The Lead October 30 2025 - LeadingAge Illinois

From the Desk of Angela Schnepf, President and CEO

Nursing and Rehabilitation
Regulatory Review Article – F571 – Charges for Medicaid & Medicare Covered Services

Housing
LeadingAge RAD for PRAC Webinar Series: Preserving Your Aging HUD Property

HCBS
OASIS E-2: What Home Health Agencies Need to Know for 2026
HOPE Submission Issues

Other
Ask the Expert
Become a 2025 LeadingAge Illinois PAC Partner

From the Desk of Angela Schnepf, President and CEO

As you know, SNFs are required to submit a daily census report for all skilled and intermediate care residents to the Illinois Department of Public Health (Department) on a quarterly basis. Census data for the 4^th quarter (July 1 – September 30, 2025) is due to the Department no later than December 1, 2025. Census data must be submitted to the Department on this Excel spreadsheet and sent to DPH.LTCDailyCensus@illinois.gov. Failure to submit a required daily census report by December 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.

Kindest Regards

Angela

New Member Resources

Patient Care Equipment Testing and Inspection Policy Template and Sample Form

Use of Insulin Pumps

Reporting Infectious Diseases

Life Support Services Risk Assessment and Statement

OIG Exclusion Resource

QAPI Resources

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Home Health Final Rule Goes to OMB for Final Review

Late on October 24, the Office of Management and Budget (OMB) received the CY2026 Home Health Final Rule. This is the final step in the process before the rule is published in the federal register and changes to the program including the proposed 9% reductions are made permanent. This is officially the latest rule that has gone to OMB in 20 years. It is unclear how long OMB will need to review the rule given the significant concerns raised by the home health sector as well as other controversial items in the rule around the durable medical equipment competitive bidding program. The latest home health final rule that has ever been published was on November 22 during the 2013 rulemaking cycle.

Hospice Shutdown Survey Clarification

On October 21, the Centers for Medicare and Medicaid Services (CMS) updated survey and certification activity guidance during the government shutdown through a memo QSO-25-01-All. The memo was a significant win for LeadingAge with regards to clarifications related to revisit surveys in nursing homes, home health, hospice and denials of payment for new admissions (DPNA). However, the memo also clarified that initial certifications, including those conducted by deemed status or accrediting agencies, are prohibited activities. If an organization is currently attempting to become a newly certified home health or hospice provider through an accrediting organization, their progress will be paused until the government reopens. The memo states that hospice survey activity funding through the Consolidated Appropriations Act (CAA) of 2021 is still allowed. That activity refers to a standard 36-month survey activity.

IDPH Updates

On October 23, the Illinois Department of Public Health (IDPH) hosted their monthly association update meeting. The overwhelming questions for the department continue to be about the staffing fines issued during the first quarter and timelines for second quarter fining as well as procedures. Unfortunately, the department does not have a time frame for processing the first quarter appeals or issuing the second quarter fines. IDPH indicated that providers who submitted appeals from the first quarter will receive some type of acknowledgement as their legal team is working through the numerous appeals they received.

IDPH also asked the associations to remind all providers and leaders to sign up for SIREN notification as many important announcements are sent through the system. Anytime there is turnover in a key leadership position, they should also enroll for SIREN alerts. You can register for SIREN updates here.

Finally, IDPH asked the associations to alert all providers (particularly assisted living and those serving the developmentally disabled) to register for access to the LLCS Portal. There are approximately 140 providers that haven’t registered yet. You can register for the portal here.

Government Shutdown: More Details on CMS’ Medicare Payment Claims Hold

On October 21, the Centers for Medicare & Medicaid Services (CMS) sent a Medicare Learning Network (MLN) Connects Newsletter Special Edition on the Claims Hold. CMS has now instructed the Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service of October 1, 2025 and later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations Act, 2025. This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims. Additionally, claims for telehealth services that are definitively for behavioral and mental health services may be processed, but those for other telehealth services must continue to be held by the MACs as well as acute Hospital Care at Home claims.

Following up on the Medicare payment claims hold announcement early this month, the Centers for Medicare & Medicaid Services (CMS) on October 15, 2025 announced, via the Medicare Learning Network (MLN) an update and, via a posting on its All Fee-For-Service Providers Spotlight Page, provided additional information.

As explained in an October 10 LeadingAge update, the hold was put in place on October 1 to avoid the reprocessing of claims for services that had been temporarily extended but expired on October 1, such as telehealth, in the event that such services can resume.

CMS then announced in an October 15 Medicare Learning Network (MLN) post that it had instructed the Medicare Administrative Contractors (MACs) to continue to temporarily hold claims dated for October 1, 2025, and later, “for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025.”

According to the October 15 MLN update, the hold “includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims. Providers may continue to submit these claims, but payment will not be released until the hold is lifted.”

However, CMS also posted on its All Fee-For-Service Providers Spotlight Page that “In light of the continuing government shutdown, CMS will continue to process and pay held claims in a timely manner with the exception of select claims for services impacted by the expired provisions [emphasis added]. To date, no payments have been delayed as statute already requires all claims to be held for a minimum of fourteen days, and this recent hold is consistent with that statutory requirement. Providers may continue to submit claims accordingly.” Through this post it appears that CMS is clarifying which providers were impacted.

What this means for providers:

CMS warns, on the All Fee-For-Service Providers Spotlight Page, “Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter.”

“In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN).” The spotlight points providers to further information on use of the ABN, including ABN forms and form instructions, here.

CMS recommends practitioners monitor Congressional action and says practitioners may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action and points to additional information here.

CMS notes on its Spotlight page that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For more information, see this CMS ACO telehealth factsheet.

Please see CMS’ telehealth coverage site for further information on telehealth.

Providers can review the full list of health provisions that have expired or are scheduled to expire in 2025 or 2026 here.

CMS Revises QSO Memo on Survey Activity

On October 21, the Centers for Medicare & Medicaid Services (CMS) revised QSO-26-01-ALL related to the contingency plans for state survey and certification activities during the Federal government shutdown. The memo clarifies survey activities and emphasizes that any survey activity that is not excepted functions authorized are illegal and must not be performed, regardless of the funding source.

Additionally, if States are completing licensure surveys during the Federal government shutdown, they shall not assume that the activity counts toward Federal survey requirements. States are expected to maintain communication with the Medicaid agencies regarding Medicaid-only survey functions and whether funding is available to conduct the activities with the provided example of Nurse Aide Training and Competency Evaluation Program (NATCEP) surveys.

CMS further clarifies that during the lapse in appropriations; it is illegal for CMS or States that are acting on behalf of CMS to carry out any federal survey and certification activities beyond those deemed to be “excepted activities” and related to the safety of human life or protection of property. If the survey agency identifies an immediate jeopardy or actual harm, the survey agency is permitted to issue a CMS 2567 to the provider and conduct necessary communication and revisits to ensure deficiencies are addressed immediately and that no further harm to the patients or residents exists. Additionally, survey agencies may request approval from CMS to conduct a revisit if the provider or supplier has alleged compliance with CMS requirements and the revisit survey is necessary to determine compliance and prevent scheduled Medicare termination of the provider or supplier, or to prevent a statutorily mandated three month denial of payment for new admissions.

During the government shutdown, if a nursing home voluntarily issues closure notice, the survey agency may conduct routine monitoring and oversight to ensure the orderly and safe relocation of the nursing home residents. Further clarification regarding surveys that were in process or recently completed prior to the shutdown should not expect that a CMS-2567 or other survey reports or communication will occur. CMS directs the survey agencies that surveys completed before the shutdown that had not completed or released the CMS-2567 prior to the shutdown should be held and not issued. These reports will generally remain valid if completed or communicated following the shutdown. Surveyors should not complete any training such as on the QSEP website or conduct the surveyor minimum qualifications test. States are also not allowed to complete any change of ownership activities until there is a restoration of funding.

With October being scheduled quarterly refresh to the publicly reported data on Care Compare, we anticipate that CMS will likely not update or post this refresh until normal operations have resumed or we receive additional communication from CMS.

Clinical Best Practice – Conducting AIMS Screening

The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD) which is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic antipsychotic medications. Many health care providers have procedures in place to complete AIMS testing on a routine basis when the residents use antipsychotic medications to promptly identify signs of TD. What is required in the nursing home regulations vs. what is the best practice?

Appendix PP for nursing home providers includes a statement in the interpretative guidance for antipsychotic medications that states “use of a tool, such as the CMS Adverse Drug Event Trigger Tool, may assist in identifying resident risk factors and triggers for adverse drug events as well as in determining whether a facility has systems and processes in place to minimize risk factors and mitigate harm to residents.” As you can see, the guidance does not indicate specifically that the AIMS must be used as a tool to identify possible TD, nor does it identify the frequency that these tools must be used.

The Gerontological Advanced Practice Nurses Association (GAPNA) released a document from Neurocrine Biosciences that provides great information on the AIMS tool entitled The Abnormal Involuntary Movement Scale (AIMS): What, Why, When, and How. The guidance indicates that the AIMS tool is great to identify when the providers should discuss possible TD with the resident’s practitioner. However, it identifies that the practitioner should also be completing the AIMS along with other TD assessments during each visit when the resident takes an antipsychotic medication. For individuals not at high risk, they recommend completing at baseline and then every 12 months. Individuals at high risk should be assessed at baseline and then every 6 months. High risk individuals include those 55 years and older, white, African, and African American race/ethnicity, presence of a mood disorder, intellectual disability, or central nervous system injury, and past or current akathisia, clinically significant parkinsonism, or acute dystonic reactions.

At the end of the day, if your policy and procedures indicate that you will complete an AIMS quarterly, the surveyors will expect that you are following your policy. Before you change any practices, you should discuss the risk vs. benefits of the change with your medical director to ensure they support the change. If your medical director is not comfortable with recommending changes, you can consult with your mental health provider and then pass their input to your medical director to influence their decision.

References:

(Retrieved 2025. Oct. 21). Abnormal Involuntary Movement Scale. https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/abnormal-involuntary-movement-scale

GAPNA. (Retrieved 2025. Oct. 21). The Abnormal Involuntary Movement Scale (AIMS): What, Why, When and How. https://www.gapna.org/sites/default/files/documents/sponsors/theaimswhatwhywhenhow.pdf

CMS. (2025. Jul. 23). Appendix PP – Guidance to Surveyors for Long Term Care Facilities. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

AHRQ Toolkit to Strengthen Skin Care and Infection Prevention in LTC

The Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) has released a new toolkit for Improving Skin Care and Multidrug-Resistant Organism Prevention in Long-Term Care, which outlines four evidence-based strategies to reduce infection risks and maintain skin integrity among older adults. The toolkit strategies which include keeping skin clean and safe, reducing MDRO transmission, using antibiotics wisely, and cleaning and disinfecting high-touch surfaces. You can access the complete toolkit here.

LeadingAge Advocates for Revisions to Enforcement

LeadingAge sent a letter to the Centers for Medicare & Medicaid Services (CMS) on October 15 advocating for a change to enforcement policies enacted during the government shutdown. With survey and certification activities severely limited for all provider types, LeadingAge has heard concerns from members related to the suspension of revisit surveys and the impact on enforcement remedies. LeadingAge has recommended that CMS temporarily revise policies related to denials of payment for new admissions to prevent access issues to post-acute and long-term care services during this period. Read the letter 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.

Upcoming IDPH Training

Top Sited Deficiencies in Long-Term Facilities on November 12, from 1 – 2 p.m. CT

Life Safety & Construction on December 17, from 1 – 2 p.m. CT

Writing Plans of Corrections on January 21, 2026 from 1 – 2 p.m. CT

Regulatory Review Article – F571 – Charges for Medicaid & Medicare Covered Services

F571 in Appendix PP directs the nursing home providers that they are unable to charge a resident for any services that are covered under Medicare or Medicaid services, unless the charge is for deductible or co-insurance. The regulation outlines that covered services include:

Nursing services
Food and nutrition services
Activities programming
Maintenance services
Routine personal hygiene items or services including but not limited to hair hygiene supplies, comb, brush, bath, soap, disinfecting soaps, or specialized cleansing agents when needed to treat special skin problems or fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry.
Medically related social socials
Hospice services if elected by the resident and paid for under Medicare or Medicaid.

The regulation also includes items or services that can be charged to a resident, if they are not required to achieve goals in the resident’s care plan and payment is not made by Medicare and/or Medicaid for the service. These include:

Telephone, including cellular phone (note this would be a personal phone as the resident is able to make or take private calls on the nursing home’s phone line).
Television, radio, personal computers, or other electronic devices for personal use.
Personal comfort items including smoking materials (if allowed), notions, novelties and confections.
Cosmetic and grooming items in excess of those excluded above.
Personal clothing
Personal reading matter
Gifts purchased on behalf of the resident
Flowers and plants
Cost to participate in special outs or social events that are outside of the scope of the activities program.
Non-covered special care services such as privately hired nurses or aides
Private rooms (unless it is medically necessary with an example provided of isolation to prevent transmission of infection).
Specially prepared or alternate food requested (unless it is generally prepared with the meal)
- The nursing home may not charge for special foods or meals that are medically prescribed such as dietary supplements that are ordered by the resident’s practitioner
- The nursing home must take into consideration the residents’ needs and preferences and the overall cultural and religious make-up of the population

Additionally, the nursing home can only charge a resident for a non-covered service if the resident specifically requests the item. (For example, you cannot charge all residents for the use of a personal phone if the resident did not request the personal phone.) You cannot require that the resident use special items or services as a condition of admission or retention and you must inform the resident or their responsible party of any charges and the amount of those charges both orally and in writing.

While this regulation is not frequently cited, there are occasions when it has been. An example would be that a nursing home began charging a resident for a specific item but did not include the item on the admission paperwork as a possible charge and did not notify the resident prior to charging the item that they would receive a charge for it. If the documentation in the resident’s record does not support the nursing home’s due diligence in notifying the resident or their representative of possible charges, then you may be facing non-compliance.

Some examples of when you can charge vs. cannot:

General shampoo and conditioner would be an item that could not be charged, but if a resident requested a specific type of shampoo and conditioner that is not medically necessary, the nursing home can require that the resident pay for it.
The nursing home cannot charge for items used during a craft that is part of the activity programming, but if the activity programming included an outing to go to a specific restaurant, then the nursing home could require the resident pay for their meal.
Specialty diet or food items can get tricky, as you need to allow for cultural and religious needs. For example, if your nursing home admits a Jewish resident, you should expect that the resident will want Kosher foods.

LeadingAge RAD for PRAC Webinar Series: Preserving Your Aging HUD Property

Join LeadingAge for a special mini-series on the Rental Assistance Demonstration (RAD), a critical senior housing preservation tool administered by the Department of Housing and Urban Development (HUD). Many affordable senior housing providers are exploring preservation options for aging PRAC properties with limited opportunities to attract recapitalization and rehabilitation investment; the September webinar series, taught by affordable housing expert Gates Kellett, reviews the basics of RAD and then dives into best practices and pitfalls to avoid. Whether you are just beginning to explore RAD or seeking to refine your approach, this insightful two-part webinar will provide valuable knowledge and practical guidance for making informed decisions and ensuring the long-term success of your housing portfolio.

OASIS E-2: What Home Health Agencies Need to Know for 2026

To help providers prepare for implementation of OASIS updates on April 1, 2026, LeadingAge prepared a detailed article on what’s changing and how to prepare.

HOPE Submission Issues

LeadingAge is aware that multiple electronic medical records (EMRs) are experiencing issues with submitting data for the Hospice Outcomes and Patient Evaluation (HOPE) tool which launched October 1, 2025. LeadingAge is advising members to continue submitting data, even if EMR vendors have recommended holding until changes can be made to their system. These issues include inconsistent coding between the HOPE manual and EMR expectations, issues with demographic information pulling correctly, and errors with insurance A1400 Payer Information. Despite these issues, the Centers for Medicare & Medicaid Services (CMS) has not delayed implementation or changed their expectation of 90% compliance with documentation submission within 30 days of assessment.

Additionally, some issues with hospice providers submitting HOPE assessments when the A1400 Payer Information lists both A (Medicare FFS) and B (Medicare Managed Care). While this is correct coding according to the HOPE guidance manual, the data specification provided to EMR vendors allows only one selection. CMS clarified via email that they are working to correct the issue and at this time is advising providers to only select A (Medicare FFS) in order to timely submit their documentation.

If you have specific issues encountered with HOPE implementation, please reach out to Katy Barnett at LeadingAge, who is tracking the issues to share with CMS.

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: Can you provide a brief overview of what we should consider if a resident is interested in sexual relations with other residents but has cognitive impairment?

A: If a resident has cognitive impairment that may limit their decision-making ability and they express interest in having a relationship with other residents, you first want to identify whether the resident has the capacity to consent to a relationship. The nursing home interpretive guidance provides this link to help providers understand capacity capacity-psychologist-handbook.pdf.

If the resident has the capacity to make these decisions, you’ll want to look at whether they have consented to it. Consent can be either verbal or non-verbal. For example, if the resident appears frightened when another resident is touching them (even in a non-sexual way), then you can surmise that the resident is not consenting to that interaction.

Finally, if the resident does not have the capacity to consent you will need to identify if there is a substitute decision maker in place. If there is, you need to review the document to identify when that decision making authority is effective and what decisions they can make for the resident.

If a family member states they don’t agree with the relationship of their loved one with another resident, but their loved one has the capacity and consents to the relationship, the family member does not have the authority to limit the resident’s independent decision making.

Have a question? Email yours now.

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