Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Just a few minutes ago, CMS posted QSO-22-19-NH. This QSO Memorandum has a lot of moving parts that impact ALL LTC facilities.
Beneath the hyperlink in the 1st paragraph of this blog, you’ll find these resources:
- QSO-22-19-NH (PDF)… 6 pages
- Appendix PP Guidance to Surveyor for Long Term Care Facilities (PDF)… 847 pages
- SOM Chapter 5 – Complaint Procedures (PDF)… 101 pages
- SOM Exhibit 23 – ACTS Required Field (PDF)… 10 pages
- SOM Exhibit 358- Sample Form for Facility Reported Incidents (PDF)… 7 pages
- SOM Exhibit 359- Follow-up Investigation Report (PDF)… 6 pages
- Psychosocial Outcome Severity Guide (PDF)… 7 pages
There is a lot of information and updated guidance contained within this QSO and its attachments. Please share the information in this blog with your team and colleagues.
The Appendix PP included with this QSO Memorandum is an advance copy. The last revision date on this copy is 11/22/2017. Starting on page 20 of the advance copy is where you encounter the first instance of red ink which indicates revised and/or added material.
Areas addressed in the QSO Memorandum include:
- Recommendations for Resident Rooms
- Abuse & Neglect
- Admission, Transfer & Discharge
- Mental Health/Substance Use Disorder
- Payroll Based Journal/Nurse Staffing
- Resident Rights
- Potential Inaccurate Diagnosis and/or Assessment
- Pharmacy Services
- Infection Control
- Arbitration Requirements
- Psychosocial Outcome Severity Guide
- Chapter 5: State Investigations of Complaint Allegations
- Trauma Informed Care, Compliance and Ethics, and Quality Assurance Performance Improvement (QAPI)
Additionally, you’ll want to share and review the Updated Guidance for Nursing Home Resident Health and Safety Fact Sheet.
“To further support the implementation of the Long-Term Care (LTC) Facilities Requirements for Participation, which were published in 2016, CMS is issuing surveyor guidance which clarifies specific regulatory requirements and provides information on how compliance will be assessed. In addition, CMS is revising its guidance to State agencies, to strengthen the management of complaints and facility reported incidents.
Today’s updates to guidance are just one piece of CMS’s ongoing effort to implement President Joe Biden’s vision to protect seniors by improving the safety and quality of our nation’s nursing homes, as outlined in a fact sheet released prior to his first State of the Union Address in March 2022.”
These two (2) sections of the QSO are also important to you/your team:
[NOTE: Briggs subscribers to 1766 … Survey Guide – Interpretive Guidelines for Long-Term Careand 1766E … Survey Guide – Interpretive Guidelines for Long-Term Care – eManual will receive the digital update next week. That update will include the advance copy of Appendix PP as well as all the other materials provided in the Survey Guide. The printed copy of will be sent when CMS provides the final version of Appendix PP.]
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