Our office regularly receives urgent calls from providers in crisis.  We are in the business of coming alongside nursing facilities to shoulder a portion of the burden, drive corrective actions and assist to remedy problem situations. Given the choice and resources, our clients and consulting team would agree that preemptively addressing potential risks is preferred to putting out a fire.  With that in mind, this week’s blog examines the top 5 actions I would take in the coming quarter if I were your Compliance Officer.

1.) Conduct an audit of your facility NHSN reporting data accuracy with an emphasis on facility COVID-related deaths. Keep in mind that the important difference for when to report the death of a resident is contingent upon if that resident was transferred or discharged. If a COVID positive resident is transferred to another facility, the originating facility is responsible for following that resident and reporting the death if that were to occur.  There is not a time limit on the facility’s responsibility to continue following a resident– the originating facility will need to do so until the resident is officially discharged from that facility. When the resident is officially discharged from the facility (not expected to return), then it is no longer the responsibility of the originating facility to follow the resident status and report the death.

Here are some sample scenarios:

A resident develops COVID-19 in Assisted Living (AL) and is transferred to the nursing home’s COVID unit for COVID care, with the expectation that the resident will return to AL following COVID treatment, but the resident dies from COVID in the nursing home.

The nursing home is NOT responsible for reporting the death if the resident has not been officially discharged from the Assisted Living facility

A resident who is admitted to the nursing home from the hospital with COVID prior to facility admission dies from COVID in the nursing home

If a resident is admitted to your facility and they have had a positive COVID-19 viral test result, had signs and/or symptoms of COVID-19 as defined by the CDC, were on transmission-based precautions for COVID-19, or who died from ongoing complications related to a previous COVID-19 infection this will need to be reported in the COVID-19 death count for the facility.

Death of a resident who tested positive during 14-day quarantine period following admission to facility If a resident is admitted to your facility and they have had a positive COVID-19 viral test result, had signs and/or symptoms of COVID-19 as defined by the CDC, were on transmission-based precautions for COVID-19, or who died from complications related to a COVID-19 infection this will need to be reported in the COVID-19 death count for the facility.  

In addition, NHSN does not differentiate between hospital acquired COVID-19 and non-hospital acquired COVID-19 for the LTCF COVID-19 module. The module is a platform to report test results. For COVID-admissions, a newly admitted patient who is known to have COVID would be counted in this category. Otherwise, if a patient tests positive for COVID-19, then this is documented in the category “Positive Tests.” If a test is performed in your facility, and the results are positive, you will need to record these results in the covid-19 module. This applies regardless of how long the resident has been in your facility. All positive tests must be reported to NHSN. Should you find errors in prior reporting, contact the help desk at  nhsn@cdc.gov for guidance on submitting corrections.

2.) Assess compliance with receipt and use of Provider Relief Funds in preparation for the expected scrutiny of pandemic related CARES Act funding. A COVID-19 Fraud Enforcement Task Force was announced in May 2021 to drive enforcement efforts in response to pandemic fraud. Healthcare providers should consider focusing compliance program efforts on (1) ensuring reporting deadlines are met depending on the date COVID-19 related funds were received and on (2) compliance with allowable uses of funds.  Reporting Period 2 closes March 31, 2022 for providers who received one or more general and/or targeted PRF payments exceeding $10,000 in the aggregate from 7/1/20-12/31/20. Reporting period 3 opens on July 1, 2022.  Access detailed PRF reporting requirements  and PRF Reporting Non-Compliance Fact Sheet

3.) Prioritize chart audit activities in the following areas:

      • Care plan reviews to ensure that all relevant conditions are effectively addressed, interventions are appropriate and person-centered, and that care plan updates are completed as necessary in response to accidents/incidents, clinical changes, new risks, etc.
      • MDS coding accuracy for appropriate reimbursement by government payers. Consider registering your MDS team for the upcoming 8-week webinar series beginning May 4 which focuses on avoiding top MDS errors and missed opportunities and ensuring QM accuracy.
      • Compliant application and supportive documentation of Part A SNF PPS related waivers which relaxed requirements for a 3-day qualifying stay and skilled benefit period during the Public Health Emergency. Recent medical review activity has focused on supportive documentation that clearly demonstrates that care meets waiver requirements and that SNF level of skilled care was medically necessary.

4.) Review the current QAPI work plan and consult with QAPI leadership on recent and planned Performance Improvement Projects (PIPs). Have QAPI efforts addressed these priority areas? (1) QM opportunities (2) Infection Prevention Program (3) Survey preparedness and deficiencies (4) Abuse prevention and reporting (5) Professional liability claims activity (consider reviewing the recent CNA Aging Services Claim Report 11th ed. for a snapshot summary of top industry exposure risks from 2018-2020.) (6) Staffing issues with consideration of potential minimum staffing requirements proposed by the Biden Administration, promoting optimal staffing levels during the current nursing staff shortage, re-assessing essential duties of nursing staff and considering opportunities for non-clinical support staff assistance, cross training back up personnel for critical roles such as MDS and Infection Preventionist, and updating the facility assessment as needed in response to significant changes in census to reflect the current population

5.) Prioritize conducting a cybersecurity risk assessment in light of escalating cybersecurity threats and consider these gap-stop measures (1) patch vulnerable software that may be exploited as a point of entry to your system (2) change passwords across your network (3) create multiple back ups of your data to prepare to bounce back from potential ransomware attacks (4) require multi-factor authentication wherever you can (5) educate staff on common threats and when to report a problem such as a computer that is running slowly, or behaving in an unusual manner.

It’s easy to become overwhelmed with the many challenges providers continue to face, but framing a plan that prioritizes actions for addressing the most critical risks is a good place to start. Contact Proactive for help in carrying out your compliance work plan activities.



Amie Martin OTR/L, CHC, RAC-CT, MJ

Learn more about the rest of the Proactive team.