The weekly Council newsletter, This Week, often contains information important to the nursing department. This week’s Vital Signs will recap some of this important information and guide you to the This Week issue for the complete coverage of topics covered since May.

This Week Number 1069, May 20, 2005 reviewed the Determination of Compliance for F-Tag 314, Incontinence. Examples of what the Centers for Medicare and Medicaid Services (CMS) feel are Immediate Jeopardy, Actual Harm or Potential for Actual Harm are listed.

This Week Number 1073, June 17, 2005 reviewed a new law regarding the screening of nursing home residents for previous offenses as sex offenders and felons. The new law requires facilities to check two website on all existing and new residents, informing other residents in the facility that the facility has an identified offender, and providing for additional risk assessments and care planning. This Week Number 1077, July 15, 2005 reviewed the IDPH emergency regulations effective July 21, 2005, calling for a police background check on all new admissions and all existing residents after January 1, 2006. These emergency regulations have since been modified and are under further review, as explained in several faxes sent to members in late July and early August. Final regulations are expected in December.

The Council often gets calls regarding citations that are written for the same violation under different OBRA Tags. This Week Number 1086, September 16, 2005 addressed this issue. According to the newsletter these are referred to as "Independent but Associated Deficiency Citations" and are instances where a deficient practice creates noncompliance with more than one regulation. The instructions given to the state survey agencies instructs the surveyor to site the noncompliance with each requirement or OBRA Tag. If an investigative protocol for an OBRA Tag instructs the surveyor to also look at other requirements under other F Tags then the same violation may be cited for that OBRA Tag.

This Week Number 1089, October 7, 2005 reported on the CMS initiative to combine the existing 17 Quality Indicators (QI) with the 14 Quality Measures (QM). The QIs are used as a quality assurance tool and OBRA survey spotlight on potential problem areas and the QMs are used on the CMS consumer website, Nursing Home Compare. According to the newsletter, "Both systems are being combined resulting in 31 chronic care QI/QMs and 3 post-acute, short-stay QI/QMs. All the existing QMs are included. Where there were similar overlapping categories of QIs and QMs, the calculation method of the QMs was adopted and the QI eliminated, and where there was QI with no corresponding QM, the QI was adopted." These QI/QM reports are a very important part of the review process the survey team uses to pinpoint problems needing their focus during the survey process.

This Week Number 1071, June 3, 2005 and Number 1076, July 8, 2005 covered the CMS requirements for the use of a facility unique National Provider Identifier to be used in all billing

situations. The Council has been receiving calls regarding this issue because new Section W 1 of the Minimum Data Set asks for this number. There will be a transition period for the use of the NPI. Beginning May 23, 2007, all facilities will be required to have an NPI and the CMS system will only accept this number. This Week number 1071, June 3, 2005 gave instructions for facilities to follow to apply for a NPI and This Week Number 1076, July 8, 2005 gave the important transition dates.

The new Medicare Part D Drug program was reviewed in This Week Number 1079, July 29, 2005 and Number 1087, September 23, 2005. Residents who are dual eligible, both Medicare and Medicaid, shouldn’t see a big change in how their prescriptions are handled; however, private pay residents will have choices that will have to be made between November 15, 2005 and May 15, 2006. The Council will be having seminars on this important issue in the coming weeks. The seminars will be held at Lincolnwood and Oak Lawn on Tuesday, November 1^st and in Springfield on Thursday, November 3^rd.

In July IDPA received a new name. The office locations, mailing addresses and phone numbers remain the same, but the website changed to http://www.hfs.illinois.gov.

This Week Number 1081, August 12, 2005 reviewed the guidance to surveyors on medical directors. The new investigative protocol focuses on concerns or noncompliance that the facility failed to involve the medical director in the implementation of resident care policies and the coordination of medical care in the facility. This Week outlines the details of this new investigative protocol.

The Illinois Foundation, the quality initiative organization for Illinois, will be conducting two free seminars in the coming weeks. For information or to register contact the Nursing Home department of the IFQHC at 1-800-386-6431.

Approaches to Improving Your Quality Measures

Tuesday, November 8, 2005 8 a.m. – 12 p.m. OR 12 p.m. – 4 p.m.

Wyndham Hotel, Itasca, Illinois

Limit of two representatives per facility

Kathy Baker will discuss strategies for implementing change into the nursing home setting and IFQHC staff will highlight the benefits of target setting and introduce attendees to the Setting Targets-Achieving Results (STAR) CMS Web Site. Computers will be set up on site and quality improvement advisors will be on hand to provide assistance with the online target setting process.

Innovative Consultation Strategies

Tuesday, December 6, 2005 10 a.m. – 12 p.m.

IFQHC Offices in Oakbrook, Illinois

This free seminar is designed for LTC corporate consultants and independent consultants and will concentrate on target setting and the use of the STAR website.