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CMS Releases Revisions to the Special Focus Facility Program
CMS has released a revised Special Focus Facility (SFF) Program policy memo QS0-23-01-NH and updated the monthly SFF posting. These revisions are meant to increase the requirements for completion of the program and enforcement for facilities that do not demonstrate improvement.
A high-level overview of key changes made in the revised memo is as follows:
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Adding staffing levels as a consideration for SFF selection: CMS has directed states to consider a facility’s staffing level when selecting facilities for the SFF program. CMS recommends if a state is considering two candidates with a similar compliance history, it should select the facility with lower staffing ratios/rating as the SFF.
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Increased Criteria for Completion of the Program: CMS has added a threshold that prevents a facility from exiting based on the total number of deficiencies cited. To graduate from the program, facilities must complete two consecutive standard health surveys, with no intervening complaint, LSC, or EP surveys with 13 or more total deficiencies, or any deficiencies cited at scope and severity of “F” or higher.
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Involuntary Termination: SFFs with deficiencies cited at immediate Jeopardy (IJ) on any two surveys (standard health, complaint, LSC, or EP) while in the SFF program, will now be considered for discretionary termination.
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Increasing enforcement actions: CMS will impose immediate sanctions on an SFF that fails to achieve and maintain significant improvement in correcting deficiencies on the first and each subsequent standard health, complaint and LSC/EP survey after a facility becomes an SFF. Enforcement sanctions will be of increasing severity for SFFs demonstrating continued noncompliance and failure to demonstrate good faith efforts to improve performance.
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Incentivizing sustainable improvements: CMS will closely monitor graduates from the SFF program for a period of three years to ensure improvements are sustained. For SFFs that graduate but continue to demonstrate poor compliance identified on any survey (e.g., actual harm, substandard quality of care, or IJ deficiencies), CMS may use its authority to impose enhanced enforcement options, up to, and including discretionary termination from the Medicare and/or Medicaid programs.
AHCA/NCAL is reviewing the memo in detail and will follow up with additional information as needed. Please contact regulatory@ahca.org with any questions.
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Clinical Update from KHCA Consultant Linda Farrar
Well…what seemed like an eternity to get ready, October 24th is next Monday, so everyone should be ready. Check out the revised Critical Element Pathways, review your Facility Assessment, review your policies & procedures, put your staff education documentation in organized, convenient order for review, make sure your Elder Justice poster is up in the breakroom, review your Admission Agreements for required changes…etc., etc., etc. You have received all kinds of in-services and education about the revisions. You are ready. And oh, by the way, you faced new CDC/CMS guidance for COVID. I could not be prouder of you and your resilience along with your continued passion. READ MORE
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Nursing Scholarship Application
The Kansas Health Care Association's Nursing Advisory Committee (NAC) is pleased to sponsor the Joan Hamel Nursing Education Scholarship Program. KHCA will award up to $2,000 in scholarship grants to KHCA or KCAL member facility employees who wish to further their education.
Click here for details on the Infection Preventionist Specialized Training Scholarship.
Click here for details on the general scholarship that includes Gero Nurse Prep, IV Certification and Nursing School ($500 per semester).
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Joint Provider Surveyor Training - Topeka & Wichita
Don’t miss this Fall’s Joint Provider Surveyor Training with special opening Keynote from Jerald Cosey on “What’s Next? The Power of COVID Conviction to Advance Healthcare Leadership”
In cooperation with Kansas Department for Aging and Disability Services, Kansas Adult Care Executives and LeadingAge Kansas
3 Ways to Attend:
November 9 – In Person in Topeka
November 10 – In person in Wichita
November 10 – Live Virtual
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UPDATED Focus F-Tag of the Week
Each week through October, AHCA will be focusing on a particular F-tag(s) to help providers break down the Phase 2 updates and Phase 3 new guidance.
§483.10-Resident Rights
The Centers for Medicare and Medicaid Services made changes to the §483.10-Resident Rights. Changes include the following:
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F557-Respect, Dignity/Right to have Personal Property. CMS added guidance related to staff searches, signs, symptoms, and triggers of possible substance use, referrals to law enforcement and references to other areas of noncompliance.
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F561-Self Determination. CMS added guidance related to facility smoking policies.
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F563-Right to Receive/Deny Visitors. CMS added guidance related to denying visitor access, visitation during communicable disease outbreaks, triggers of substance use after visits, referrals to law enforcement, staff searches, and references to other areas of noncompliance.
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F582-Medicare/Medicaid Coverage/Liability Notice. CMS made changes to align with the Medicare Claims Processing Manual and simplified the Notice of Medicare Non-coverage (NOMNC) form and SNFABN form.
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F587-Request/ Refuse/ Discontinue Treatment. Formulate Advance Directives-CMS changes were technical as they corrected a tag reference under the key elements of noncompliance.
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Novavax Monovalent COVID-19 Booster Approved
Yesterday, October 19, the U.S. Food and Drug Administration amended the emergency use authorization (EUA) of the Novavax COVID-19 Vaccine, Adjuvanted to authorize use as a first booster dose to individuals 18 years of age and older. The Centers for Disease Control and Prevention (CDC) Director Rochelle P. Walensky, M.D., M.P.H., signed a decision memo allowing Novavax monovalent COVID-19 boosters for adults. This follows the Food and Drug Administration’s (FDA) authorization.
This action gives people ages 18 years and older the option to receive a Novavax monovalent booster instead of an updated (bivalent) Pfizer-BioNTech or Moderna booster if they have completed primary series vaccination but have not previously received a COVID-19 booster—and if they cannot or will not receive mRNA vaccines.
Click here to read the health alert for more information. Providers who have questions may contact the Kansas Immunization Program at kdhe.vaccine@ks.gov.
Reported by McKnights Long-Term Care News READ MORE
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Biden Administration Urging Health Care Providers To Prepare For End Of COVID-19 Public Health Emergency
CNBC (10/19, Kimball, 7.34M) reports "the Biden administration is telling health-care providers to begin preparing for an end to the" COVID-19 public health emergency. This "change will have broad implications for Medicaid health insurance recipients and could significantly impact how hospitals and pharmacies operate," and "HHS estimates up to 15 million people will be disenrolled from Medicare and the Children’s Health Insurance Program." HHS Secretary Xavier Becerra "renewed the emergency declaration until Jan. 11 last week as the U.S. presses ahead with a fall booster campaign."
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The Long Term Care Survey manual, Phase 3 is available for pre-order!
Order your copy today for October delivery.*
Phase 3 of The Long Term Care Survey manual includes all the updates from CMS' three-phase implementation.
Survey guidance for Phase 3 was released in June 2022. Surveyors will begin using this guidance on October 24, 2022.
Save money by ordering through KHCA!
Learn more about updates to this important resource and place your order today! E-mail Jennafer Sumner with desired quantity.
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Webinar: Survey Top 10 Citation Series - Survey Success! Avoiding Top Citations. #10 Top Citation: F758 Free from Unnecessary Psychotropic Meds/PRN Use
11/1/2022 1:30PM-2:30PM
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Joint Provider Surveyor Training
11/9/2022 8:30AM-4:00PM (Topeka)
11/10/2022 8:30AM-4:00PM (Wichita & Virtual)
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DON Boot Camp
11/14 - 11/17/2022 8:00AM-4:00PM
Olathe, KS
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Webinar: The Proficient Infection Preventionist Series: Ship-shape Cleaning & Disinfection for the Infection Preventionist
11/15/2022 1:30PM-2:30PM
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Webinar: Survey Success! Avoiding Top Citations. Post Survey Activities: Developing Effective Plan of Correction & IDR
12/6/2022 1:30PM-2:30PM
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Webinar: The Proficient Infection Preventionist Series: Astute Survey Preparedness & Application of Infection Control Regulatory Requirements
12/20/2022 1:30PM-2:30PM
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Looking for options for required Staff In-Service?
KHCA’s online learning platform is BACK! We’ve loaded the in-services for SNF and for AL first. Many more education sessions to come.
Questions about education can be directed to Polly Berkley VP of Operations and Education.
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Kansas Health Care Association and the Kansas Center for Assisted Living
1100 SW Gage Blvd. | PO Box 4770 | Topeka, KS 66604
PH: 785-267-6003 FAX: 785-267-0833
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