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FAQ for PBJ

Link refers to frequently asked questions re PBJ reporting requirements.

Nursing Home Action Plan FY 2016-2017

CMS memo dated 5/20/2016 related to the Nursing Home Action Plan FY 2016-2017 that outlines 5 actionable strategies to improve nursing home safety and quality.

New QMs on Nursing Home Compare

Today, the Centers for Medicare & Medicaid Services (CMS) added six new quality measures to its consumer-based Nursing Home Compare website. Three of these six new quality measures are based on Medicare-claims data submitted by hospitals, which is significant because this is the first time CMS is including quality measures that are not based solely on data that are self-reported by nursing homes. These three quality measures measure the rate of rehospitalization, emergency room use, and community discharge among nursing home residents. They include:

Percentage of short-stay residents who were successfully discharged to the community (Medicare claims- and MDS-based)

  1. Percentage of short-stay residents who have had an outpatient emergency department visit (Medicare claims- and MDS-based)
  2. Percentage of short-stay residents who were re-hospitalized after a nursing home admission (Medicare claims- and MDS-based)
  3. Percentage of short-stay residents who made improvements in function (MDS-based)
  4. Percentage of long-stay residents whose ability to move independently worsened (MDS-based)
  5. Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based)

With today’s quality measure updates, CMS is nearly doubling the number of short-stay measures, which reflect care provided to residents who are in the nursing home for 100 days or less, on Nursing Home Compare. CMS is also providing information about key short-stay outcomes, including the percentage of residents who are successfully discharged and the rate of activities of daily life (ADL) improvement among short-stay residents.

Press release: MailFilterGateway has detected a possible fraud attempt from "links.govdelivery.comtrack" claiming to behttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-27.html

Fact sheet: MailFilterGateway has detected a possible fraud attempt from "links.govdelivery.comtrack" claiming to behttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-27.html

From the PADOH Message Board dated 4-26-16:

Dear Administrator,

As you may be aware, the Pennsylvania Department of Health (PADOH) has engaged in a multifaceted initiative to improve the quality and safety in the care for residents in Pennsylvania’s nursing care homes. In August 2015, PADOH engaged a panel of state and national experts to serve on a Nursing Home Quality Improvement Task Force. The Task Force will deliver recommendations later this summer.

Part of the Task Force’s work has been focused on current state licensure and Federal nursing home certification regulations. We are interested in soliciting your perspective in order to assist the Task Force on specific regulatory requirements that support your efforts to design and deliver the highest possible quality of care and services for your residents.

PADOH is seeking comments from every licensed long term care facility regarding three sets of regulations: the state licensure regulations, CMS current Conditions of Participation and CMS proposed Conditions of Participation. Links to each of these sets of regulations are provided below:

State licensure regulations and CMS current Conditions of Participation
CMS proposed Conditions of Participation

The survey is available at https://www.surveymonkey.com/r/Nursing_Home_Regulations. This survey should ONLY be completed by each nursing home and each facility should only provide comments on each regulation set one time.

Accompanying this message is a worksheet for your use in preparing your responses. Please complete and submit the survey by 5 p.m. Friday, May 13, 2016.

Thank you for your participation in this important work.

https://sais.health.pa.gov/commonpoc/content/FacilityWeb/attachment.asp?messageid=3183&filename=160425+NH+Reg+Survey%2Epdf&attachmentnumber=1

Report Retention Change for MDS 3.0 Facility- and Resident Level QMs

Report Retention Change for MDS 3.0 Facility-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Preview Reports (posted 04/21/2016)

The retention time period for the MDS 3.0 Facility-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Preview reports will be changing. These automatically-created preview reports are currently stored in each nursing home’s shared facility folder for a period of 230 days. Effective November 1, 2016, the above mentioned preview reports will only be stored in the shared facility folder for a period of 90 days.

The report retention time period change affects the following:

  1. Any new MDS 3.0 Facility-Level Quality Measure and Resident-Level Quality Measure Preview reports saved into each nursing home’s shared facility folder afterNovember 1, 2016. These new reports will be retained for a period of 90 days following the date the report was added to the folder.
  2. Any existing MDS 3.0 Facility-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Preview reports with a create date older than 90 days prior toNovember 1, 2016 will be automatically deleted from the system.

Action: Facilities are encouraged to print or save a copy of the MDS 3.0 Facility-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Preview reports prior to November 1, 2016. Any reports not printed or saved prior to the retention period time change will be permanently deleted from the facility shared folder if the date the report was added to the folder is older than 90 days. Facilities are encouraged to print or save a copy of the MDS 3.0 Facility-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Preview reports prior to November 1, 2016. Any reports not printed or saved prior to the retention period time change will be permanently deleted from the facility shared folder if the date the report was added to the folder is older than 90 days.

Note: These reports cannot be recreated once they have been deleted. The report retention time period change does not affect the MDS 3.0 Five Star Preview reports.

Procedures for Conducting the Exit Conference

Advance Guidance: Procedures for Conducting the Exit Conference: The Centers for Medicare & Medicaid Services (CMS) is clarifying guidance to surveyors regarding the procedures for conducting the exit conference in the review of compliance with Medicare or Medicaid Conditions of Participation, Conditions for Coverage, and Requirements for Participation. Review Exit Conference Procedures: Please review with surveyors the exit conference procedures for conducting the federal surveys to ensure consistency of this process across States.

New Dietary Guidelines

Secretary of Health and Human Services Sylvia M. Burwell and Secretary of Agriculture Tom Vilsack on 1/7/2016 released updated nutritional guidelines that encourage Americans to adopt a series of science-based recommendations to improve how they eat to reduce obesity and prevent chronic diseases like Type 2 diabetes, hypertension, and heart disease.

CDC Update

As a public awareness update on Multistate Outbreaks of Shiga toxin-producing Escherichia coli O26 Infections Linked to Chipotle Mexican Grill Restaurants see below link:

Joint CDC and CMS Infection Control Pilot

The Centers for Medicare & Medicaid Services (CMS) has begun a three year pilot project to improve assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care.

Survey details: All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor. New surveyor tools and processes will be developed and tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care). Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes. Surveys in FY17 and FY18 will be conducted in nursing homes and hospitals.

Project Outcomes: New surveyor infection control tools and survey processes that can be used to optimize assessment of new infection control regulations.

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