Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls (Volume 9, Issue 4).
In this issue:
- Another Gem Added
- ICAR Corner
- Coming Soon… New Surveyor Guidance
- GDR in Psychotropic Medication Management
- Coaching Skills
- Value-Based Purchasing Incentive
Please visit QIPMO’s website here for this and other previous newsletters.
As of 12/30/21, the new CNA regulations require the CNA instructor to take a four-hour update training every five years. Please see below the regulatory language:
Any instructor who has not completed the required four (4) hour update training by August 31, 2022, and every five (5) years thereafter shall be removed from the department-approved list of instructors. If removed from the department’s list, the instructor shall attend and successfully complete the Nursing Assistant Instructor Workshop in order to be reinstated to act as an instructor
All current instructors who have not taken the instructor 4-hour update training by August 31, 2022, will be removed as a CNA Instructor from the registry.
*The four-hour update training is still required to be completed by August 31, 2022 even if you have recently taken the Train the Trainer course (unless the four-hour update training was included) to become a CNA instructor.
If you have any questions, please contact the Health Education Unit at CNARegistry@health.mo.gov or call us at 573-526-5686.
Health Quality Innovation Network (HQIN), the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Missouri, recently released a new tool in the fight against COVID-19.
The Vaccine Champion Social Media Package can help your facility boost vaccine confidence by encouraging staff, residents, families and visitors to share their “why” for getting the COVID-19 vaccine. The customizable package includes pages you can print and display for staff, residents, families and visitors to add their reason for getting vaccinated. It includes instructions and suggestions to promote their positive messages on social media channels.
Download the package and customize it for your team to help spread the word, rather than the virus.
SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. MDS and NHSN data for 1/1/22 through 3/31/22 must be submitted no later than 11:59 p.m. on August 15, 2022.
The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Assessment Submission and Processing (ASAP) system to the Quality Improvement Evaluation System (QIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.
As a reminder, it is recommended that providers run applicable CASPER reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.
Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.
More information about SNF QRP can be found on the following webpages:
- CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
- CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
- CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
- CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training
Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 4/1/22 through 6/30/22 is due August 14, 2022.
Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.
Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.
More information about PBJ can be found on the following webpages:
- CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
- PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
- PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj
- PBJ FAQs – https://www.cms.gov/files/document/general-user-registration-and-submission-faq.pdf
CMS is providing notifications to facilities that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2021, which will affect their FY 2023 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were placed into SNFs’ CASPER folders in QIES on July 13, 2022. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 11, 2022.
If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.
CMS released a PDF file labeled “MDS3.0RAIManualv1.17R.Errata.v2.July.15.2022,” available in the Downloads section of the MDS 3.0 RAI Manual webpage. This file contains revisions to pages in Chapter 3, Section I, of the MDS 3.0 RAI Manual v1.17.1R that clarifies the need for a detailed evaluation and appropriate diagnostic information to support a diagnosis, such as for a mental disorder, prior to coding the diagnosis on the MDS, and the steps that may be necessary when a resident has potentially been misdiagnosed. An example of when a diagnosis should not be coded in Section I due to lack of a detailed evaluation and appropriate diagnostic information to support the diagnosis has also been added to this section. Changed manual pages are I-12 and I-16 and are marked with the footer “October 2019 (R).”