 18 from 1 – 2 p.m.
Vaccine Storage and Handling on June 27 from 1 – 2 p.m.

Off-Cycle Medicare Revalidations Delayed

The Centers for Medicare & Medicaid Services (CMS) posted in their weekly Medicare Learning Network (MLN) newsletter on April 17, 2025, that the deadline to submit SNF revalidation information on ownership, managerial and related party information has been extended until August 1, 2025.

LeadingAge compiled a quick reference guide and members may check out the recording of a February 11 webinar Understanding the New Off-Cycle Nursing Facility Revalidation.

LeadingAge Illinois/Iowa also hosted a webinar on the Off-Cycle Revalidation process, particularly around the additional disclosable parties’ requirements. If you’re interested in reviewing this free webinar, please email Michelle Rybicki for access.

Reminder – Annual Healthcare Personnel Influenza Vaccination Reporting Due Soon

Nursing homes’ annual reporting of healthcare personnel influenza vaccination rates to satisfy the requirements of the Skilled Nursing Facility (SNF) Quality Reporting Program) is due by May 15! Nursing homes must submit at least one report covering the vaccination status of all healthcare personnel who worked at least one day in the nursing home during the influenza season (October 1, 2024 – March 31, 2025). Data is submitted through the National Healthcare Safety Network (NHSN) Healthcare Personnel Safety (HPS) Component. This component is different from the component that respiratory illness data is reported. Only the person designated in NHSN as the Facility Administrator can activate the HPS component. Once it has been activated, new users to the component can be added to allow other staff to submit the data. Instructions for adding the HPS Component can be provided here. There are generally no exceptions for submissions after the May 15 deadline, so it may be best to allow additional time in the event of complications as failure to submit will impact the nursing home’s Annual Payment Update (APU).

Regulatory Review – F699 Trauma Informed Care

In 2016 with the major revision to the nursing home regulations, trauma informed care was included in the federal regulations and nursing home providers have spent nearly the last decade trying to understand what regulators expect for compliance.

Nursing homes are required to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. In the surveyor guidance, trauma is defined as results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. What stands out to me in this definition is that trauma can be different for everyone. Historically, we associate trauma with post-traumatic stress disorder or PTSD and with veterans fighting in war. While this is a traumatic event, there are many other types of trauma that we need to assess for in those we serve.

According to the surveyor guidance, the Substance Abuse and Mental Health Services Administration (SAMHSA) noted that 70% of adults have experienced some type of traumatic event at least one time in their life and that these events have a direct correlation between health conditions such as diabetes, COPD, heart disease and others.

Additionally, CMS expects that providers take a culturally competent approach to trauma informed care as we know that individuals of various cultural backgrounds have different triggers along with various beliefs on how assistance in overcoming the traumatic event varies.

What are nursing homes expected to do? Conduct an assessment that identifies each resident’s traumatic experiences in life. These events must be identified in the resident’s care plan. Additionally, with the traumatic events, providers must establish possible triggers that may re-traumatize the residents and instruct staff on how to avoid these triggers. For example, veterans with PTSD may experience triggers from fireworks or loud bangs. While it is outlined in F741, staff must be competent in providing care under behavioral health, therefore providers should also ensure that staff know what trauma informed care is and how they provide these services to residents.

A recent example of noncompliance includes that a resident diagnosed with PTSD did not have a trauma care plan focus, goals, and interventions.

Upcoming COE-NF Behavioral Health Training

The Center of Excellence for Behavioral Health in Nursing (COE-NF) has the following FREE trainings upcoming:

Question, Persuade, Refer (QPR) Suicide Prevention Training May 6 from 1 – 2:30 p.m. CT and May 28 from 1 – 2:30 p.m. CT
Mental Health 101, Suicide Prevention & De-Escalation Strategies May 13 from 1-2 p.m. CT
Implementing a Behavioral Health Ambassador Program May 15 from 1-1:45 p.m. CT
An Introduction to Trauma-Informed Care May 21 from 1 – 2 p.m. CT
Understanding Co-Occurring Disorders: A Brief Overview May 22 from 1-1:30 p.m. CT
Mental Health First Aid (MHFA) May 30 from 10 a.m. – 3:30 p.m. CT

CMS Releases HOPE Manual Version 1.01

The Centers for Medicare & Medicaid Services (CMS) released an updated Hospice Outcomes and Patient Evaluation (HOPE) Guidance Manual and accompanying Change Table. There are a number of clarifications on HOPE Update Visits (HUV) and Symptom Follow Up Visits (SFV) which are not conducted within the expected timelines. One item was replaced, A0800 Gender items for A0810 Sex item, which is consistent with other post-acute settings.

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: Do hours worked at assisted living buildings count towards a certified nurse aide maintaining their nurse aide registry eligibility status?

A: Certified nurse aides will lose their eligible status on the registry if they go for a continuous 24-month period without providing nursing or nursing-related services for monetary compensation. The nursing or nursing-related services must be under the supervision of a licensed nurse. Since assisted living provides nursing or nursing-related services under the supervision of a licensed nurse the hours count towards the nurse aide remaining eligible on the registry. Assisted living providers must enter nurse aide information in the registry portal to ensure that each nurse aide remains eligible.

Have a question? Email yours now.