Federal CMS (Centers for Medicare & Medicaid Services) Nursing Home Regulation Resources
Minnesota Department of Health Resources
Online Resources for Long Term Care Providers
Links to relevant sites for surveyors and providers.
CMS, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memo QSO-19-09: Revisions to Appendix Q, Guidance on Immediate Jeopardy
Surveyor Resources When an Immediate Jeopardy is Called in Accordance with QSO 19-09
Surveyor Guide to Calling an Immediate Jeopardy
Submitting a Removal Plan for Immediate Jeopardy
2017 Long-Term Care (LTC) Training Resources
Quality, Safety & Education Portal (QSEP) - LTC Survey Process SME Videos
This course consists of a series of videos created by CMS outlining essential topics related to changes in the LTC regulations scheduled to be implemented for Phase 2. CMS videos on guidance provide regions and states a resource that can be used for training and education with surveyors, providers, and other stakeholder groups.
- Admission, Transfer, Discharge
- Appendix PP-Overview of Revised Interpretive Guidance
- Behavioral Health
- Facility Assessment
- Freedom from Abuse, Neglect and Exploitation
- Infection Control
- Person-Centered Care
- Pharmacy Services
- Quality Assurance and Process Implementation Plan- The Basics
- Quality of Life and Quality of Care
- Nursing Services
PLEASE NOTE: More training videos to come, which will include the following areas: Comprehensive Person-Centered Care Planning, Physician Services, Lab/X-ray/Diagnostic, Dental, Food and Nutrition, Specialized Rehab, Administration, Physical Environment, Training, and additional videos on Resident Rights, Quality of Life, Quality of Care and Nursing Services.
Instructions for finding survey process videos on CMS website:
- Go to Quality, Safety & Education Portal (QSEP) website.
- Select I AM A PROVIDER.
- Select Course Catalog on top of task bar.
- In the search box, type “LTC Survey Process SME Videos.”
- Select course under Course Information.
- Select Launch the Course, select a SME video, wait for course to download. When complete, return to list of videos for additional training.
Quality, Safety & Education Portal (QSEP) - Overview of the New Long Term Care (LTC) Survey Process for LTC Providers
Provider training available on Quality, Safety & Education Portal (QSEP). This presentation provides an introduction to new regulatory reform, key changes to the survey process, the rationale behind the changes to the survey process, and the basic steps in the survey process that are important to the LTC Provider. The expected run time for this training is an hour.
MDH Provider, Surveyor, Investigator, Ombudsman Training
The 2017 Federal Nursing Home Regulations: A Person Centered Approach (PDF)
Hand in Hand Training Series
The updated Hand in Hand: A Training Series for Nursing Homes is now available on the CMS’s Integrated Surveyor Training Website (ISTW). Hand in Hand is available as a self-paced training as well as an instructor-led course and may be accessed using the links below. The self-paced training may take approximately 24 hours to complete.
Self-Paced Online Training: Quality, Safety & Education Portal (QSEP) - Hand in Hand: A Training Series for Nursing Homes Online
Downloadable Materials for Instructor-Led Training: Quality, Safety & Education Portal (QSEP) - Hand in Hand: A Training Series for Nursing Homes Download
This training focuses on caring for residents with dementia and on preventing abuse. CMS, supported by a team of training developers and subject matter experts, created this training to address the need for nurse aides’ in-service training on these important topics.
The Hand in Hand: A Training Series for Nursing Homes was previously developed as an instructor-led training conducted by nursing home staff for nurse aides. The Hand in Hand training will now be available as a self-paced, online training and available to download for use as an instructor-led course.
Federal law requires that nurse aides complete in-service training on dementia management and resident abuse prevention. Additionally, facilities must provide dementia management and resident abuse prevention training to all facility staff, (direct and indirect care and auxiliary functions) contractors, and volunteers.
Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities
This site provides additional vital information about the background and overview of the final rule, frequently asked questions and other related resources. Includes access to documents, forms and information regarding the new long-term care survey process. This site provides links to the current Appendix PP 03-08-2017 (Effective through November 27, 2017), Advance Appendix PP including Phase 2 (Effective November 28, 2017), List of revised F-tags, F-tags Crosswalk and other useful information.
It will be the responsibility of providers to check periodically for new information listed on the CMS Reform for Long-Term Care Facilities website. This website is subject to change by CMS.
CMS Survey and Certification (S&C) Memos
CMS Policy & Memos to States and Regions
Below are S&C memos related to emergency preparedness (S&C 17-29) and LTC regulations (S&C 17-19 and 17-36). CMS issues S&C memos weekly. It will be the responsibility of providers to check weekly for new information listed at the CMS S&C memo website.
- Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues (S&C: 17-36-NH) (PDF)
- Advanced Copy - Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures (S&C 17-29) (PDF)
- Revision to State Operations Manual (SOM) Appendix PP (S&C 17-19) (PDF)
November 22, 2017 CMS Transmittal: Revisions to State Operation Manual (SOM), Appendix PP Guidance to Surveyors for Long Term Care Facilities (PDF)
Federal Nursing Home Regulation Clarifications
- Crushing of Medications
- Director of Food and Nutrition Services clarification posted 4/2018
Question: Does the Minnesota Certified Food Manager course administered through the Minnesota Department of Health Environmental Health Division meet the federal nursing home regulatory requirement at §483.60(a)(2)(ii)?
Federal Data including Deficiency Citations
CMS Memo: Quality and Certification Oversight Reports (QCOR) Website Launch (PDF)
Quality and Certification Oversight Reports (QCOR) Website includes federal data, including deficiency data link for on-site inspections of providers and suppliers.
Emergency Preparedness Resources and Surveyor Tool
Dementia Care in Nursing Homes
Educational Resources and Optional Tools/Forms:
- National Partnership – Dementia Care Resources
- Pharmacy Review Forms:
Admit to Facility (PDF)
Facility Initiated (PDF)
Medication History (PDF)
- Physician Round Tool and Instructions
Letter from the Minnesota Partnership to Improve Dementia Care to Medical Directors, Physicians, Physician Extenders (PDF)
Quality, Safety & Education Portal (QSEP) - “Hand in Hand: A Training Series for Nursing Homes,” on Person-Centered Care of Persons with Dementia and Prevention of Abuse
Food and Drug Administration
Food and Drug Administration for Health Professionals
Publication provides information to healthcare professionals to enhance communication of new drug safety information, raise awareness of reported adverse events, and stimulate additional adverse event reporting.
Root Cause Analysis
Presentations: Updated July 2010
- Root Cause Analysis: Understanding the Regulatory Perspective (Powerpoint Presentation)
- Root Cause Analysis - The Process (PPT)
- Root Cause Analysis - Laying the Groundwork (PPT)
- Root Cause Analysis - Beginning the Investigation (PPT)
- Root Cause Analysis - Next Steps (PPT)
- Root Cause Analysis - What's in it for you? (PPT)
- Root Cause Analysis - Developing Action Plans (PPT)
- Case Study: Medication Error (PDF)
- RCA Tracking Tool Template (PDF)
- Long Term Care - Critical Event Review (CER): A Facilitated Process for Hutchinson Area Health Care (PDF) - Sample forms/worksheets
- Fall Investigation Tool (PDF) - Sample falls data collection tool
Minnesota Department of Health
Health Regulation Division
85 East Seventh Place, Suite 300
St. Paul, Minnesota 55101