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Nursing Home Quality Improvement Spotlight On…

Managing Behaviors: Mental Health Disorders

Nursing homes face many challenges when managing behaviors with schizophrenia and other mental health diagnoses.  These challenges include the need for staff training on behavior management, implementation of strategies to maintain resident safety and other changes that meet the needs of residents.  Click on the following links (PDFs) to learn more.

Teaching and Maintaining Behavior Management Skills in the Nursing Home
Tips and Techniques for Supporting Residents with Mental Illness: A Guide for Staff in Housing for Older Adults


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

New QIPMO Newsletter – May 2016

The Quality Improvement Program for Missouri (QIPMO) has published MDS Tips and Clinical Pearls – Volume 3, Issue 3.  Topics in this issue include Bullies in Long-Term Care, Pneumococcal Vaccines, Accidents and Supervision, and more including MDS and ICD-10 news.  Please visit QIPMO’s website here for this and other previous newsletters.

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.  The new manual can be found in the Download section at the bottom of the page at

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

Pioneer Network Welcomes New Director of Education

Pioneer Network is pleased to welcome Joan Devine next week as our new Director of Education.  No stranger to us, Joan has long been a member of the Pioneer Network extended family!  She currently serves as Board President of MC5 (Missouri Coalition Celebrating Care Continuum Change), the state’s culture change coalition.  She has also been a frequent speaker at our conferences, in addition to the fearless leader of our group of dedicated onsite volunteers.

Joan has over 20 years of experience in leadership positions in senior services, supporting the clinical departments of Skilled Nursing and Assisted Living communities in Missouri and Illinois.  Her work has been devoted to preparing and equipping administrators and other care leaders to transform their homes and embrace resident directed care.

Joan holds a B.A. in Music Education/Music Therapy, a B.S. in Nursing and a Masters in Management.  She is also author of the book “Word of the Week:  Creating a Culture Change Dictionary” and is a certified Eden Educator and Mentor.

Conversations with Carmen

May 20, 2016:  Improving Mobility the “Advancing Excellence” Way
Guest:  Carol Benner, Advancing Excellence Campaign

For years we have talked about preventing and reducing falls, searching for the right solution.  We even tied people to their chairs to keep them from falling, not yet realizing that the key to preventing falls is to improve mobility.  Then we “alarmed” them, which only resulted in increased immobility.  Mobility is the key to maintaining both physical health and quality of life.  The Advancing Excellence Campaign has selected Mobility as one of its nine goals.  With an expert panel, it has prepared a full set of quality improvement tools to help assess, measure and improve mobility for nursing home residents.  This conversation will focus on:

  • What mobility is
  • Why maintaining/improving mobility is important
  • How to measure mobility using an evidence-based tool
  • How to incorporate mobility in your QAPI efforts
  • How to use a root cause analysis to help you identify areas for improvement

Please visit the event page here for more information including registration.

Most Frequently Cited Deficiencies Report – 1st Quarter 2016

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