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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

VOYCE’s Long Term Care Conference

June 10, 2016:  The Changing Landscape of Long Term Care Conference
Location:  Renaissance St. Louis Airport Hotel

Hear national and local experts discuss dynamic strategies, innovative tools and available long-term care options.

The format has been set with two educational tracks throughout the day; one for professionals working in long-term care and one for the general public who are looking for answers to the complexity of long-term care.

See the registration packet for the full description of the topics and the national and local expert speakers on the VOYCE event web page here.

2016 Pioneer Network Conference

July 31-Auguest 3, 2016:  Revolutionizing the Culture of Aging
Location:  Hyatt Regency New Orleans, New Orleans, LA

This highly regarded, dynamic meeting weaves together the experiences and expertise in all sectors of the aging field, from C-suite corporate staff, administrators, managers, nurses, social workers, activity professionals, researchers, regulators to elders and care partners, etc.  Attendees are self-selected learners and “movers and shakers” interested in improvement and excellence in care and support of elders.  Attendees from past conferences enthusiastically report high satisfaction and comment on how different the Pioneer Network conference is from other conferences.  They share receiving benefit from:

  • Being with like-minded people from across the United States and internationally who share their passion for changing the culture of long-term care
  • Learning from experts who are on their “culture change journey”
  • Making connections that will help them with their personal and professional journey
  • Connecting with resources and vendors that can help them achieve their goals

Please visit the Pioneer Network’s Conference webpage here for more information including registration.

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.