MHA Extended Care Services
Skilled Nursing Facilities 2008
Regulatory Information - 2009
1. Final FY2010 SNF PPS Rates
CMS released the final rule for fiscal year (FY) 2010 payment updates to SNFs in late July, (http://www.federalregister.gov/OFRUpload/OFRData/2009-18662_PI.pdf), including the finalization of the Resource Utilization Groups, Version Four (RUG-IV) for implementation in 2011.
The FY 2010 recalibration of the CMIs results in a reduction in payments to nursing homes of $1.050 billion, or 3.3 percent. However, this decrease would be largely offset by this fiscal year’s update to Medicare payments to skilled nursing facilities. The update—an increase of 2.2 percent or $690 million for FY 2010—is based on the change in prices of a “market basket” of goods and services included in covered skilled nursing facility stays. The percentage increase in the market basket is used to compute the update factor annually. The combination of the market basket increase and the recalibration of the CMIs yields a 1.1 percent reduction (on AVERAGE).
The new rates are effective OCTOBER 1, 2009 (see attached Excel file; on the URBAN worksheet, you will have to use the drop down file to find your county's wage index--for Cascade, Missoula, and Carbon/Yellowstone counties only. The rest of Montana will use the RURAL wage index).
In the final rule, CMS addressed many comments they received about RUG-IV and provided responses and explanations. Ultimately, CMS plans to implement RUG-IV as it appeared in the proposed rule, with a few minor modifications, such as:
- Fever with feeding tube will be added to the Special Care High category
- CMS clarified that dehydration has been deleted as a qualifier in any category, including the Special Care and Clinically Complex categories
- Respiratory failure in combination with oxygen therapy while a SNF resident will be added to the Special Care Low category
- Oxygen therapy while a SNF resident will be moved to the Clinically Complex category
- A patient will also qualify in the Special Care Low category if one of the following is present along with two or more skin treatments:
- Two or more venous/arterial ulcers; or
- One Stage 2 pressure ulcer and one venous/arterial ulcer
AAHSA members may use the rate calculation tool on their website to determine how the new rates will impact their facilities: http://www.aahsa.org/paymentdata/; scroll down to item: “NEW! 2010 Payment, FINAL RULE.”
The final rule for 2010 included provisions for both FY 2010 (Oct. 1, 2009 - Sept. 30, 2010) and for FY 2011 (Oct. 1, 2010 - Sept. 30, 2011). CMS decided to finalize the FY 2011 rule well in advance of its actual implementation date in anticipation of the RUG-IV revision. To see the FY 2011 final rule: http://www.aahsa.org/article.aspx?id=9741, or click on it from this page: http://www.aahsa.org/paymentdata/.
Attachment 1 - FY2010 SNF PPS Rates
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2. F309 Training Information
Attached is the Power Point presentation used by CMS to train surveyors on the revised interpretive guidance at F309. Here is a recap of what was sent out last week with the Advance Copy of the new language:
CMS issued a Survey & Cert Memo for Nursing Homes last Friday (1/23/09): “Issuance of Revised Quality of Care Guidance at F309, including Pain Management as Part of Appendix PP, State Operations Manual (SOM), Additional Minor Changes Made to Appendices P and PP” as described below: (http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCletter09-22.pdf)
This memo releases the advance copy of revised F309 guidance and training materials.
- The revised guidance for long-term care surveyors at F309, Quality of Care, including a new general investigative protocol and new pain management guidance and investigative protocol, will be effective March 31, 2009.
- PowerPoint training materials were created to train all surveyors who survey nursing homes. Training needs to be completed by March 31, 2009.
- Other changes to the SOM include: hospice and dialysis survey protocol language moved from Appendix P to F309.
- Removal of the weight loss investigative protocol from Appendix P due to the June 2008 issuance of F325 investigative protocol.
- Deletion of guidance requiring paper copy storage of Minimum Data Set (MDS) in homes with electronic records at Tag F286, 483.20(d).
- Use; and removal of the demand billing survey process at Appendix P, Part VII, which has been inserted as a new procedure at Task 5C.
- The revised guidance at F309 - pain management - is effective 3/31 [CMS promised there would always be at least 60 days notice].
The Survey & Cert memo itself actually has instructors' notes within its content that apply to the attached slides; now there is a visual to go with the text in the memo pages.
Attachment 1 - F309 Instructor Slides
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3. 5-Star Technical Users Manual Update 3/25/09
This info is from AAHSA--though I made some changes to the Excel file for easier reading. Montana facilities are highlighted in yellow. The meaning of the data in the columns is explained in the second set of bullets, below.
The Five-Star Quality Rating System Technical Users' Guide has been updated, effective 3/25/09.
http://www.cms.hhs.gov/CertificationandComplianc/Downloads/usersguide.pdf
- Beginning with this (March 2009) version, the Technical Users' Guide consists of two documents: (1) The Five-Star Quality Rating System Technical Users' Guide and (2) the Five Star Quality Rating System State-Level Cut Point Tables.
- This first edition of the state-Level Cut Point Tables document contains a brief description of each five-star domain for which state-level cut points are used [pages 1, 2]; updated State-level cut point tables for health surveys [page 2 - 4]; ADL QM, Late Loss ADL Worsening [pages 5, 6]; ADL QM Worsening Locomotion [pages 7,8]. + Cut points for the staffing ratings and for the non-ADL QM ratings have been fixed and do not vary monthly.
- Removal of Table A3 – information is contained in Tables 3 and 4 in the text [pages 9, 10].
In addition, beginning with this version, CMS has posted a data file that contains the reported, expected, and adjusted staffing time values used in the staffing star calculations.
- It contains one record for every nursing home currently shown on Nursing Home Compare.
- Each of these records contains the CMS Certification Number (CCN) for the provider, the name of the provider, the city and state in which the provider is located, and 15 staffing values, calculated as hours per resident per day.
- The 15 staffing variables are divided into 3 groups of 5 values each.
- The first group includes values derived from those reported by the nursing home on the CMS 671 and 672 reporting forms.
- The second group of values represents CMS’s calculation of expected staffing time based on the RUGS 53 staff time values for residents in the nursing home at the time of the survey.
- The third group of values represents the adjusted time, which is calculated by this formula: Hours Adjusted = (Hours Reported/Hours Expected) * Hours National Average
CMS will update this spreadsheet on a monthly basis, coinciding with website updates.
Attachment 1 - 5-Star Technical Users Manual Update 3/25/09
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4. CMS Survey and Certification Letter: FDA Warning to LTC Facilities on Recalled Peanut Products
Please have a look at this warning (from AAHSA):
Attached is the link to a new CMS Survey and Certification Letter: “Food and Drug Administration (FDA) Warning to Nursing Homes Regarding Recalled Food Products Containing Peanuts” (3/27/09)
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_29.pdf
- The FDA and Centers for Disease Control and Prevention (CDC) have received reports of deaths of elderly nursing home residents who had underlying health conditions and had consumed recalled food products containing peanuts contaminated by Salmonella.
- The FDA has requested CMS’ help in issuing a warning to nursing home and other long-term care facility administrators, owners, and food managers to ensure they are aware of the dangers of their residents eating recalled food products, and urging them to check their institutional supply of peanut butter and other products containing peanut ingredients for food items that may be affected by the recent voluntary recalls.
- CMS has attached the FDA notice to nursing homes / long term care facilities. It includes an FDA call-in number, 1-888-SAFEFOOD; and a CDC call-in number, 1-800-CDC-INFO, for inquiries when internet access in not available.
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5. CMS Quality of Life and Environment IG Revisions
Following please find the link to the CMS Survey and Certification Letter, Nursing Homes - Issuance of Revisions to Interpretive Guidance at Several Tags, as Part of Appendix PP, State Operations Manual (SOM), and Training Materials (4/10/09): http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_31.pdf.
As indicated, these revisions, effective 6/17/09, involve a series of F-tags. They were developed in response to the results of the April, 2008, symposium, Creating Home in the Nursing Home, co-sponsored by CMS and the Pioneer Network - the focus of this symposium was person-centered living environments.
Attached to the Letter are:
- The Transmittal describing the changes;
- Advance copy of the surveyor guidance revisions [changes are redlined];
- A Instructor Training Guide outline in Microsoft Word; and
- An article on person-centered word usage to accompany F241 Dignity revision, The Language of Culture Change.
Following is a list of the F-tags that include revisions:
- F172 Access and Visitation;
- F175 Married Couples;
- F241 Dignity;
- F242 Self-Determination and Participation;
- F246 Accommodation of Needs;
- F247 Notice before Room or Roommate Change;
- F252 Safe, Clean, Comfortable and Homelike Environment;
- F461 Private Closet Space;
- F256 Adequate and Comfortable Lighting; and
- F463 Resident Call System.
- F371 Sanitary Conditions
Summary of Revisions:
F172 Access and Visitation Rights
- • The Guidance was amended to state that facilities must provide 24-hour access to any visitor who is visiting with consent of the resident.
- • “Reasonable restrictions” regulatory language is defined as those restrictions that keep the home’s residents safe
- – Keeping home locked at night
- – Restricting persons who are disruptive
- – Providing alternate locations for visits (other than the resident’s bedroom) to minimize disruption to a roommate.
- • The Guidance states that the home has the right to “reasonable restrictions” including keeping doors locked at night, and denying access or providing limited and supervised access to certain visitors if they have been found to be exploiting the resident or other residents, or denying access to persons who are inebriated and disruptive. However, “reasonable restrictions” is not defined to include the actual limiting of visiting hours.
- • Surveyors are to follow-up if the facility has posted signs indicating visiting hours less than 24-hours or has otherwise advised residents of restricted visiting hours.
F175 Married Couples
- • Recognizing that the language at this tag refers only to married couples, the Guidance is amended to clarify that this requirement does not prohibit the facility from accommodating residents who wish to room with a person of their choice; could include, e.g., family members, friends, or an unmarried couple. Language has also been added at F242 Self-Determination and Participation on this issue.
F241 Dignity
- • The definition of Dignity:
- – “Dignity means that in their interactions with residents, staff carry out activities that assist residents to maintain and enhance their self-esteem and self-worth.”
- • The previous bullet about grooming was deleted because it pertained more to ADL care. It was replaced with new language emphasizing the dignity aspects of grooming, i.e., according to personal preferences, e.g., hair length and style, beards, mustaches, clothing style.
- • Language has been added to encourage and assist residents to wear their own clothing rather than hospital-type gowns
- • Clarification has been added that use of bibs / clothing protectors should be avoided, except by resident choice; that napkins should be used instead. Also notes that staff should refrain from standing over a resident while assisting her / him to eat, and that they should be interacting with residents rather than each other while giving care.
- • Remaining bullets include previous language and some additions - address respecting residents’ space; not changing radio or TV stations to suit staff; knocking; keeping belongings where the resident prefers; speaking respectfully to residents; focusing on and addressing residents as individuals [e.g., name preferences]; avoiding the use of labels for residents such as “feeders.”
- • Language has been added on the use of signage in bedrooms and where the public can view, including staff work areas.
- – It is not compliant to place signage with confidential resident information where it can be readily seen by visitors and other residents.
- – Exceptions to this include when the resident or responsible party requests a sign about an aspect of care (e.g., do not take blood pressure in right arm) and for isolation precautions as mandated by CDC - but those signs should not display the specific infection.
- – Clarifies that resident names on doors and resident memorabilia are allowable with consent.
- • Guidance has been added on when to use this F-tag [F241 for privacy of body issues, i.e., keeping residents sufficiently covered when in public
- – Adds guidance on when to use F241 for bodily privacy [e.g., while transporting through a public area] and when to use F164-Privacy and Confidentiality [assure visual privacy while providing care].
- – Suggests that one method of ensuring bodily privacy is to take residents to bathing rooms in their clothing, and change them there, but this is not required.
- • Demeaning practices – includes examples:
- – Uncovered urinary catheter bags.
- – Refusing to comply with a resident’s request to receive toileting assistance during meal times.
- – Restricting residents from use of common area restrooms.
- • Exceptions are made for certain restrooms, e.g., too small for wheelchairs or other mobility devices, and for residents who are restricted from common areas due to, e.g., infection control or because the resident resides in a secured unit / household.
F242 Self-Determination and Participation
- • New language clarifies some of the choices included in the requirements:
- – Activities;
- – Schedules;
- – Health care;
- – Interactions with members of the community;
- – Aspects of his or her life that are significant to the resident.
- • Language has been added to the Intent that directs the facility to actively seek information about resident references to help meet these choices.
- • Choices over schedules is specified to include schedules of waking, eating, bathing, and going to bed at night, as well as health care schedules.
- • Language has been added to clarify that choice over health care extends to method of bathing (bath, shower, in-bed method) as well as to timing.
- • Language has been added regarding the right to make choices over matters that are significant, including the example of choosing to room with a particular person. [echoing F175-Married Couples].
F246 Accommodation of Needs
- • The Guidance stresses that this tag’s focus is on the physical environment
- • Bedroom, bathroom, plus some degree of individualization in common areas
- – E.g., the facility should furnish common areas with furniture that enhances residents’ abilities to maintain their independence in sitting and rising, and should strive to accommodate residents of different heights through different sizes and types of seating choices.
- • Language has been added that the facility should be accommodating needs and preferences, i.e., the facility should be assessing both needs and preferences of each resident and accommodating them to the extent reasonable, so long as others are not endangered.
- • The guidance covers the general concept of reasonableness. Some specifics have been added about individualizing the bedroom and bathroom to assist resident to:
- – Open/close drawers, turn faucets on/off;
- – See her/himself in a bathroom mirror, have toiletries at hand;
- – Open/close doors, operate room lighting;
- – Use bathroom facilities (access grab bars, etc.);
- – Other – use call bell, turn table light on/off;
- • A probe has been added to the survey procedures asking, “…if the facility’s smoking areas are all outdoors, what does the facility do to accommodate residents when the weather is inclement?”
F247 Room/Roommate Change
- • Guidance has been added to make this more specific and to emphasize the need for facilities to be sensitive to resident needs when moving to a new room or getting a new roommate.
F252 Environment
• The examples of places in the facility frequented by residents have been expanded to include dining areas, lobby, outdoor patios.
- • Text has been is added to explain intent of the word “homelike” in the regulatory language, i.e., “…as close to that of the environment of a private home as possible, eliminating odors and institutional practices as much as possible….”
- • Examples of institutional practices that homes should strive to eliminate include:
- – Overhead paging [this one has been there since 1990, but the rest are new];
- – Meals served on trays in dining room [e.g. plate service instead];
- – Institutional signage labeling rooms;
- – Medication carts;
- – Widespread use of audible seat and bed alarms;
- – Mass purchased furniture;
- – Nursing stations.
- • The Guidance states that most homes cannot make these changes right away, but should strive toward them. It is not considered a deficiency if these remain.
- The Guidance acknowledges that some residents, especially if there for a short stay, may not wish to bring in personal belongings. Surveyors are instructed that this is not a problem and there is no need for further investigation for those residents.
F256 Lighting
- • Regulatory language addresses both adequate and comfortable lighting: “…levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform.”
- • Features of adequate lighting design are described:
- – Sufficient light with minimal glare;
- – Even light levels in common areas;
- – Use of daylight as much as possible;
- – Elimination of glare from shiny floors and unshielded windows.
- • Additional suggested features of adequate lighting design:
- – Extra lighting available as needed for particular tasks [e.g. puzzles, reading], i.e., table or floor lamps;
- – “Way-finding” light to help residents find their way to their bathroom at night;
- – Dimmers where possible and when desired can give residents more control over light level;
- • Staff can also use them for care at night.
- • Facilities unable to change basic lighting design due to voltage or wiring issues are encouraged to minimize glare and provide extra task lighting as needed.
- • The Guidance advises that facilities can consult lighting guidance from the authoritative source – the Illuminating Engineering Society of North America.
- • The Guidance also addresses some additional issues to enhance residents ability to distinguish surfaces / see better:
- – Contrasting colors between:
- • Floor/baseboard;
- • Bathroom fixtures/walls;
- • Dishes/table.
F371 Sanitary Conditions
- • The recent release of new guidance at this Tag has reportedly caused some questions about residents accepting food from visitors – CMS has clarified this Tag to make it clear that this requirement concerns facility procurement and does not limit the rights of residents to accept food from visitors.
- • The confusion was created by a Note: stating that the requirement does not prohibit family or visitors from bringing in food for that resident’s consumption. CMS received many questions regarding whether, e.g., a resident’s roommate would be prohibited from accepting something from the visitor. The revision makes it clear that any resident has the right to accept food brought in by visitors.
F461 Resident Rooms
- • LSC reference has been updated to the 2000 Edition.
- • Language from the LSC has been added for windows:
- – Window sill height cannot exceed 36 inches;
- – Window may be operable [can open / close].
- • Floor at grade level clarified
- • The regulatory language regarding “private closet space” from 483.15, F255 has been brought into this Tag; F255 has been deleted. The language currently at F461 regarding “individual” closet space is retained.
- • The Guidance regarding closets makes it clear that clothing racks / shelves (if any) need to be accessible to the resident. Closets include free standing furniture such as wardrobes. If the facility is using wardrobes, the racks/shelves need to be accessible to the resident.
F463 Call System
- • Language has been added to address homes that do not have nursing stations and homes that use wireless systems
- • The guidance adds language that to be in compliance, the system must not merely be functional, but it must be actually being used, that is, calls must be answered. For wireless systems, the devices in possession of staff must be functional and in use, and calls are being answered.
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6. Culture Change Surveyor Guidance Training Slides
Attached is a copy of the training slides used by CMS to train surveyors on the modifications to surveyor guidance focused on culture change. CMS Region V provided these slides with permission from CMS Baltimore (per AAHSA).
These might be useful in training your staff about all the recent changes to the Ftag interpretive language.
Attachment 1 - Quality of Life and Environment Tag Changes
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7. CMS Guidance for Tracking H1N1 in SNFs
CMS last week sent survey guidance to state agencies regarding infection control in SNFs. Although the H1N1 virus acts like a seasonal influenza with relatively mild effects on otherwise healthy people, elderly residents in care centers are a concern. The following information is taken directly from the CMS guidance to survey agencies.
To help prevent the transmission of all respiratory infections in healthcare settings, including the H1N1 virus infection, respiratory hygiene and cough etiquette infection control measures should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of standard precautions
For further information, visit:
http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
Healthcare facilities should establish mechanisms to screen patients and caregivers for signs and symptoms of febrile respiratory illness who are presenting to any point of entry to the facility for care or making appointments to be seen at the facility. Provisions should be made to allow for prompt segregation and assessment of symptomatic patients.
During the survey process, surveyors should look for the following:
Visual Alerts
Facilities should have signage at entry points instructing patients/residents and visitors about facility policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness.
Facilities should have signage emphasizing appropriate respiratory hygiene/cough etiquette and hand hygiene.
Adherence to respiratory hygiene/cough etiquette
Facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette including:
- Tissues and receptacles for used tissue disposal.
- Conveniently located dispensers of alcohol-based hand rub and/or adequate soap and disposable towels where sinks are available.
Staff, patients, and visitors should cover their nose/mouth when coughing or sneezing (the insides of elbows are preferable to hands when covering noses and mouths).
Staff, patients, and visitors should use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use.
Staff, patients, and visitors should perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after having contact with respiratory secretions and contaminated objects/materials.
Patient Placement/Transport/Personal Protective Equipment (PPE)
Facilities should have a plan in place to appropriately manage patients with confirmed, probable or suspected cases of H1N1 virus infection.
- Nonsterile gloves, gowns, eye protection, and fit-tested disposable N95 respirators or equivalent.
Facilities should have a policy for communicating information about confirmed, probable or suspected cases of H1N1 virus infection to other facilities.
Management of ill healthcare personnel
Facilities should have a policy for management of ill healthcare personnel. Guidance related to H1N1 virus infection can be found at http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm.
If deficient practices resulting in noncompliance have been identified, surveyors should review the appropriate interpretive guidelines for Infection Control, such as the guidance at F441 - F444 for SNFs.
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8. New CMS Survey and Certification Letter: F371
Following is the link to a new CMS Survey and Certification Letter, “Food Procurement at 42 CFR 483.359i)(1)(2), Tag F371, and Self Determination and Participation at 42 CFR 483.15, Tag F242” (5/29/09):
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_39.pdf
This memorandum clarifies that:
- F371 The language at 42 CFR 483.35(i), Tag F 371 requires that foods procured by the facility for resident consumption come from “…approved sources approved or considered satisfactory by Federal, State or local authorities.” The intent of this requirement is to monitor the foods procured by the facility and is not to be applied to food(s) provided by visitors, friends, or family members that the resident has chosen to accept.
- While the facility does have a responsibility to help visitors, etc., understand safe food handling practices and to use safe food handling practices when assisting with reheating or other preparation activities, “…foods accepted by residents from visitors, family, friends, or other guests are not subject to the regulatory requirement at F 371;
- Residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices at §483.15, F 242, Self Determination and Participation.
- The interpretive guidelines at F371 have been revised to clarify the intent.
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9. CMS Infection Control Survey and Certification Memo
Please find attached the CMS Survey & Cert letter re the changes made to Infection Control Interpretive Guidelines.
CMS made changes to surveyor guidance for Infection Control in Appendix PP of the SOM. The changes will provide clarification to nursing home surveyors when determining compliance with the regulatory requirements for infection control. The regulatory language will remain unchanged.
They deleted F Tags 442, 443, 444, and 445 which contained language about preventing the spread of infections, and incorporated the guidance into F Tag 441. A training document with speaker notes for CMS Regional Offices and State Survey Agencies to use to train surveyors on this revision to F tag 441 in the SOM is included in this memorandum--we should see the actual powerpoint slides that go with this in the near future.
This revision will be implemented on September 30, 2009.
Casey Blumenthal, MHSA, RN, Vice President
Casey@mtha.org 406- 442-1911
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