CMS Posts Frequently Asked Questions about the SNF Validation Program

In the FY 2025 SNF Prospective Payment System (PPS) Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized a policy for Skilled Nursing Facilities (SNFs) who participate in the SNF Quality Reporting Program a validation (i.e., audit) process beginning in the fall of 2025 for the FY 2027 SNF QRP. This process is a similar one adopted for the SNF Value-Based Purchasing Program. 

Key components of the validation program include: 
  • CMS’ contractor Healthcare Management Solutions, LLC (HMS) will randomly select up to 1,500 SNF each FY to submit MDS records for review.  
  • Selected SNFs will be notified through their iQIES MDS 3.0 Provider Preview Report folder.  
  • Selected SNFs are required to submit requested medical chart documentation to support validation of 10 MDS assessment records.  
  • Any selected SNF that fails to submit requested medical chart documentation within 45 calendar days of the audit notification will be considered noncompliant, resulting in the SNF losing 2% of Medicare reimbursement for the applicable fiscal year. 
CMS has a webpage where additional information is available, including resource materials. This includes a Frequently Asked Questions document providing comprehensive information about the program. 
 
If after reviewing the available resources, you are still seeking additional information, you may contact the SNF Validation Help Desk at snfvalidation@hcmsllc.com.

Open Office Hours with CDC and SMEs

Do you have questions about infection prevention topics? Join the Centers for Disease Control and Prevention (CDC) Project Firstline, along with the National Infection Prevention Forum (NIPF) for monthly Open Office Hours on 7/24/2025. The CDC and NIPF’s Subject Matter Experts will review previously submitted questions along with live Q&A. While these sessions are open to all, they are geared for Infection Preventionists (IPs), giving them an opportunity to ask questions and connect with other IPs. 

 
Questions should be submitted​ in advance of the call by Friday 7/18/2025 at 1pm EST. Please note – these are not recorded sessions. 
 
July Open Office Hour Details: 
  • Topic: NIPF Office Hours 
  • Time: July 24,2025 at 1:00 PM Eastern Time (US and Canada) 
  • Meeting ID: 898 9181 4415 
  • Passcode: 804904 
Future dates and links will be posted on the NIPF Connect Community, which is open to all. If you are not a member, you may join here. 

GNP Faculty Dr. Joyce Black wins award.

Winning an award is usually enough of a surprise for the recipient. But for Joyce Black, PhD, one of her recent awards came with an extra element of surprise – it was named after her.

Dr. Black, a professor in the UNMC College of Nursing-Omaha Division, was named the inaugural winner of the National Pressure Injury Advisory Panel’s Joyce Black Award, at the organization’s annual conference in February. It is given to individuals or groups who have made significant contributions to advancing pressure injury evidence-based practice through educational initiatives.

Dr. Black was honored for “extraordinary efforts in disseminating evidence-based knowledge and her unwavering commitment to educational initiatives have set a high standard for excellence,” according to a release issued by the National Pressure Injury Advisory Panel.

Not only did Dr. Black not know she was up for the award, she didn’t even know it existed until the awards ceremony at the organization’s conference.

“They started talking about a new award and how they named it for me because of all the teaching I had done,” she said. “I was just sitting in the audience, looking at who would be a good person for the award, and the next thing I heard was they were giving to the person it was named for.

“I was so flattered to get an award in my name. I didn’t see that coming at all.”

While it was unexpected, Dr. Black said she’s excited about the new tradition and the chance to hand it off to the next winner.

“The next time this is given out, I’ll be the person handing it to someone else,” she said. “That means they’re an excellent teacher.

“I’m already thinking about the next award winners in my head.”

OSHA Releases Several Proposed Rules

The Occupational Safety and Health Administration (OSHA) this week released several proposed rules on the Federal Register. The proposed rules appear to have a direct impact on long term care and include the following:  

  1. Federal Register: Occupational Exposure to COVID-19 in Healthcare Settings 
    • ​OSHA is proposing to remove OSHA’s COVID-19 Emergency Temporary Standard and its associated recordkeeping and reporting provisions from the Code of Federal Regulations. 
    • ​OSHA proposes to clarify its interpretation of the General Duty Clause, 29 U.S.C. 654(a)(1), to exclude from enforcement known hazards that are inherent and inseparable from the core nature of a professional activity or performance. 
    • ​OSHA is proposing to remove some medical evaluation requirements in the Respiratory Protection Rule for certain types of respirators. This proposed change would only impact filtering facepiece respirators and loose-fitting powered air-purifying respirators. 
An additional proposed rule was withdrawn: 
    • ​​​OSHA is withdrawing the proposal to amend the OSHA 300 Log by adding a column that employers would use to record work-related musculoskeletal disorders. Withdrawal of the proposal does not change any employer’s obligation to complete and retain occupational injury and illness records under OSHA’s regulations. Withdrawal of the proposal also does not change the recording criteria or definitions used for these records. 
Please send any questions to regulatory@ahca.org. AHCA will submit comments to the Federal Register.

Last Chance to Order Free CDC Print Materials!

The Centers for Disease Control and Prevention Publications on Demand service is ending. As part of the ongoing commitment to quality care and safety, now is the time to stock up on these free, print resources before they’re gone for good.
After September 2025, the CDC will no longer offer print materials through the CDC Publications on Demand service, and supplies will not be restocked. Facilities are encouraged to order large quantities now to support future trainings, infection prevention campaigns, and regulatory readiness.
What’s Available? 
CDC materials are perfect for augmenting your existing programs—whether you’re focusing on:
  • Antibiotic Stewardship (ASP) 
  • Hand Hygiene 
  • Sharps Safety 
  • Sepsis Prevention 
  • Dialysis Safety 
  • C. Difficile Infection Prevention 

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Why Orientation and Ongoing Training Matter for Reducing Turnover.

Onboarding isn’t just a checklist of HR paperwork and a quick tour of the building. It’s the first impression new employees get of the organization’s culture, and it can set the tone for whether they stay or leave. Research indicates that 69 percent of employees are more likely to remain with a company for at least three years if they experience a positive onboarding process.

Read the complete article at https://www.providermagazine.com/Articles/Pages/Why-Orientation-and-Ongoing-Training-Matter-for-Reducing-Turnover.aspx

 

What You Can Do to Prepare for a Data Incident.

While long term care and senior living organizations may not be able to prevent a data incident, there are many steps an organization can take to prepare.

Read the full article at https://www.providermagazine.com/Articles/Pages/What-You-Can-Do-to-Prepare-for-a-Data-Incident.aspx

New Quality in Focus Videos Available

The Centers for Medicare and Medicaid Services (CMS) recently added four new Quality in Focus (QIF) videos to its Quality, Safety & Education Portal (QSEP). The video modules address commonly cited deficiencies in long term care related to food safety requirements, infection prevention and control, and developing a plan of Correction. These videos are available on demand, 24/7.
To access the videos, log into QSEP, then select the ‘Quality in Focus’ tab to access the newest videos and others in the series. For all technical issues and those requiring an urgent response, such as accessing the training, email helpdesk@qsep.org. For all content-related questions, email QSOG_GeneralInquiries@cms.hhs.gov​.  ​

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CMS Posts Updated Draft MDS 3.0 Item Sets

The Centers for Medicare and Medicaid Services (CMS) recently posted an updated version of the draft Minimum Data Set (MDS) 3.0 Item Sets v1.20.1v3 and draft Item Matrix v1.20.1v3. These are located in the Downloads section on CMS’ Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Of note, CMS removed Section R from these documents.
This version of the MDS item sets does not include items R0310. Living Situation, R0320. Food, R0330. Utilities. It also replaces item R0340. Transportation with item A1255. Transportation.
The final MDS item sets v1.20.1 will be posted in late summer, depending on the decisions finalized in rulemaking. The SNF PPS Proposed Rule is available here​.

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Monitoring Resident-Owned Electronics for Compliance

Long term care facilities have numerous responsibilities when it comes to building components, systems, and equipment. Among these, ensuring the safety of resident-owned electronics is an important consideration. NFPA 99 (The Health Care Facilities Code®) provides clear guidelines for patient care-related electrical equipment (PCREE), but it also includes provisions for visually inspecting all nonpatient care-related electrical devices, including those owned by residents. This encompasses everyday items such as cell phones, chargers, tablets, radios, and alarm clocks, helping maintain a safe environment for everyone.
A comprehensive policy that addresses the inspection of resident owned electronics will include inspection frequency, who conducts the inspection, and inspection criteria. NFPA 99 does not specify any of these items, nor does it include a specific inspection checklist. Some general best practices include inspecting for issues such as frayed cords, cracked casings, damaged plugs, and loose wires. The inspection is essentially focused on identifying any items indicative of an unsafe condition.
Electronics that do not have grounding conductors (three prong plug) are generally not permitted in resident areas unless they are double insulated. A device that is double insulated is identified by a double square symbol on the device itself, as seen in the images below.
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In addition to having a policy, facilities should have a mechanism to inform residents, families, and responsible parties of the process for inspecting such items. While a visual inspection most commonly occurs at the time of resident admission, electronics that are introduced to the facility at other times must also go through the inspection process. Establishing that expectation and clarifying the process at the time of admission can help maintain compliance thereafter.
One newer area to monitor is the introduction of items that include integrated charging ports and/or electrical outlets. These are becoming more common in items such as table lamps and even lounge chairs. Having an integrated USB charger should not be an issue since USB operates under low voltage. However, where there is an integrated traditional electrical outlet, it could be a concern. A surveyor could interpret the device to be similar to a power strip which could mean the requirements for relocatable power taps apply.  These would be restrictive and likely limit the use of such items in a resident room or care area.
Ensuring life safety compliance is an important responsibility, and while it can be complex, having the right resources makes the process more manageable. A great starting point is obtaining a copy of the applicable codes and standards. The 2012 editions of both NFPA 101 and NFPA 99, along with all referenced codes and standards, are available for access and purchase at the National Fire Protection Association’s (NFPA) website (www.nfpa.org). For additional support from AHCA/NCAL, please reach out via email at emergencyprep@ahca.org.