Survey Preparedness

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Skilled nursing centers and nursing facilities are required to follow extensive rules in the Requirements of Participation (ROP) to receive payment under the CMS Medicare or Medicaid programs. These requirements are contained in the Federal Regulations for Nursing Facilities, which also state each center must comply with all applicable Federal, State, and local laws, regulations, and codes with accepted professional standards. The AHCA regulatory team provides members guidance and resources to help understand the survey process and implement the requirements.  
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 Focus F-Tags: Guidance for ROP Phase 2 and 3

​​On June 29, ​2022, CMS released new guidance for Requirements of Participation Phase 3. Each week through October, AHCA will highlight a particular F-tag(s) to help providers better understand the Phase 2 updates and Phase 3 new guidance. Providers can find Focus F-Tag weekly summaries on this page.

Please refer to Appendix PP Gu​​idance to Surveyor for Long Term Care Facilities​​​ for the most up to date regulations and guidance.​​ ​

 F-Tag Action Briefs & Much More on ROP

Additional resources and tools to help you navigate the ROP are available on ahcancalED, including F-Tag Action Briefs, which complement the summ​a​ries above and highlight implementation strategies and tips​.  

 

 

Trauma Informed Care Proficiency is Critical for SNF Survey Compliancehttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/Trauma-Informed-Care-Proficiency-is-Critical-for-SNF-Survey-Compliance.aspxTrauma Informed Care Proficiency is Critical for SNF Survey Compliance3/20/2023 4:00:00 AM<div><span style="font-size:14.6667px;">Trauma Informed Care (TIC) is an approach to care that requires specific staff competency and a system of care delivery that provides the necessary support to care for residents who may suffer from trauma. TIC is an important aspect of care given that 62 percent of adults have had at least one traumatic event and 25 percent have had three or more traumatic events.  </span></div><div><span style="font-size:14.6667px;"><br></span></div><div><span style="font-size:14.6667px;">TIC also is a regulatory requirement for all skilled nursing facilities. Nine CMS F-Tags (F699, F656, F659, F740, F741, F742, F743, F745, F949) cover various aspects of TIC (including the psychosocial outcome severity guide) making compliance with this critical form of care vital to nursing facility survey success and quality care. </span></div><div><span style="font-size:14.6667px;"><br></span></div><div><span style="font-size:14.6667px;">The <a href="https://educate.ahcancal.org/products/trauma-informed-care-2#tab-product_tab_overview" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]">Trauma Informed Care Training</a> contains simple foundational steps and practical recommendations for implementing a TIC program that can help improve resident outcomes and regulatory compliance. Individuals will learn how to screen and assess for trauma and incorporate TIC into the discharge process. There also is a focus on building awareness of TIC among staff to help them deliver appropriate care and deliver meaningful activities and other services from a TIC perspective.  </span></div><div><span style="font-size:14.6667px;"><br></span></div><div><span style="font-size:14.6667px;">This nine-module online course was developed through a joint collaboration between AHCA/NCAL and the American Association of Post-Acute Care Nursing (AAPACN). The training is designed to educate long term care providers and nurses about how to implement TIC in their facilities with staff who are appropriately trained and competent to care for residents who are at risk for re-traumatization. </span></div><div><span style="font-size:14.6667px;"><br></span></div><div><span style="font-size:14.6667px;">The cost of the program is $350 for AHCA/NCAL members and $650 for non-members. The program is approved for 5.75 NAB CEs for administrators and 5.10 AANC continuing education hours for nurses.</span></div><div><span style="font-size:14.6667px;"><br></span></div><div><span style="font-size:14.6667px;">Members will need to login to <em>ahcancalED</em> with their AHCA/NCAL usernames and passwords to <a href="https://educate.ahcancal.org/products/trauma-informed-care-2#tab-product_tab_overview" data-feathr-click-track="true" target="_blank" data-feathr-link-aids="["60b7cbf17788425491b2d083"]">register for the course</a>.  For assistance obtaining usernames and passwords, members should e-mail <a href="mailto:educate@ahca.org" data-feathr-click-track="true" target="_blank" data-feathr-link-aids="["60b7cbf17788425491b2d083"]">educate@ahca.org</a> with their name and facility contact information.  </span></div><div><br></div>Trauma Informed Care is an approach to care that requires specific staff competency and a system of care delivery that provides the necessary support to care for residents who may suffer from trauma.
Free Webinar Examines Enhanced Barrier Precautions & OIG Recommendations for SNFshttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/Free-Webinar-Examines-Enhanced-Barrier-Precautions-&-OIG-Recommendations-for-SNFs-.aspxFree Webinar Examines Enhanced Barrier Precautions & OIG Recommendations for SNFs3/13/2023 4:00:00 AM<p></p><div>HealthCap® hosted a free webinar last week titled <a href="https://riskmanagement.healthcapusa.com/products/oig-recommendations-more-than-just-smoke" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">OIG Recommendations: More Than Just Smoke?.</a>  The webinar detailed risk areas related to the Office of Inspector General’s (OIG) and the Centers for Medicare and Medicaid Services’ (CMS) recent focus on infection control issues. </div><div><br></div><div>The webinar dives into changes surrounding enhanced barrier precautions compliance that SNFs must follow to reduce and prevent multidrug-resistant organisms (MDROs). As COVID wanes, surveyors will pay greater attention to other infection risks such as MDROs.  Relatively new CDC guidance stresses what SNFs should be doing in many common care activities in order to comply with CDC recommendations. </div><div><br></div><div>The OIG has raised concerns about infection control in SNFs and those concerns capture the attention of survey agencies that feel pressure to address the OIG’s concerns and recommendations. The OIG said that “significant changes are needed to protect the health and safety of residents and better prepare nursing homes for current and future health emergencies.”  Paying close attention to enhanced barrier protection requirements will be key to reducing infection spread in and avoiding F-880 citations.   </div><div><br></div><div>The <a href="https://riskmanagement.healthcapusa.com/products/oig-recommendations-more-than-just-smoke" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">webinar</a> is approved for 1.0 ANCC contact hours and 1.0 NAB CEs upon completion.  </div><div><br></div><div>AHCA/NCAL has embraced <a href="https://nam10.safelinks.protection.outlook.com/?url=http://www.healthcapusa.com/&data=04%7c01%7candrea.haupt%40chelsearhone.com%7ca06de39d68734186308f08d99e0475be%7c780a31273c7141dbbc3809e32ef3e62a%7c0%7c0%7c637714564287907466%7cUnknown%7cTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7c1000&sdata=4IpeRHUcTTtcM7ZIkOV%2BEt0L9dMuq%2BX/iuFPs3Y7ntg%3D&reserved=0" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">HealthCap​</a>® for more than a decade as a premier provider of liability insurance that is solely dedicated to serving senior care communities. HealthCap® clients have the fewest liability claims in the industry, and HealthCap settles claims below the industry average. <br></div><p>​</p>HealthCap® hosted a free webinar last week titled OIG Recommendations: More Than Just Smoke?.
NHSN Annual Facility Survey Clarificationhttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/NHSN-Annual-Facility-Survey-Clarification.aspxNHSN Annual Facility Survey Clarification2/28/2023 5:00:00 AM<p><span data-contrast="auto" lang="EN-US" class="TextRun SCXW194129297 BCX9" style="margin:0px;padding:0px;color:#000000;white-space:pre-wrap;background-color:#ffffff;font-size:11pt;line-height:19.425px;font-family:calibri, calibri_embeddedfont, calibri_msfontservice, sans-serif;"><span class="NormalTextRun CommentStart SCXW194129297 BCX9" style="margin:0px;padding:0px;"></span></span></p><div>Facilities may notice a prompt on the NSHN reporting module to complete the <a href="https://www.cdc.gov/nhsn/forms/57.137_LTCFSurv_BLANK.pdf" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">LTC Annual Facility Survey</a>. <strong>Please note, this survey is not required for facilities only participating in the COVID-19 module and these facilities will not lose NHSN access after March 1</strong>. Additionally, there is no CMS requirement for completion of this survey, but facilities are advised to check any applicable local/state requirements to complete this survey. Facilities may continue to see the “Survey Required 2022” alert under Action items on the NSHN LTCF home page.  </div><div> </div><div>However, if you currently or plan to participate in additional modules any time during 2023, you are required to complete the survey either prior to March 1 or prior to reporting in the non-COVID-19 module(s), if beginning after March 1. Other modules may include health associated infection (urinary tract infections), laboratory-identified events for C. difficile and/or multidrug resistant organisms, and/or prevention process measures.  </div><div> </div><div>If you complete the LTC Annual Facility Survey, note that most of the questions are based on facility characteristics and practices during the previous calendar year. This means you will complete the 2023 survey using facility characteristics and practices during the 2022 calendar year. There is one exception, and that is the question about primary service type, which is based on current activities the day the survey is completed.  </div><div> </div><div>The Annual Survey Table of Instructions and form are at the bottom of the <a href="https://www.cdc.gov/nhsn/ltc/index.html" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">Long Term Care Facilities Component page</a>. </div><div> </div><div>For additional questions, email <a href="mailto:nshn@cdc.gov" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">nshn@cdc.gov</a>.<br></div>Facilities may notice a prompt on the NSHN reporting module to complete the LTC Annual Facility Survey.
Free HealthCap® Webinar Will Examine OIG Recommendations for Nursing Facilitieshttps://publish.ahcancal.org/News-and-Communications/Blog/Pages/Free-HealthCap®-Webinar-Will-Examine-OIG-Recommendations-for-Nursing-Facilities.aspxFree HealthCap® Webinar Will Examine OIG Recommendations for Nursing Facilities2/27/2023 5:00:00 AM<p>​HealthCap® is hosting a free webinar titled <a href="https://riskmanagement.healthcapusa.com/products/oig-recommendations-more-than-just-smoke#tab-product_tab_overview" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">OIG Recommendations: More Than Just Smoke?</a> on Tuesday, March 7 at 2 p.m. EST.  This program will assist providers in identifying areas of risk related to the Office of Inspector General’s (OIG) and the Centers for Medicare and Medicaid Services’ (CMS) recent focus on infection control issues. <br></p><p>A recent OIG study found that nursing homes were not prepared for the sweeping health emergency that COVID-19 created. The OIG said that “significant changes are needed to protect the health and safety of residents and better prepare nursing homes for current and future health emergencies.”  <br></p><p><span style="font-size:11pt;">The report went on to say “the survey process did not identify any deficiencies in infection control for the majority of the nursing homes with extremely high infection rates.” Beyond this perceived regulatory gap is also a renewed interest in Enhanced Barrier Precautions. The webinar will discuss what these developments mean for providers with a focus on risk reduction. Webinar learning objectives include: </span><br></p><ul><li><span style="font-size:11pt;">Identify the importance of accessing OIG website information  </span></li><li><span style="font-size:11pt;">Review the current OIG report and recommendations </span></li><li><span style="font-size:11pt;">Discuss the implications of the findings  </span></li><li><span style="font-size:11pt;">Identify the importance of ensuring effective implementation of Enhanced Barrier Precautions </span></li></ul><p><span style="font-size:11pt;"><a href="https://riskmanagement.healthcapusa.com/products/oig-recommendations-more-than-just-smoke#tab-product_tab_overview" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]">Registration</a> for all participants is free. The webinar is approved for 1.0 ANCC contact hours and 1.0 NAB CEs upon completion.  </span><br></p><p><span style="font-size:11pt;">AHCA/NCAL has embraced<a href="https://nam10.safelinks.protection.outlook.com/?url=http://www.healthcapusa.com/&data=04%7c01%7candrea.haupt%40chelsearhone.com%7ca06de39d68734186308f08d99e0475be%7c780a31273c7141dbbc3809e32ef3e62a%7c0%7c0%7c637714564287907466%7cUnknown%7cTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7c1000&sdata=4IpeRHUcTTtcM7ZIkOV%2BEt0L9dMuq%2BX/iuFPs3Y7ntg%3D&reserved=0" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank"> HealthCap​</a>® for more than a decade as a premier provider of liability insurance that is solely dedicated to serving senior care communities. HealthCap® clients have the fewest liability claims in the industry, and HealthCap settles claims below the industry average. </span><span style="font-size:11pt;">​</span><br><br></p>HealthCap® is hosting a free webinar titled OIG Recommendations: More Than Just Smoke? on Tuesday, March 7 at 2 p.m. EST.

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Phase 3 Interpretive Guidance – Delayed

Phase 3 of the Requirements of Participation (RoP) went into effect on November 28, 2019. However, as the Centers for Medicare & Medicaid Services (CMS) announced in a memo (QSO-20-03-NH) released on November 22, 2019, CMS will not be releasing the interpretive guidance (IG) for Phase 3 until the second ​quarter of 2020.  Read More>>​