MDS Alert

Published on Mon Jul 25, 2016 PDF

Plus: Why OCR thinks you’re not connecting residents to the right referral sources.

The quality-of-care train continues to chug along into the next year, as the Centers for Medicare & Medicaid Services (CMS) has unveiled its action plan for nursing homes into 2017. Find out what CMS has in store for your quality reporting and surveys.

On May 20, CMS released a Survey & Certification (S&C) memo, “Fiscal Year (FY) 2016 to FY 2017 Nursing Home Action Plan.” The Plan outlines five
inter-related and coordinated approaches (or “principles of action”) for nursing home quality, aligned with CMS’s main goals.

CMS has organized the Plan into the following five actionable strategies, each with sub-items:

1. Enhance Consumer Awareness and Assistance

    A. Five-Star Quality Rating System
    B. Improving staffing data on the CMS website

2. Strengthen Survey Processes, Standards and Training

    A. Interpretive guidance to surveyors
    B. Improvements to the nursing home survey processes
    C. Fire Safety and Life Safety Code (LSC) in nursing homes
    D. Surveyor and regional office training
    E. Long-term care (LTC) surveyor training and testing
    F. Complaint investigation process
    G. Infection control in LTC
    H. State performance standards

3. Improve Enforcement Activities

    A. Enforcement policies
    B. Federal Civil Money Penalty (CMP) fund
    C. Monitor CMP amounts
    D. Special Focus Facilities (SFF)
    E. Notice of facility closure of nursing homes

4. Promote Quality Improvement

    A. Maintenance of MDS 3.0
    B. Quality Assurance and Performance Improvement (QAPI)
    C. National Partnership to Improve Dementia Care in Nursing Homes

5. Create Strategic Approaches through Partnerships

    A. Collaboration between State Agencies (SAs) and Quality Improvement Organizations (QIOs)
    B.  Advancing Excellence in America’s Nursing Homes campaign
    C. Nursing Home Convergence
    D. National Background Check Program

Link: To access the S&C memo (S&C: 16-26-NH), go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-26.pdf.

In Other News …

Take A Closer Look At Your Section Q Compliance

Beware: Your facility is falling short on properly referring residents to appropriate sources and avoiding discriminatory practices. So says a new guidance document from the HHS Office for Civil Rights (OCR).

On May 20, OCR issued new guidance to help long-term care (LTC) facilities comply with their civil rights responsibilities and obligations under Centers for Medicare & Medicaid Services (CMS) regulations. Specifically, these regulations require LTC facilities that are Medicare and/or Medicaid-certified to ensure that residents receive services in the most integrated setting appropriate to their needs.

This guidance comes as a result of OCR’s analysis of MDS data from a large sample of facilities. OCR discovered that many LTC facilities “are misinterpreting the requirements of the MDS or inadequately administering the MDS,” OCR stated in a June 23 announcement. “In particular, [LTC] facilities are not referring residents who are interested in living in the community to appropriate referral sources.”

Best practices: The guidance provides recommendations for steps you can take to ensure you’re properly using the MDS to facilitate compliance with regulations and to avoid discriminatory practices against residents. Focusing on Section Q — Participation in Assessment and Goal Setting, the major recommendations include:

    1. Strong relationships with the local contact agency can help LTC facilities understand the availability of community-based services;
    2. Proper administration of MDS Section Q, including questions Q0400, Q0500, and Q0600, is critical in assisting residents to receive services in the most integrated setting; and
    3. LTC facilities should update their policies and procedures to comply with this guidance document and provide periodic training.

Link: To read the new guidance, visit www.hhs.gov/sites/default/files/mds-guidance-2016.pdf.