During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.” With use of these waivers the following should be considered:
- Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs.
- A signed physician certification will not suffice; the documentation needs to clearly support the order.
- The patient assessment, physician documentation, justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
- Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
- Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond.
After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.
In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.
CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs). CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to
- Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding
- States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days.
- Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys.
- COVID-19 Survey Activities
- Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually.
- Expanded Survey Activities
- Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
- Enhanced Enforcement for Infection Control Deficiencies
- For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis.
- Support From Quality Improvement Organizations (QIOs)
- Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here.
Read the memo from CMS here.
The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.
In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.
The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.
Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.
For the full Medicare Learning Network article, CLICK HERE.
The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:
Visitation for compassionate care situations
- CMS clarifies compassionate care situations are not exclusive to end-of-life situations. An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family. Therefore, this may qualify as a compassionate care situation.
- CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.
- Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
- 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 a cloth face covering or facemask.
Steps for reopening to visitors
- Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
- CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
- No new onset of COVID-19 in the nursing home for 38 days
- No staff shortages
- Adequate supplies of PPE and essential cleaning and disinfection supplies
- Adequate access to testing for COVID-19
- Referral hospitals have bed capacity on wards and ICUs
Factors to consider regarding visitation
- CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.
To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.
In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM codes and thereby inform their future payment models.
For more information, visit MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, also posted in the Downloads section of the MDS 3.0 Technical Information page.
CMS has delayed the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).
The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.
For more information, visit CMS’ SNF Quality Reporting Program Training page.
CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.
The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.
The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.
View the full press release from CMS here. The toolkit can be accessed here.
After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country. State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.
CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:
- Case status in community
- Case status in the nursing home(s)
- Adequate staffing
- Access to adequate testing
- Universal source control
- Access to adequate personal protective equipment (PPE) for staff
- Local hospital capacity
Reliant’s Real Time Memo on this topic can be accessed here.
CMS’ guidance can be accessed here.
The Frequently Asked Questions (FAQ) document can be accessed here.
or questions or concerns related to this memo, please email the DNH Triage Team.
On April 26, the Centers
for Medicare & Medicaid Services (CMS) announced that it is reevaluating
the amounts that will be paid under its Accelerated Payment Program and
suspending its Advance Payment Program to Part B suppliers effective
immediately. The agency made this announcement following the successful payment
of over $100 billion to health care providers and suppliers through these programs
and in light of the $175 billion recently appropriated for health care provider
had expanded these temporary loan programs to ensure providers and suppliers
had the resources needed to combat the beginning stages of the 2019 Novel
Coronavirus (COVID-19). Funding will continue to be available to hospitals and
other health care providers on the front lines of the coronavirus response
primarily from the Provider Relief
Read press release here.
Access updated fact sheet here.
provided supplemental information for transferring or discharging residents
between skilled nursing facilities (SNFs) and/or nursing facilities based on
COVID-19 status (i.e., positive, negative, unknown/under observation). In
general, if two or more certified LTC facilities want to transfer or discharge
residents between themselves for the purposes of cohorting, they do not need
any additional approval to do so. However, if a certified LTC facility would
like to transfer or discharge residents to a non-certified location for the
purposes of cohorting, they need approval from the State Survey Agency.
A copy of the guidance can be found here.
The Centers for Medicare &
Medicaid Services (CMS) announced new regulatory requirements that will require
nursing homes to inform residents and resident representatives of COVID-19
cases in their facilities.
In addition, CMS will now
require nursing homes to report cases of COVID-19 directly to the Centers for
Disease Control and Prevention (CDC).
The CDC will be providing a
reporting tool to nursing homes that will support Federal efforts to collect
nationwide data to assist in COVID-19 surveillance and response.
For more information on the
upcoming requirements for reporting, click here.
The Centers for Medicare
& Medicaid Services (CMS) issued a proposed rule for fiscal year 2021 that
updates Medicare payment rates and the quality programs for skilled nursing
facilities. If finalized, updates would take effect October 1, 2020.
For more information on proposals including a market basket increase, monitoring of the PDPM clinical diagnosis mapping, changes in SNF PPS wage index, and SNF VBP updates, review Reliant’s Real Time Memo.
Click for the SNF PPS CMS Fact Sheet and for the Proposed Rule.
Comments are being accepted until June 9, 2020.
Reliant has worked closely with
the National Association for the Support of Long Term Care (NASL) to raise
awareness of the activity associated with Medicare’s medical review process
during this pandemic, including pre-pay targeted probe and educate (TPE) activity
and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas,
First Coast and CGS have suspended TPE activity until further notice. Our
contacts indicate current pre-pay TPEs will be released and paid in the coming
According to an FAQ
released on 3/30/2020, CMS
indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews
during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the
reviews for TPE and post-payment reviews conducted by the MACs, Supplemental
Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are
suspended for the duration of the Public Health Emergency (PHE).
The FAQ also notes that “no additional documentation requests will be issued
for the duration of the PHE for the COVID-19 pandemic.” Current post-payment
review by the MACs, SMRCs, and RACs will be suspended and released from review
as well. CMS is suspending these medical review activities for the duration of
the PHE, but could conduct medical reviews “during or after the PHE if there is
an indication of potential fraud.”
to the COVID-19 pandemic, Medicare Advantage plans are issuing temporary
suspensions in prior authorization requirements for post-acute settings and
revising policies to improve patient access to care.
(UHC) is suspending prior authorization requirements for post-acute settings
through May 31, 2020, with the waiver applying to skilled nursing facilities
(SNFs), long-term care facilities (LTCFs), and acute inpatient rehabilitation
(AIR). In addition, UHC will reimburse physical, occupational and speech
therapy telehealth services provided by qualified health care professionals
when rendered using interactive audio/video technology, emphasizing state laws
and regulations apply.
Cigna has indicated a similar suspension for commercial and
Medicare Advantage plans, noting it will make it easier for hospitals to
transfer patients to long-term acute-care hospitals (LTACHs) and other
sub-acute facilities to help manage the demands of increasingly high volumes of
On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded the current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief and the Economic Security (CARES) Act, is one way CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic and ensures the nation’s providers can focus on patient care.
qualifications state the provider/supplier must:
- Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form
- Not be in bankruptcy
- Not be under active medical review or program integrity investigation
- Not have any outstanding delinquent Medicare overpayments
Medicare will start accepting and
processing the Accelerated/Advance Payment Requests immediately. CMS
anticipates that the payments will be issued within seven days of the
step by step guide for eligibility and processes here.
is empowered to take proactive steps through 1135 waivers and rapidly expand
the Administration’s aggressive efforts against COVID-19. As a result, the
following blanket waivers are available:
Stay Waiver: CMS is waiving the
requirement at Section 1812(f) of the Social Security Act for a 3-day prior
hospitalization for coverage of a skilled nursing facility (SNF) stay, providing
temporary emergency coverage of SNF services without a qualifying hospital stay
for those who need to be transferred as a result of the effect of a disaster or
Part A 100-Day Benefit Waiver: For certain beneficiaries who recently exhausted their SNF
benefits, it authorizes renewed SNF coverage without first having to start a
new benefit period.
Completion and Submission Waiver: CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the
timeframe requirements for Minimum Data Set assessments and transmission.
Read the Coronavirus
On March 23, 2020 CMS released guidance to state survey agencies further prioritizing and suspending most federal and state surveys and delaying revisit surveys for the next three weeks beginning March 20.
CMS has released this survey tool to
review infection prevention and control practices. Providers are encouraged to
perform a self-assessment utilizing this same tool. Surveyors will review for:
effectiveness of the Infection Prevention and Control Program (IPCP) including
policies and procedures
and transmission-based precautions (with the understanding that certain
essential supplies are scarce, and facilities should not be penalized for not
having certain supplies if they are unable to obtain them)
of resident care practices, including those with COVID-19 (laboratory-positive
cases), if applicable
entry and facility screening practices
monitoring and screening practices of staff
policies and procedures to address staffing issues during emergencies, such as
transmission of COVID-19
here for the Survey Prioritization
CDC issued guidance for
optimizing the PPE supply, specifically facemasks, gowns and eye protection, including suggestions on what to do
in case of shortages.
recommends reaching out to a health care coalition (HCC) in your area for
emergency response assistance. Click here for an interactive map with contact information.
AHCA has warned providers to beware of COVID-19 scams selling PPE or other
supplies. To aid in differentiation between legitimate businesses and scams,
the Federal Trade Commission (FTC) has provided general guidance on COVID-19-related
As the COVID-19 pandemic continues to evolve,
the guidance from the CDC and CMS is updated regularly. Reliant is monitoring
the below sites and encourages our care partners to do the same.