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Indiana FSSA Division of Aging Issues Updates to e450B Process
'Why' I Originally Chose to Work in Long-Term Care
ISDH Publishes Update to Advance Directives Brochure
CMS QAPI Material Rollout for Nursing Homes
National Nursing Home Week - Team*Care - 10 Simple Ways to Work as a Team


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Indiana FSSA Division of Aging Issues Updates to e450B Process

Indiana FSSA's Division of Aging is revising the e450B process.  The changes will be effective November 1, 2013.  A memo was published 10/14/13 which has some potentially valuable information for the staff who complete the e450B in your nursing facility. The memo can be found in its entirety here.  It includes not only the upcoming changes but also examples, a quick-reference table,  and reminders of the process.  

Indiana FSSA's Division of Aging Updates e450B Process - Simmons Healthcare Consulting, LLC - - Providing Social Service, QMRP consulting to the long-term care industryThe Division of Aging will also be hosting several webinar/training sessions to review the changes along with an opportunity for questions and answers.  

Webinar Training Sessions (Registration is required) - 

An "In-Person" training session is scheduled for Monday, October 28 from 1P-3P at the Indiana Government Center South Auditorium (402 W. Washington St, Indianapolis).  Registration is not required for the Indianapolis session.  However, bring a printed copy of the 10/14/13 FSSA Memo for reference. The Division of Aging is also expecting to have a PowerPoint presentation available on the e450B website by the end of the business day 10/18/13.  It is recommended that it be printed and brought to the training session also.

Simmons Healthcare Consulting, LLC, provides Social Service, QIDP (QMRP) consulting services to the long-term care industry.  Our primary focus includes regulatory compliance, timely MDS 3.0 documentation completion, survey preparation, and behavior management.  Based in Indiana, we bring 19 years of 'hands-on' trusted experience to our valued clients.  Contact us today to discuss how SHC can assist your nursing facility to gain the results you need.

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ISDH Publishes Update to Advance Directives Brochure

An updated version of the 'Advance Directives - Your Right to Decide' brochure has been released by the Indiana State Department of Health (ISDH).  Included in the revision is information related to the new Physician Orders for Scope of Treatment (POST) form which Indiana has approved beginning July 1, 2013.  The brochure also now includes Out of Hospital Do Not Resuscitate Declaration and Order guidance.  

Advance Directives Simmons Healthcare Consulting, LLC BlogPertinent information - 

If your nursing facility's Social Service department is needing assistance with compliance regarding code status, Advance Directives, or end-of-life documentation, contact Simmons Healthcare Consulting, LLC at

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Monthly Report of Indiana CaseMix/PASRR Audits

Background - Every month in Indiana, the HP LTC Unit conducts on-site audits of Medicaid-certified long-term care facilities with oversight provided for the Division of Aging and the Office of Medicaid Policy & Planning. The purpose of the LTC review is to ensure that the IHCP (Indiana Health Coverage Program) is reimbursing for the appropriate RUG classification as demonstrated by the MDS version 3.0 and supporting documentation.  The LTC auditing team also performs Level of Care (LOC) and Pre-Admission Screening Resident Reviews (PASRRs) of LTC residents.  The frequency of the audits was changed approximately 3 years ago and is determined according to the nursing facility's risk criteria.

HP LTC Audit Objectives - 
  • Determine whether residents continue to have needs requiring NF placement in accordance with State LOC criteria defined by 405 IAC 1-3-1 and 405 IAC 1-3-2.
  • Ensure all services recommended by the Level II assessments are provided.
  • Determine whether IHCP is reimbursing the provider for the appropriate RUG-III classification, reflective of resident needs.
  • Verify that the MDS responses that impact the RUG score are accurate and supported with the appropriate documentation within the assessment reference period.

Average Monthly Validation Rate - 90.5%
Validation Threshold, per IAC (Indiana Administrative Code) - 80%

Nursing facilities that exceed the 20% error threshold rate as outlined in the IAC receive a 15% Administrative Component Corrective Remedy penalty applied for one quarter. The facility is required to respond to a Validation and Improvement Plan (VIP). All unsupported worksheets are reclassified, and the facility is subject to a Case Mix audit within 12 months. 

January 2013 Findings - 

The Case Mix audit validation rate average was 87.6%.  
Five areas of concern emerged from January's audits with the elements having 20% or greater inconsistency with the MDS data transmitted by the nursing facility.  
  • C1000 - Decision Making
  • H0200C - Urinary Toileting Program
  • O0500G - Dressing/Grooming
  • O0500B - Active Range of Motion
  • C0700 - Short Term Memory Problem

At least one of the ten elements comprising Nursing Restorative has appeared in the Areas of Concern for eleven out of the last thirteen months and for eleven straight.

January 2013 Percentage of Records Fully Supported by RUG (Resource Utilization Groupings) Classification - 
  • Extensive Services - 85%
  • Special Rehabilitation - 97%
  • Special Care - 76%
  • Clinically Complex - 92%
  • Impaired Cognition - 78%
  • Behavior - 0%
  • Reduced Physical - 77%

Seven residents were referred for Level II's including - 
  • Four residents had a diagnosis of Depression, with ongoing psychotropic medication administration and symptoms noted.
  • Two residents had diagnoses of Depression and Anxiety, with medication administration and exhibiting symptoms.

Requirements that will continue to be reinforced - 
  • Utilization of The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for Active Diagnosis.
  • That RUGgable diagnosis has two parts, physician signature within 70 days and “Active” meaning documentation within the 7 day time frame of the direct relationship of the diagnosis to the resident’s current status.
  • MDS 3.0 requires individualized, measureable care plans for nursing restorative and evaluations completed in the 7 day assessment time frame.

Social Service remains an important factor in achieving a successful HP audit. Timely, descriptive, accurate documentation is essential for the Case Mix component. Proper screening and referrals are necessary for PASRR compliance.  

Does your nursing facility need assistance preparing for your HP audit? Do you feel that your Social Service department could benefit from an outside audit before the actual one? Do you know if you are in compliance with the required QMRP consultation for your ID/DD residents? Is your current Social Service or QMRP consultant not achieving your desired results? Contact Simmons Healthcare Consulting, LLC, at or 260-894-1417 and we'll discuss efficient, cost-effective solutions.

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CMS Updates Forms for QIS Survey Process

CMS has posted changes to a few QIS forms.  Full information can be found at  

Resources - 

Entrance Conference - 

Mandatory Facility Task Pathway Forms - 

Stage I Forms - 

Stage 2 CE Pathways Forms - 

Triggered Facility Tasks Pathway Forms - 

Need assistance with preparation for QIS?  Does your nursing facility need increased support while awaiting a PSR?  Contact Simmons Healthcare Consulting, LLC, to discuss many options that can assist with regulatory compliance.

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Recent ISDH and CMS Updates / Resources for Nursing Facilities

Several important pieces of information to pass on to our long-term care followers today - 

  • ISDH (Indiana State Department of Health) has recently increased the number of survey areas to 10. They have released an updated map and the roster of surveyor assignments / supervisors.  If you need assistance obtaining the new map and roster, send us an email ( and we'll get that information to you in the form of a Word document.

  • CMS (Centers for Medicare & Medicaid Services) has stated that under healthcare reform there must be regulations requiring nursing facilities to have an effective compliance and ethics program by March 23, 2013.  CMS is expected to publish a 'draft' regulation by December 31, 2012.  
  • The "Hand in Hand" training materials should be arriving to nursing facilities shortly from CMS.  If you're not familiar, the program focuses on person-centered care for residents with Dementia and abuse prevention.  All facilities are supposed to receive one free copy of the training program.  SHC would like to hear feedback from facilities once you review the toolkit.  Contact SHC if you need assistance with implementation of the program.  
  • The most recent information that SHC has on the top F-tag citations for Indiana - F441 (Infection Control), F323 (Supervision/Accidents), and F282 (Comprehensive Care Plans).
  • CMS has released a webinar (available via YouTube at this link) on the CMS National Partnership to Improve Dementia Care in Nursing Homes - formally referred to as the Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Home Residents.  The webinar provides an overview of the national partnership, resources for technical assistance, and plans for upcoming educational offerings.
  • CMS has also released a "Discharge Planning" booklet (ICN 908184).  It is designed to provide education on Medicare discharge planning.  Again, email SHC if you need assistance obtaining a copy of the booklet and we'll send you the PDF version.  

Hope everyone stays safe and has provisions in place for staffing today & tomorrow with the pending winter storm!

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Don't Overlook the "Easy" F-tags in Your #SNF

Many of us know that there are certain F-tags that are difficult to avoid no matter how fantastic the nursing facility is.  F309, F329, and F441 come to mind.  However, there are citations that can be avoided with little effort.  Several different tags deal with the posting of information and information provided to residents/families.  For example, F156 (Notice of Rights, Rules, Services, Charges) has seemed to be an issue recently in some areas.  

  • Assign rotating staff in your facility to conduct a regular walk-through to look for the required postings.
  • Do the required postings have the correct information?  Example, current Ombudsman / Administrator, correct phone numbers?
  • Are the postings printed with a larger font?
  • Are the postings at an appropriate height?
  • Are residents being given a copy of the facility charges along with their Medicare denial letters?
  • Is the facility using the most recent Medicare denial letter?
  • Is the facility using the most recent Notice of Transfer/Discharge and Request for Hearing?
  • Is information on how to obtain Medicaid assistance posted?
  • Is the required staffing information posted in an accessible area?
  • If your facility has an electronic wandering system, is information available that those residents would have access to also?

Taking a few minutes each week to ensure compliance with these areas can potentially save a lot of headaches once the surveyors enter the home.  Need assistance with your Social Service or Activity department?  Is your Indiana facility in compliance with required QMRP visits?  Contact Simmons Healthcare Consulting, LLC, and we will schedule a visit to help continue improving Quality of Life services for your residents.

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Upcoming IHCA QIS Intermediate Training

IHCA (Indiana Health Care Association) has QIS Intermediate Training sessions scheduled for next week  -  December 11 in Merrillville and December 13 in Edinburgh.  Information on IHCA's website can be found at this link and a PDF flyer can be found here.  If you haven't signed up yet, I believe that there's still time to do so.  And if you are planning to attend the Merrillville session, look for SHC and say 'hello'.  

If your facility is needing assistance with ISDH survey preparation, survey management, or achieving regulatory compliance following a survey, contact SHC and we'll schedule a visit to help continue improving Quality of Life services for your residents.

Have a great weekend everyone!

Top 10 #LTC Deficiencies, Top 10 Troubled States

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The latest Top 10 regarding nationwide nursing facility survey citations is out.  Indiana makes the list as one of the states with the most serious deficiencies.  Having participated in survey management in several states, ISDH surveyors consistently are definitely thorough, in my experience.  F-tags among the top 10 include F241 (Dignity), F329 (Unnecessary Medication), F279 (Develop Comprehensive Care Plans), F309 (Highest Practicable Well-Being), F323 (Accidents and Hazards) and F281 (Professional Standards).  

Social Service staff has the potential to be directly involved in these 6 tags.  A functioning Behavior Management program helps with F323 and F329, timely and accurate documentation assists with F279 and F281, and proper observations and psychosocial interventions can cover F309 and F241.  

  • Is your Behavior Management program truly working?  
  • Is it utilized effectively and do the direct caregivers understand the potential benefits of behavioral interventions?  
  • Are Social Service staff made aware of important resident changes in order to intervene and update care plans as appropriate?  
  • Does the Social Service department have systems in place for time management in order to be able to document in a timely manner?  

If your facility needs assistance with Social Service and/or survey management,
contact SHC and we'll schedule a visit to continue improving Quality of Life services.