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State Operations Manual Update to Appendix PP and Chapter 4

• Revisions to Appendix PP of the SOM: We have revised the Interpretive Guidelines and, where appropriate, Investigative Protocols for the following F Tags to incorporate Survey & Certification (S&C) policy memos issued from October 2003 through May 2014. Specifically, the guidelines have been updated for the following F Tags:  

F161 - Assurance of Financial Security

F202 - Documentation for Transfer and Discharge

F208 - Admission Policy

F221 - Physical Restraints

F278 - Accuracy of Assessment/Coordination/Certification/Penalty for Falsification

F281 - Services Provided Meet Professional Standards of Quality

F286 - Maintaining 15 Months of Resident Assessments (Use)

F332 - Medication Errors/Free of Medication Errors of 5% or Greater

F333 Medication Errors/Residents are Free of Significant Medication Errors

F371 - Sanitary Conditions

F387 - Frequency of Physician Visits/Timeliness of Visits

F388 - Personal Visits by the Physician

F390 - Physician Delegation of Tasks in SNFs/Performance of Physician Tasks in NFs

F425 - Pharmacy Services

F428 - Drug Regimen Review

F431 - Service Consultation/Labeling of Drugs and Biologicals/Storage of Drugs and Biologicals

F441 - Infection Control

F492 - Compliance with Federal, State and local laws and Professional Standards

F514 - Clinical Records

F516 - Resident Identifiable Information/Safeguard against loss, destruction, or unauthorized use

CMS announces Medicare Recovery Audit Program changes
On February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) announced an upcoming “pause” in Recovery Audit Contractors requests. According to the CMS Website notice, “CMS is in the procurement process for the next round of Recovery Audit Program contracts. It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program. Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program. CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers. CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders.  Providers should note the important dates below:

    February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)
    February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration
    June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment

AMDA Releases Free Interactive Program Aimed at Improving Care for Dementia Patients

AMDA – Dedicated to Long Term Care Medicine (AMDA) is pleased to announce
the release of a program of free, interactive courses aimed at decreasing the inappropriate use of
antipsychotic medications for nursing home residents and improving the overall quality of care
given to persons with dementia. Two courses, “Dementia in the Long-Term Care Setting, Clinical
Practice Guideline for Prescribers” and “Dementia in the Long-Term Care Setting, Clinical Practice
Guideline for Non-Prescribers,” were developed by AMDA with assistance and funding from an
Agency for Healthcare Research & Quality (AHRQ) grant. The program supports a more
appropriate care process for nursing home residents with dementia by providing an innovative,
interactive, technology-based means of disseminating evidence-based clinical practice guidelines
for the assessment and management of nursing home residents with a suspected diagnosis of
A five-hour professional development experience, each course focuses on the recognition,
assessment, treatment, and monitoring of dementia in the long-term care facility, and is free to both
prescribers and non-prescribers, as is a certificate of completion. The only requirement is that the
participant agrees to take an immediate post-course survey, a three-month post-course survey, and a
six-month post-course survey. These surveys will help AMDA evaluate the impact of the course on
patient care. Participants will also have the option to apply for CE, CME, and CPE.
Principle Investigator Ladislav Volicer, MD, PhD, hopes the program will educate people about
non-pharmacologic alternatives to antipsychotics. “Behavioral problems often can be prevented by
an adequate program of activities and opportunities for social engagement and mental stimulation.
Practitioners and interdisciplinary team members can work together to develop and implement an
individualized person-centered care plan that considers each resident’s particular needs, interests,
diagnoses, and comorbidities. But they need to be on the same page to do this effectively. These
courses will facilitate that.”
For more information about the program, visit

Informal Conferences Are the First Step in the Appeals Process    (from DIA)

New administrative rules were recently adopted detailing the role of independent reviewers.  The Iowa Department of Inspections and Appeals (DIA) would like to take this opportunity to clarify for health care providers the process for appealing a state citation.  An informal conference is the first step in the process by which facilities may contest a citation issued by the Department.  Iowa Code section 135C.41(2), requires that facilities initiate an appeal with an informal conference.  In the past, DIA permitted facilities challenging citations to bypass the informal process and proceed directly to a contested case proceeding.  With the move to independent reviewers and in accordance with chapter 135C, all facilities challenging a citation will be required to go through the informal process before requesting a contested case proceeding.

Facilities may contest a citation or fine issued by the Department through an informal conference, as provided by Iowa Code section 135C.42, as amended by 2013 Iowa Acts Chapter 26.  An informal conference allows facilities an opportunity to present information relating to the citation that was not originally available at the time of the survey, investigation or revisit.  The conference may occur in person or by telephone.  Attorneys need not be involved in the informal conference.  At the conclusion of the conference, the independent reviewer may affirm, modify, or dismiss the citation based upon information provided by the facility.

A facility wishing to further contest the state citation following the informal conference must request a formal contested case hearing.  The formal contested case hearing is held before an administrative law judge, pursuant to Iowa Code chapter 17A.  The Iowa Administrative Procedure Act governs the way in which the hearing is conducted, and outlines the admission of evidence, issuance of subpoenas, discovery, and more.  Similar to the informal conference, an administrative law judge may affirm, modify, or dismiss the citation and any corresponding fine.  Decisions made by the administrative law judge are subject to director review.  A decision by the director is considered the final agency action.  Should a facility wish to further contest this final agency action, it may then file a petition for judicial review.

“Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius” MLN Matters® Article — Released

MLN Matters® Article #MM8458, “Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius” has been released and is now available in downloadable format. The article was prepared and is being distributed as a result of the settlement agreement in the case of Jimmo v. Sebelius. This article is designed to provide education on the updated portions of the “Medicare Benefit Policy Manual” (MBPM). It includes clarification on the coverage requirements of skilled nursing and skilled therapy services to Medicare beneficiaries.