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Category Archives: SLCR Guidance

CMS Memo S&C 16-21-ALL: Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals

Surveyor Guidance:  The Centers for Medicare & Medicaid Services (CMS) are clarifying requirements for providing services to justice involved individuals in skilled nursing facilities (SNFs), nursing facilities (NFs), hospitals, psychiatric hospitals, critical access hospitals (CAHs), and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID). Specifically, this guidance seeks to assure high quality care that is consistent with essential patient rights and safety for all individuals.

Please see the attached memo and scenarios below or you may visit

SC16-21.01 Final Memo Justice-Involved
SC16-21.02 Scenarios Justice-Involved Individuals

New MDS Updates

New MDS 3.0 Quality Measure User’s Manual Available

The MDS 3.0 QM User’s Manual Version 10 was posted April 28, 2016, which includes new Quality Measures.  The MDS 3.0 QM User’s Manual v10.0 contains detailed specifications for the MDS 3.0 quality measures that are only MDS based.  The new manual can be found in the Download section at the bottom of the page at


New Measures Technical Specifications

There are also now QMs that are claims based in addition to being MDS based.  The specifications for these Quality Measures can be found in the download section at the bottom of the page at


Nursing Home Compare Five-Star Rating

Beginning in July 2016, five of the new measures (all except for the antianxiety medication measure), will be used in the calculation of the Quality Measure rating.  Gradual phase-in of the new measures will occur between July 2016 and January 2017.  Prior to July, the Technical Users’ Guide, which is also available in the downloads section of the CMS website (same link as above), will be updated to reflect the changes to the Quality Measure rating calculation.


Payroll-based Journal (PBJ)

Beginning in July 2016, all Medicare- and Medicaid-participating nursing homes must submit staffing

data to CMS through a new electronic system called the Payroll-based Journal (PBJ).  More information about staffing data submission is available at

For additional assistance with or questions related to PBJ registration process, please contact the QTSO Help Desk at 877-201-4721 or via email at


Draft RAI Manual v1.14

On May 11, 2016, CMS posted a new DRAFT RAI Manual v1.14 in the Related Links section at so that users can preview significant changes before they become effective October 1, 2016.  There are many item set changes, including the new Chapter 3, Section GG: Functional Abilities and Goals. Chapter 2 and Chapter 3, Section A provide information on the new Part A PPS Discharge assessment.  Please note that it does not include Appendices F and H or replacement pages, which will be published with the final version 1.14 in September 2016.


If you have any questions about the above information, please contact Stacey Bryan, BSN, RN, State RAI Coordinator, Department of Health & Senior Services, Telephone 573-751-6308 or E-mail

CMS Memo S&C 16-22-LSC: Notification of Final Rule Published: Adoption of 2012 Life Safety and Health Care Facilities Code

Fire Safety Requirements for Certain Health Care Facilities:  On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published a final rule titled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities,” which updates the fire safety requirements for health care providers and suppliers.  This regulation requires certain providers and suppliers to meet the requirements of the 2012 edition of the Life Safety Code (LSC), National Fire Protection Association (NFPA) 101 and the 2012 edition of the Health Care Facilities Code, NFPA 99.

Please see the Press Release attached stating health care providers affected by this rule must comply with all regulations within 60 days of the date of the publication of the final rule (May 4, 2016).  More information is coming from CMS and we will provide updates as we receive them.

SC16-22 – Release of Final Rule LSC
Press Release for Fire Safety Requirements

Most Frequently Cited Deficiencies Report – 1st Quarter 2016

Please view the quarterly report from the Section for Long-Term Care Regulation attached.

Administrator Licenses Expire June 30, 2016

Administrator licenses expiring June 30, 2016 are up for license renewal.  Renewal reminder postcards were mailed early April.  Please visit the Missouri Board of Nursing Home Administrator’s web page for the renewal instructions and renewal application at

LPN Licenses Expire May 31, 2016

LPN licenses expire May 31, 2016.  Approximately 25,000 renewal postcards were mailed to LPNs in early March.  The postcard provides online renewal instructions, including the PIN you need to renew online.

Please visit the Missouri Division of Professional Registration, Board of Nursing’s web page here for details.

CMS Memo S&C 16-11 ALL: Exit Conferences- Sharing Specific Regulatory References or Tags

The Centers for Medicare & Medicaid Services (CMS) has clarified guidance to surveyors regarding the procedures for conducting exit conferences, specifically related to the sharing of regulatory tags.  There are significant changes to the exit conference process in this memo.  In addition to the guidance in this memo, CMS has also given direction that the staff identifier list is not to be released even if requested.  This guidance applies to Medicare/Medicaid certified homes only.  The Section for Long-Term Care Regulation will implement these changes no later than March 31, 2016.

Please see the memo and attachments below or visit

SC16-11-ALL Memo
SC16-11-ALL.02 SOM Chapter 2
SC16-11-ALL.03 SOM Chapter 5
SC16-11-ALL.04 SOM Appendix P