Annual regulatory updates from CMS come as no surprise; however, when coupled with significant updates from the CDC we may feel overwhelmed.
Successful implementation of regulatory, survey, federal, and state updates is possible when we implement the following strategies.
- BREATHE! – You’re not alone, and change does not have to be a bad thing. As a matter of fact, the new CDC and CMS guidance is leading us into a highly anticipated phase of the pandemic… a new beginning for our patients, visitors, and employees.
- Subscribe to CMS and CDC websites to receive fact sheets, FAQs, invites to webinars, and the latest updates.
- Know your company structure and departments of expertise. Watch for their guidance and recommendations.
- Review policies and procedures to ensure they are compliant with the new guidance.
- Consider any information that may need to be communicated to residents, families, and visitors (e.g., updated visitation guidance) and the best method to deliver this information (e.g., posting signage).
- Communicate with staff; consider various methods of delivery (email, webinars, in-person meetings).
- Assess the effectiveness of your facility’s implementation of new guidance and regulations. For areas needing improvement, make a plan to ensure preparedness.
- Connect with Reliant to receive Real Time Memos and the monthly Reliant Reveal newsletter.
In case you missed these recent publications from Reliant, click the links below to review our summaries of recently updated and upcoming regulatory guidance:
On June 29, 2022, the Centers for Medicare & Medicaid Services (CMS) issued updates to guidance on minimum health and safety standards that Long-Term Care (LTC) facilities must meet to participate in Medicare and Medicaid. CMS also updated and developed new guidance in the State Operations Manual (SOM) to address issues that significantly affect residents of LTC facilities.
Surveyors will begin using this guidance to identify noncompliance on October 24, 2022.
Key areas of guidance include
- Requirements for surveyors to incorporate the use of Payroll Based Journal (PBJ) staffing data for their inspections.
- CMS indicates the believe this will help identify potential noncompliance with CMS’ nursing staff requirements, uncover instance of insufficient staffing, and yield higher quality care. In addition, they state this allows facilities to begin addressing the staffing issues while the new rule making for minimum staffing levels is underway.
- Requirements for an onsite at least part-time Infection Preventionist (IP) who has specialized training to effectively oversee the facilities infection prevention and control program.
- CMS believes that the role of the Infection Preventionist (IP) is critical in the facility’s efforts to mitigate the onset and spread of infections. CMS cites the IP role as critical to mitigating infectious diseases through an effective infection prevention and control program.
- For additional guidance and details, refer to the State Operations Manual and QSO-22-19-NH.
CMS included in memorandum QSO-22-19-NH recommendations related to resident room capacity. There are no new regulations related to resident room capacity. However, CMS wanted to highlight the benefits of reducing the number of residents in each room given the lessons learned during the COVID-19 pandemic for preventing infections and the importance of residents’ rights to privacy and homelike environment. CMS urges providers to consider making changes to their settings to allow for a maximum of double occupancy in each room and encouraging facilities to explore ways to allow for more single occupancy rooms for nursing home residents.
Additional details can be found in the following CMS documents: QSO-22-19-NH, Press Release, Fact Sheet
CMS has updated its guidance and provided specific instructions for using the Qualified Hospital Stay (QHS) and benefit period waivers, as well as how this affects claims processing and SNF patient assessments.
- To bill for the QHS waiver, include the DR condition code. To bill for the benefit period waiver:
- Submit a final discharge claim on day 101 with patient status 01, discharge to home.
- Readmit the beneficiary to start the benefit period waiver.
- For ALL admissions under the benefit period waiver (within the same spell of illness):
- Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.)
- Follow all SNF Patient-Driven Payment Model (PDPM) assessment rules.
- Include the HIPPS code derived from the new 5-day assessment on the claim.
- The variable per diem schedule begins from Day 1.
- For ALL SNF benefit period waiver claims (within the same spell of illness), include the following:
- Condition code DR – identifies the claims as related to the PHE
- Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
- COVID 100 in the remarks – this identifies the claims as a benefit period waiver request
Note: Providers may utilize the additional 100 SNF benefit days at any time within the same spell of illness.
Claims are not required to contain the above coding for ALL benefit period waiver claims.
Example: If a benefit waiver claim was paid utilizing 70 of the additional SNF benefit days and the beneficiary either was discharged or fell below a skilled level of care for 20 days, the beneficiary may subsequently utilize the remaining 30 additional SNF benefit days as along as the resumption of SNF care occurs within 60 days (that is, within the same spell of illness).
Additional instructions can be found in the article if you previously submitted a claim for a one-time benefit period waiver that rejected for exhausted benefits.
CLICK HERE to view the MLN Matters article.
CLICK HERE for the updated list of blanket waivers available.
Use Medicare.gov’s Care Compare to find and compare health care providers.
In early September, the Centers for Medicare & Medicaid Services (CMS) released Care Compare on Medicare.gov, which streamlines the eight original health care compare tools. The eight original compare tools – like Nursing Home Compare, Hospital Compare, Physician Compare – will be retired on December 1st. CMS urges consumers and providers to:
- Use Care Compare on Medicare.gov and encourage people with Medicare and their caregivers to start using it, too. Go to Medicare.gov and choose “Find care”.
- Update any links to the eight original care tools on your public-facing websites so they’ll direct your audiences to Care Compare.
With just one click on Care Compare, easy-to-understand information about nursing homes, hospitals, doctors, and other health care providers is available.
Information about health care providers and CMS quality data will be available on Care Compare, as well as via download from CMS publicly reported data from the Provider Data Catalog on CMS.gov.
Direct links to the tools & additional resources
Care Compare on Medicare.gov – https://www.medicare.gov/care-compare/
Provider Data Catalog on CMS.gov – https://data.cms.gov/provider-data/
Care Compare resources for consumers and partners – Medicare blog, Promotional video, Conference card
Full Press Release: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions
In September, the Centers for Medicare and Medicaid Services (CMS) released exciting news for the advancement of safe visitation and resumption of group activities and communal dining in nursing homes (see QSO-20-39-NH). As the effects of isolation have taken a tremendous toll on our elderly population, care teams and residents are ready to implement safe steps to social reintegration. Facilities, including therapy departments, can now offer a variety of group activities while also taking the necessary precautions.
CMS provides Core Principles of COVID-19 Infection Prevention which should be incorporated as best practice to reduce the risk of COVID-19 transmission in order to resume visitation and group activities. It is indicated that group activities may be facilitated (for residents who have fully recovered from COVID-19 and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of cloth face coverings or facemasks. CMS’ examples of group activities include book clubs, crafts, movies, exercise and bingo.
As facilities implement these principles and activities, it is important to remember, early in the pandemic, resident-centered care plans were adapted for isolation considerations. These care plans should now be reviewed, especially in the light of infection control prevention, trauma-informed care, cognitive changes and fall prevention. It should not be assumed that residents will function at the same level as they did pre-pandemic; therefore, consider the increased risks associated with the possible secondary effects of the pandemic and isolation precautions:
- Infection Prevention and Control: Review the resident’s ability to safely wear cloth face coverings and understanding of or cueing needed for social distancing. Identify assistance and reminders needed to perform hand hygiene.
- Trauma-Informed Care (TIC): Consider whether the resident is suffering from anxiety associated with infection risk or recovery and provide a facility plan for safe reopening. Ensure staff buy-in to the plan and implementation in order to set good examples and provide TIC support. Be sensitive to the effects of a busy, potentially noisy, environment following a period of social isolation.
- Cognitive changes: As social interaction increases and the physical environment changes, be aware of behavioral responses and signs or symptoms of confusion. Assess behaviors as a form of communicative response to the environment and adapt as appropriate.
- Fall prevention: Consider that as the resident’s access to the facility and grounds expands, their environment is now exponentially larger. Review their ability to safely ambulate throughout the facility as this may place the resident at increased risk of falls and wayfinding confusion.
Protecting residents from COVID-19 highlights the struggle between keeping residents healthy and providing beneficial, daily experiences that can impact quality of life. Nursing, therapy, and facility staff must work as a team to implement creative means to facilitate safety during group activities and social reintegration to allow our residents to safely flourish in light of the challenges they encounter.
What is a breach of Protected Health Information (PHI)? A breach means the impermissible acquisition, access, use, or disclosure of PHI as defined under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule that compromises the security or privacy of PHI.
Whenever a breach of PHI occurs, the residents impacted must be notified along with the secretary of the United States Department of Health and Human Services (HHS). Residents must be notified as soon as possible but no later than 60 days from discovery of the breach. This notification deadline to the Secretary of HHS varies depending on the number of residents impacted. If less than 500 residents are impacted, the deadline for notification to the Secretary is 60 days after the end of the calendar year in which the breach occurred. If 500 or more residents are impacted, the deadline for notification to the Secretary is no later than 60 days from the discovery of the breach.
Covered entities are required to report breaches to the Office of Civil Rights Breach reporting portal. The United States Department of Health and Human Services, in accordance with section 13402(e)(4) of the Health Information Technology for Economic and Clinical Health Act (HITECH), posts online a list of breaches impacting 500 or more individuals. This breach portal is unofficially labeled the “Wall of Shame”. CLICK HERE to visit the portal.
The Centers for Medicare & Medicaid Services (CMS) released a memo reiterating the continued right of nursing home residents to exercise their right to vote. While the COVID-19 Public Health Emergency has resulted in limitations for visitors to enter the facility to assist residents, nursing homes must still ensure residents are able to exercise their Constitutional right to vote. A resident’s rights, including the right to vote, must not be impeded in any way by the nursing home staff.
Nursing home personnel should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee, or other authorized process. For residents who are otherwise unable to cast their ballots in person, nursing home staff must ensure residents have the right to receive and send their ballots via the U.S. Postal Service or other authorized mechanism allowed by the State or locality.
CLICK HERE to read the full memo from CMS.
The Centers for Disease Control & Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) are now requiring nursing facilities to utilize the CDC’s National Healthcare Safety Network (NHSN) as the required reporting pathway for the COVID -19 testing results that nursing facilities are generating from point of care (POC) testing devices which were provided by the Department of Health & Human Services (HHS).
Data collected via NHSN is pushed to the AIMS platform, which is hosted by the Association of Public Health Laboratories, every two hours. The AIMS platform then shares this data with state and local health departments as well as with HHS.
Currently, entry of data into NHSN is manual and entered one patient at a time. The CDC indicated that it plans to make accepting a CSV file, for multiple persons and test results at one time, possible in the future.
CLICK HERE for more information from HHS on reporting requirements.
On Oct. 22, The Department of Health and Human Services (HHS) released a memo stating that they are no longer limiting providers’ use of Provider Relief Funds for covering lost revenue due to the coronavirus. HHS announced that it will go back to allowing providers to calculate their lost revenue based on the difference between their 2019 and 2020 actual patient- care revenue, and eliminate limits on how much Provider Relief Fund (PRF) payments can be applied to that lost revenue.
HHS added that the amended reporting instructions should allow providers to fully apply PRF distributions to lost revenues.
CLICK HERE to read the full memo.
The Centers for Medicare & Medicaid Services (CMS) announced a change in its methodology for calculating county-level community infection rates for COVID-19. Facilities are expected to use the county-level color coded rating (green, yellow, or red) to determine the frequency for testing facility staff and residents in accordance with CMS guidance.
The earlier guidance and methodology required facilities to test staff once monthly if the county in which the facility is located had a positivity rate of less than five percent (< 5%); testing frequency increased to once each week for county positivity rates between five and 10 percent (5 – 10%) and twice weekly for county positivity rates that exceeded 10 percent (>10%). The shift in methodology will mean a change in the color-coding rates. For example, CMS’ new methodology classifies counties with both fewer than 500 tests and fewer than 2,000 tests per 100,000 residents, along with a positivity rate greater than 10 percent over 14 days as “yellow” whereas the earlier methodology would have put these counties in the red zone.
CLICK HERE to read CMS’ press release about the change in methodology.
CLICK HERE for the latest county positivity rates.
The Centers for Medicare & Medicaid Services (CMS) posted an updated PDPM Grouper DLL v1.0007 to the MDS 3.0 Technical Information webpage.
CMS indicates that six ICD-10 codes were “inadvertently excluded from the NTA calculation.” The ICD-10 codes include: T8484XA, T8389XA, T8321XA, T82399A, T82392A and T83021A.
The PDPM Grouper DLL v1.0007 package notes that PDPM can be used for OBRA assessments where A0310A =[01,02,03,04,05,06] and A0310B =  as determined by each state. CMS also notes that FY2021 ICD-10 codes must be used for I0020B in these assessments as well as for the I8000A-J items in MDS assessments with a target date on or after October 1, 2020.
CLICK HERE to access the zip file.
The Centers for Medicare & Medicaid Services (CMS) announced new actions to pay for expedited COVID-19 test results. CMS announced that starting January 1, 2021, Medicare will pay $100 only to laboratories that complete COVID-19 diagnostic tests within two calendar days of the specimen being collected.
Also, effective January 1, 2021, for laboratories that take longer than two days to complete these tests, Medicare will pay a rate of $75. CMS reports they are working to ensure that patients who test positive for the virus are alerted quickly so they can self-isolate and receive medical treatment.
CLICK HERE to review the full press release from CMS.
The Centers for Medicare & Medicaid Services (CMS) announced amended terms for payments issued under the Accelerated and Advance Payment (AAP) Program. Under the Continuing Appropriations Act, 2021 and Other Extensions Act, repayment will now begin one year from the issuance date of each provider or supplier’s accelerated or advance payment.
Providers were required to make payments starting in August of this year, but repayment will be delayed until one year after payment was issued. After that first year, Medicare will automatically recoup 25 percent of Medicare payments otherwise owed to the provider or supplier for eleven months. At the end of the eleven-month period, recoupment will increase to 50 percent for another six months. If the provider or supplier is unable to repay the total amount of the AAP during this time-period (a total of 29 months), CMS will issue letters requiring repayment of any outstanding balance, subject to an interest rate of four percent.
Guidance is also provided on how to request an Extended Repayment Schedule (ERS) for providers and suppliers who are experiencing financial hardships. An ERS is a debt installment payment plan that allows a provider or supplier to pay debts over the course of three years or up to five years in the case of extreme hardship. Providers and suppliers are encouraged to contact their Medicare Administrative Contractor (MAC) for information on how to request an ERS.
CLICK HERE to read the full press release from CMS.
Earlier this year, the U.S. Centers for Medicare and Medicaid Services (CMS) deleted certain Correct Coding Initiative (CCI) edits related to physical, occupational, and speech therapy during the public health emergency. Recently, CMS announced that effective October 1, it will reinstate previously deleted coding edits for code pairs that represent common and appropriate therapy practice (i.e. 97116 and 97530 or 92526 and 97129).
The reinstated edits will require the use of the 59-modifier when these code pairs are provided on the same date of service. For clinicians, data entry within Optima will remain the same. The 59-modifer will automatically be added by Optima when appropriate and viable on the Service Delivery Logs.
CLICK HERE for the list of edits from CMS.