Regulatory Reminder!

Well we are two weeks into a new year and there is no rest for the weary for sure. CMS has been busy and there have been several regulatory adjustments that have been announced to which we need to pay attention. This installment of Regulatory Reminders will focus on four updates that have been implemented rather quietly.


  1. Two weeks ago, CMS posted a revision to memo QSO-20-31-All that updated the criteria a facility may meet that could trigger a focused infection control survey. This is important in light of the 5-Star user’s Guide posted today which is addressed below. Among other things, CMS added 5, “criteria requiring states to conduct focused infection control surveys due to the increased availability of resources for the testing of residents and staff and factors related to the quality of care.” These new criteria are considered, “other factors that may place residents’ health and safety at risk.”

  • Multiple weeks with new COVID-19 cases;

  • Low staffing;

  • Selection as a Special Focus Facility per Section 1819(f)(8)(B) of the Social Security Act ;

  • Concerns related to conducting outbreak testing per CMS requirements; or

  • Allegations or complaints which pose a risk for harm or Immediate Jeopardy to the health or safety of residents which are related to certain areas, such a abuse or quality of care (e.g., pressure ulcers, weight loss, depression, decline in functioning).


The memo goes on to indicate that, “CMS will work with State Survey Agencies to identify facilities that meet the above criteria, and the FIC survey must start within 3-5 days of identification. State Survey Agencies are also encouraged to communicate with their State Healthcare Associated Infection coordinators prior to initiating these surveys.”


“Facilities that meet the criteria above to trigger an FIC survey do not need to be re-surveyed if a FIC survey was conducted (as a stand-alone FIC survey or as part of a recertification survey) within the previous three weeks. For example, if a facility is surveyed with a FIC survey within 3-5 days after meeting the criteria, and the same facility meets the criteria for being surveyed within 3-5 days in any of the next three weeks, the survey team does not need to conduct another survey within those three weeks. However, if the facility meets the criteria for a survey in the fourth week after a FIC survey was conducted, an additional FIC survey must be conducted within 3-5 days.”


CMS makes a special note related to these surveys indicating that, When conducting FIC surveys, long-term care (LTC) facility surveyors should be alert to, and investigate any concerns related to residents who have had a significant decline in their condition (e.g., weight loss, mobility) during the PHE.”


  1. Late in December 2020, CMS made changes to the ICD010 CM mapping associated with the PDPM clinical categories for PT and OT as well as NTA comorbidities. These changes were made with regard to new ICD-10-CM codes that the CMS and the CDC approved for certain conditions associated with COVID-19. These changes were noted in a CDC memo dated Dec. 3, 2020, with an effective date of January 1, 2021. The FY 2021 PDPM ICD-10 Mappings (ZIP) on CMS’ PDPM website have a effective date of 1/1/2021 and the update notes inside the mapping tool itself indicate an effective date of January 1st, 2021.


The CDC memo indicates that, “As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for reporting to include:

  • Encounter for screening for COVID-19 (Z11.52)

  • Contact with and (suspected) exposure to COVID-19 (Z20.822)

  • Personal history of COVID-19 (Z86.16)

  • Multisystem inflammatory syndrome (MIS) (M35.81)

  • Other specified systemic involvement of connective tissue (M35.89)

  • Pneumonia due to coronavirus disease 2019 (J12.82)


These new codes will be effective January 1, 2021 to identify conditions resulting from COVID-19. Full addenda information regarding the new codes and the final code titles will be published shortly.” In this memo, the CDC also referenced ICD-10-CM interim coding guidance relative to these coding updates. These updated guidelines may be found starting on page 28 of the linked document.


From the list of new codes, all but Multisystem inflammatory syndrome (MIS) (M35.81) and Other specified systemic involvement of connective tissue (M35.89) map to return to provider not to any clinical category. For M35.81 and M35.89. the following revisions apply.


  • ICD-10-CM code, (M35.8) Other specified systemic involvement of connective tissue, has been removed from both the clinical category Mapping and NTA comorbidities and replaced by M35.81 and M35.89.

  • These new codes map to Non-Surgical Orthopedic/Musculoskeletal for the PT and OT categories and Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies for the NTA category.


For Broad River customers, these revisions have been made to the PDPM navigator in both app stores as well as the web based version in BRRIT.


  1. Late last week on Jan. 7th, HHS Secretary Alex Azar extended the COVID-19 public health emergency that had been scheduled to expire on January 21st, the day after President-elect Joe Biden’s inauguration. The public health emergency will be renewed for 90 days unless the secretary declares the emergency to be ended before then. The text of the official announcement is below and may be found online at this link.


Renewal of Determination That A Public Health Emergency Exists

As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Alex M. Azar II, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective January 21, 2021, my January 31, 2020, determination, that I previously renewed on April 21, 2020 October 23, 2020, my January 31, 2020, determination, that I previously renewed on April 21, 2020, July 23, 2020, and October 2, 2020, that a public health emergency exists and has existed since January 27, 2020, nationwide.


  1. Just today, as promised, CMS quietly posted the much anticipated revision to the 5-Star user’s guide that validates the announcement it made in memo QSO 21-06-NH to restart all parts of the 5-Star rating system with the January 2021 update to Care Compare. Please refer to the BRR Blog posting where we detailed the impending revisions that have now found there way into the user’s guide. Thankfully, the revisions to the user’s guide posted today do not contain any revisions to the QM or staffing cut points etc., rather they generally only incorporate the language noted in the December memo throughout the text, in particular related to how the infection control surveys will affect the health inspection rating. However, there are three noteworthy clarifications that are worth mentioning here. It would be prudent for you to download a copy and have it handy for your own reference.


  • Clarification 1: As noted in the December memo, relative to how deficiencies cited on focused infection control surveys are treated, these findings will be included the same way findings from complaint inspections are used in the Five Star Quality Rating System. However, in the revised user’s guide posted today, CMS further clarified that they are treated slightly differently than regular complaint surveys. “If two or more infection control inspections cite the same deficiency within a 15-day period, all are included; however, if one or more of these deficiencies was also cited on a recertification survey and/or a complaint inspection within the same 15-day window, only the infection control citations are included. Points from complaint deficiencies and deficiencies cited on infection control surveys from a given period are added to the health inspection score before calculating revisit points, if applicable.”

  • Clarification 2: Related to the abuse icon, CMS added the following clarification, “The abuse icon (and the cap on the health inspection rating) will be removed as of the first monthly website refresh following when a nursing home no longer meets the abuse icon criteria.”

  • Clarification 3: Revised guidelines related to the staffing star relative to the ongoing COVID crisis, CMS has extended by one quarter the timeframe that facilities are allowed to not report certain staffing data and receive suppressed staffing stars rather that their staffing star being reduced to a one star rating. In the revised user’s guide posted today, CNS indicated, “Beginning with the January 2021 refresh, facilities that did not report staffing for the November 14, 2020 deadline or that reported four or more days in the quarter with no registered nurse will have their staffing ratings suppressed. Their staffing ratings will show “Not Available” with the January, February, and March refreshes. Starting with the April 2021 refresh of Care Compare, when staffing data submitted by the February 14, 2021 deadline will be reported and used for the five-star ratings, nursing homes that do not report staffing data for October – December 2020 or that report four or more days in the quarter with no registered nurse will have their staffing ratings reduced to one star.


Thank you everyone. I know this seems like a lot but, these seemed to be important reminders. I hope everyone has a great weekend. More Regulatory Reminders to come soon I’m sure.


Here’s to a new year full  of hope and promise!