Empower the whole team with this quick-reference guide designed to build confidence and readiness for the survey process. Survey 101: What Every Staff Member Should Know provides all team members—from nursing to housekeeping—with a clear, …
Memo # QSO-25-26-NH Posting Date 2025-09-29 Fiscal Year 2025 Memorandum Summary CMS is committed to reinvesting civil money penalty (CMP) funds in projects thatsupport nursing home residents and protect or improve their quality of care and life.Therefore, we …
NOTABLE CHANGES TO THE MDS QM USER’S MANUAL V17 Guidance on Selecting MDS Section GG Item Columns for Measure Calculation An updated .zip file for the Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s …
Issued on 09/15/2025 | Posted on 09/18/2025 | Report number: OEI-05-24-00180 Report Materials Why OIG Did This Review What OIG Found Nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents, as required, in …
Memo # Admin Info-25-11-ALL Posting Date 2025-09-12 Fiscal Year 2025 Summary Memorandum Summary The Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG) remain dedicated to ensuring the health and safety of …
In this LTC DON Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, director of education and certification strategy for …
Facility policies serve as the backbone of consistent, safe, and compliant operations. Nursing homes rely on well-developed policies to guide staff, protect residents, and maintain compliance of care delivery that must follow state and federal …
Information on how surveyors currently manage the nursing home survey process: CMS iQIES S&C User Manual: Manage a Survey LTC Facilities v1.2 (Posted 09/03/2025) From https://qtso.cms.gov/software/iqies/reference-manuals
August 2025 Updates Weekly RP Summary – Data Collection Forms and Instructions LTCF Resident From https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html
This user manual addresses the processes necessary to perform Survey & Certification (S&C) Electronic Plan of Correction (ePOC) functions in iQIES. CMS iQIES S&C User Manual: ePOC – Provider ePOC Admin Role v1.2 (Posted 07/22/2025) …
The Association for Professionals in Infection Control and Epidemiology (APIC) has released an updated position paper titled “Safe Injection, Infusion, Medication Vial, and Point-of-Care Testing Practices in Health care (2025),” published in the American Journal of Infection Control …
This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP). It is a one-stop shop containing a multitude of reference materials that are provided to the surveyors going …
The director of nursing services (DNS) is preparing for her first annual survey. She wants to take a proactive approach regarding facility residents with enteral feedings. However, as a relatively new DNS, she is unsure …
CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Nursing Home Compare Web site features a quality rating system that gives each nursing home …
This manual provides general background and information about the submission requirements, such as sample submission screens, submission deadlines, and definitions of job categories. Note: Changes from the previous version of this policy manual are identified …
Release of CMS-2567: Statement of Deficiencies and Plan of Correction Memo # QSO-25-19-All Fiscal Year 2025 Memorandum Summary • CMS is committed to the transparency of quality of care findings, so that patients, residents, and …
Memo # QSO-25-20-NH Posting Date 2025-06-18 Fiscal Year 2025 Memorandum Summary • Post Performance Data for Nursing Home Chains – “Chains” refers to groups of Medicare-certified nursing homes that are connected through common owners, and operators (also …
AHRQ has released an updated Surveys on Patient Safety Culture (SOPS) Nursing Home Survey Version 2.0. This revised survey is designed to help nursing homes assess staff perceptions of resident safety culture in their organizations. The survey …
Medical directors at nursing homes are responsible for implementing resident care policies, coordinating medical care, and participating in quality assessment and assurance activities. Nursing homes are required to report hours worked by medical directors to …
Ensuring that nursing staff have the “appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each …
PRN Medication Use is one of the few sections of the revised F605 (Right to Be Free From Chemical Restraints/Unnecessary Psychotropic Medications) in Appendix PP of the State Operations Manual that does not have changes …
Sensory impairments, such as loss of vision, hearing, taste, smell, or touch, are common among older adults, and significantly affect their quality of life. These impairments often go unnoticed or may be mistaken for cognitive …
Analysis and Report Resources General Resources COVID-19: Understanding Key Terms and Up to Date Definitions [PDF – 1 MB] – April 2025 From https://www.cdc.gov/nhsn/ltc/covid19/rpv-resources.html
As part of their ongoing commitment to ensuring quality care and compliance with federal health and safety regulations, the Centers for Medicare & Medicaid Services’ (CMS) developed an informational provider resource about the survey process. …
The Centers for Medicare & Medicaid Services (CMS) recently confirmed the revisions to the State Operations Manual (SOM), Appendix PP, which went into effect April 28, 2025. The revisions are redlined here. While many revisions …
This workbook simulates the survey functions in iQIES and may provide a bare-bones (i.e., basic) walkthrough of how surveyors will approach survey using iQIES. To access, go to https://qtso.cms.gov/software/iqies/reference-manuals Then go to the section titled iQIES …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, director of education and certification strategy for AAPACN, discuss the new …
The Centers for Medicare & Medicaid Services (CMS) released a revised memo, QSO-25-07-NH, which detailed a launch plan to transition the long-term care survey process to the Internet Quality Improvement and Evaluation System (iQIES) platform. …
A quick review of the draft revised surveyor guidance in Quality, Safety, and Oversight (QSO) memo QSO-25-14-NH that goes into effect on April 28, 2025, may initially concern the director of nursing services (DNS) and …
Hearing a staff member say, “State just walked in the door,” shouldn’t ignite survey panic mode in the director of nursing services (DNS) and other department leaders in the nursing home, says Michelle Synakowski, RN, …
The director of nursing services (DNS) received a call in the middle of the night that a resident with a diagnosis of dementia had eloped, and it appeared she had been missing for several hours—a …
The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)17.0 is now available. The MDS 3.0 QM User’s Manual V17.0 contains detailed specifications for the MDS 3.0 QMs and includes a Notable …
FFS & MA NOMNC/DENC What’s New 11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) …
Written by Kristine Martinez BSN, RN, RAC-CTA, QCP Completing a Minimum Data Set (MDS) correctly is no small task. With approximately 510 answers or choices on a comprehensive MDS (not including CAA investigation), and approximately530 answers …
From https://oig.hhs.gov/compliance/nursing-facility-icpg/ The Nursing Facility ICPG—together with OIG’s General Compliance Program Guidance (GCPG) that applies to all individuals and entities involved in the health care industry—serves as OIG’s updated and centralized source of voluntary compliance program guidance for …
Sepsis—a key driver of hospital readmissions—can have negative clinical impacts for residents and negative financial, quality, survey, and even legal impacts for nursing homes. Here is a review of important basics: What is sepsis? The …
The newly revised Clinical Practice Guideline for Diabetes Management in the Post-Acute and Long-Term Care (PALTC) Setting provides (1) new information on overall goals in diabetes care, (2) detailed information on how to use and …
REVISED: Updates to Nursing Home Care Compare Staffing and Quality Measures Memo # QSO-25-01-NH REVISIONS TO QSO-23-21-NH, ORIGINALLY RELEASED ON September 20, 2023. • Adjustment to Staffing and Quality Measures: CMS will update the staffing …
Compliance with Residents’ Rights Requirement related to Nursing Home Residents’ Right to Vote Memo #QSO-24-21-NH Posting Date 2024-09-26 Fiscal Year 2024 Memorandum Summary• The Centers for Medicare & Medicaid Services (CMS) is affirming the regulatory …
The National Healthcare Safety Network (NHSN) Long-Term Care Facility Component Manual Tracking Healthcare-Associated Infections (HAIs) in Long-term Care Facilities The National Healthcare Safety Network (NHSN) Manual 2025 COVID-19 VACCINATION PROTOCOL Weekly COVID-19 Vaccination Module for …
With the help of contractors, CMS revised the SNF ABN, Form CMS-10055, and the form instructions. The SNF ABN form and instructions are located in the download section and are available for immediate use, but …
F-tag 689 (Free of Accident Hazards/Supervision/Devices) was the No. 1 tag cited at the immediate jeopardy (IJ) level in 2023—and remains at the top halfway into 2024, according to QCOR data accessed on June 30, …
Everyone loves a good mystery. Many like to watch their favorite mysteries on television or read a good thriller. However, mystery and suspense should not be a part of the facility assessment review. The final …
Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting; Correction SUMMARY: This document corrects typographical and technical errors in the final rule that appeared in …
Engineering controls can be implemented to isolate people from a hazard and provide protection for long-term care residents and staff. Engineering Controls for Long-Term Care
This site includes access to a provider enrollment and certification roadmap: https://www.cms.gov/medicare/provider-enrollment-and-certification/enroll-as-an-institutional-provider
The NHSN Long-term Care Facility Component supports the nation’s COVID-19 response through the LTCF COVID-19 Module. Facilities eligible to report data to NHSN’s COVID-19 Module include nursing homes/skilled nursing, long-term care for the developmentally disabled, and assisted …
Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings https://www.cdc.gov/healthcare-associated-infections/php/toolkit/icar.html AT A GLANCE ON THIS PAGE
https://www.cdc.gov/long-term-care-facilities/hcp/training/index.html AT A GLANCE ON THIS PAGE Course link: https://www.train.org/cdctrain/training_plan/3814 Training resources
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html AT A GLANCE Frequently asked questions about using enhanced barrier precautions in nursing homes to prevent MDROs. ON THIS PAGE
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html KEY POINTS How to implement personal protective equipment (PPE) use in nursing homes to prevent spread of multi-drug resistant organisms (MDROs). Summary of recent changes Enhanced Barrier Precautions in Nursing Homes – Video, Posters, …
AGENCY: Office for Civil Rights, Office of the Secretary, Department of Health and Human Services; Centers for Medicare & Medicaid Services, Department of Health and Human Services. ACTION: Final rule and interpretation. SUMMARY: The Department …
The Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule adopts the Centers for Medicare & Medicaid Services’ (CMS) proposed three-pronged, comprehensive staffing approach for Medicare- and Medicaid-certified …
When an abuse situation occurs, staff must know how to respond and must do so in a timely manner. Opportunities to practice enable staff to sharpen their responses to these events. AAPACN’s Mock Abuse Drill …
Nursing homes are required to establish a surveillance system (i.e., “the routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data”) as part of their infection prevention and control program (IPCP) under F-tag …
The expedited determination beneficiary notification process covers a lot of ground in skilled nursing facilities (SNFs), affecting residents in the fee-for-service (FFS) Medicare Part A program and Medicare Advantage plans, as well as residents who …
In the Jan. 18, 2023, Quality, Safety, and Oversight (QSO) memo QSO-23-05-NH, the Centers for Medicare & Medicaid Services (CMS) announced plans to conduct offsite audits to assess whether nursing homes appropriately assess, document, and …
The GCPG is a reference guide for the health care compliance community and other health care stakeholders. The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other items useful for understanding health …
Over the past few years, the Centers for Medicare & Medicaid Services (CMS) has placed increasing emphasis on drug regimen review (DRR) aka medication regimen review (MRR). Since 2018, skilled nursing facilities have captured one …
Admissions are vital to a facility. They may occur daily, or even multiple times a day, and should be a part of routine operations. However, the admission process can be cumbersome, and it is easy …
The admission process can be lengthy, and staff can miss important details. Use the Medical Record Audit: New Admission/Readmission checklist to ensure the facility has obtained critical information from newly admitted and readmitted residents and …
Memo # QSO-23-23-NHs Posting Date 2023-09-25 Fiscal Year 2023 Title Memorandum Summary CMS is committed to reinvesting civil money penalty (CMP) funds for projects to support the quality of care and life for nursing home …
In the long-awaited Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposes a three-pronged, comprehensive staffing approach for Medicare- …
In February 2022, the Biden-Harris Administration announced a comprehensive set of reforms aimed at improving quality and safety for residents in nursing homes. One aspect of this initiative was conducting a new Nursing Home Staffing …
F740 (Behavioral Health Services) is not a frequently cited F-tag so far in calendar year (CY) 2023, according to QCOR data posted on Aug. 13, 2023. However, the consequences can be severe—surveyors often issue this …
The use of psychotropic medications in the skilled nursing facility (SNF) is a controversial issue with implications for resident, regulatory, and financial outcomes. The many requirements can be confusing, especially for a relatively new director …
Nursing homes face significant risk and liability under F-tag 609 (Reporting of Alleged Violations), says Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a partner in the Benesch Healthcare + Practice Group at Benesch, Friedlander, Coplan …
Memo # QSO-23-18-NH Posting Date 2023-06-28 Fiscal Year 2023 Memorandum Summary • Posting Nursing Home Affiliation on Nursing Home Care Compare: CMS will include ownership and operatorship affiliation information on our Nursing Home Care Compare …
The director of nursing services (DNS) position is multi-faceted, and a new DNS must learn a lot quickly. Areas such as providing residents quality care and staffing take top priority, and rightfully so. However, another …
On May 11, 2023, the Centers for Medicare & Medicaid Services (CMS) ended certain emergency waivers; put in place during the public health emergency, these waived some F-tag elements that would otherwise have applied during …
A systematic approach to utilizing the Internet Quality Improvement and Evaluation System (iQIES), (formerly CASPER), reports is necessary for QAPI, survey readiness, and reimbursement. While there are numerous reports available via iQIES, this tool highlights …
Antipsychotic drug use among long-stay residents decreased steadily from 31 percent in 2011 to 22 percent in 2019, according to the November 2022 report Long-Term Trends of Psychotropic Drug Use in Nursing Homes from the …
Prior to the COVID-19 public health emergency (PHE), skilled nursing facilities (SNFs) were gearing up to take more medically complex fee-for-service Medicare Part A residents, including residents with infusion therapy needs, as a result of …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss the new …
F557 (Respect, Dignity/Right to Have Personal Property) is one of the shorter F-tags in terms of the amount of guidance provided by the Centers for Medicare & Medicaid Services (CMS), coming in at well under …
According to the Centers for Medicare & Medicaid Services (CMS), “Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to …
In calendar year (CY) 2022, F-tag 695 (Respiratory/Tracheostomy Care and Suctioning) was the 13th most-cited at the immediate jeopardy (IJ) level. In comparison, F695 was the 17th most frequent citation at the IJ level in …
In calendar year (CY) 2022, F-tag 695 (Respiratory/Tracheostomy Care and Suctioning) was the 11th most commonly cited F-tag nationwide. In comparison, F695 was the 16th most common citation overall in CY 2021 and only the …
In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss the latest …
The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 01/31/2026 will be mandatory on 6/30/23. …
Memo # QSO-23-11-LSC Posting Date 2023-03-31 Fiscal Year 2023 Summary Various CMS regulations governing certain providers and certified suppliers require compliance with the 2012 edition of the National Fire Protection Association (NFPA) Health Care Facilities …
Quality of life is a “fundamental principle” that feeds into—and flows from—all resident care and services, according to 42 Code of Federal Regulations (CFR) §483.24. The F-tag 675 surveyor guidance in Appendix PP of the …
The National Emerging Special Pathogen Training and Education Center (NETEC) has released a workbook for “assessing operational elements for special pathogen preparedness, response, and recovery unique to the long-term care setting.” The workbook is designed …
Find resources and technical assistance at https://nursinghomebehavioralhealth.org/ Current resources include: Center of Excellence for Behavioral Health in Nursing Facilities – Frequently Asked Questions DOWNLOAD SAMHSA informational pamphlet about bipolar disorder’s definition, signs/symptoms, types and treatment …
In this first episode of a two-part series on Special Focus Facilities, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, …
The Centers for Medicare & Medicaid Services (CMS) recently announced they would be conducting audits on MDS coding of residents with a diagnosis of schizophrenia. With the increased scrutiny of this diagnosis, nurse assessment coordinators …
Inadequate hand hygiene before and after care processes (e.g., when donning or doffing gloves) is a perennial problem for nurses and other staff members in nursing homes. However, even staff who perform hand hygiene correctly …
Listen to this podcast for a discussion on survey citation F695, Respiratory/Tracheostomy Care and Suctioning – what it is, why it is important, and how skilled nursing facilities can avoid it. Amy Stewart, MSN, RN, …
2015—the year that the Centers for Medicare & Medicaid Services (CMS) added antipsychotic medication use quality measures (QMs) to the Five-Star Quality Rating System—marked the beginning of some difficult trends in the potentially inappropriate diagnosis …
Participants will learn to identify requirements of a person-centered care plan, identify ways to develop a relationship with a resident that facilitates care planning, and define person-centered care according to the Centers for Medicare & …
While completing MDS assessments, nurse assessment coordinators can monitor for regulatory compliance during the chart review. If compliance issues arise, leadership should be notified to correct them. NACs can utilize AAPACN’s Medical Record Alert Sheet …
On June 29, 2022, the Centers for Medicare and Medicaid Services (CMS) released updates to the surveyor guidance in Appendix PP of the State Operations Manual. Some are minor technical updates, while others introduce entirely …
Nursing home leaders can reference this resource to ensure that the facility’s emergency preparedness plan is current and captures an all-hazards approach to meeting the health, safety, and security needs of staff and residents during …
AHRQ has created a guide for nursing home leaders as they implement COVID-19 vaccination programs among staff members. The resource identifies important factors to consider from planning to implementation, including guidance on updating policies and …
