• CDC - Influenza Outbreak Management in Long-Term Care Facilities

    Thursday January 5, 2012

    Influenza can spread quickly and have serious consequences in long-term care facilities, putting residents - especially those with certain medical conditions at greater risk of developing complications like pneumonia and bronchitis. The flu also can make chronic health problems worse and may result in hospitalization and sometimes even death.

    The January 6, 2012 Morbidity and Mortality Weekly Report includes a report that highlights the importance of having and following an influenza outbreak management strategy.

    CDC has posted consolidated influenza outbreak management guidance for long-term care facilities at: www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm

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  • Federal Requirements for the IDR Process

    Wednesday January 4, 2012

    Federal Requirements for the Independent Informal Dispute Resolution Process

    New regulations have been added at 42 CFR, Sections 488.331 and 488.431 as required under section 6111 of the Patient Protection and Affordable Care Act of 2010 enacted on March 23, 2010. This memorandum provides interim advanced guidance regarding the Federal requirements for the Independent IDR Process for nursing homes.

    The Centers for Medicare & Medicaid Services (CMS) is in the process of updating the SOM to reflect the new regulations found at 42 CFR Sections 488.331 and 488.431. An advance copy of the interim guidance is attached to the memorandum.

    IDR S&C Letter Dec 2011

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  • Medicare S&C Budget FY 2012

    Wednesday January 4, 2012

    CMS Issues New Guidance for 2012 Medicare S&C Budget

    The Centers for Medicare and Medicaid services (CMS) issued a new S&C memorandum on December 9, 2011 related to the Survey and Certification Budget for Physical Year 2012. The memorandum states that CMS is exploring methods to increase the focus on certain high priority areas. To make possible such increased focus and to accommodate the budget constraints, they are examining ways to reduce surveyor time in areas of lower risk. Particular areas in which they seek to increase the focus include:

    • Poorly Performing Nursing Homes
    • Inappropriate Anti-Psychotic Use
    • Avoidable Falls

      The effective date of this material is January 1, 2012.  

    For more details see attached memorandum.

    FY 2012 Medicare S&C Budget

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  • Smoking Safety in Long Term Care

    Wednesday January 4, 2012

    Smoking Safety in Long Term Care

    The Centers for Medicare and Medicaid Services (CMS) issued a Survey & Certification (S&C) Memorandum November 10, 2011 reminding both surveyors and facilities of the importance of smoking safety for residents who smoke. The S&C memo reviews some of the information contained in the Surveyor Guidance for F323 - Accidents & Supervision.

    Smoking Safety in Long Term Care

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  • Dining Practice Standards 2011

    Wednesday January 4, 2012

    Pioneer Network Announces New Dining Practices Standards 

    The Pioneer Network announced that its Food and Dining Clinical Standards Task Force: A Rothschild Regulatory Task Force has finalized new Dining Practice Standards agreed to by twelve national clinical standard-setting associations. These nationally agreed upon new food and dining standards of practice support individualized care and self-directed living versus traditional diagnosis-focused treatment for people living in nursing home. The New Dining Practice Standards document reflects evidence-based research available to-date as well as current thinking.

    The Pioneer Network stated that the importance of these new agreed upon clinical standards cannot be overstated as food and dining are an integral part of individualized care and self-directed living for people living in nursing homes.

    Pioneer Network plans to submit the new Dining Practice Standards to CMS, FDA, CDC and the long-term care community at large.  It is anticipated that CMS will refer to these new agreed-upon standards of practice within long term care interpretive guidance where they fit as CMS usually refers to the current standards of practice set by the clinicians who work within the long term care field. It is the goal of the Task Force that surveyors, clinicians and interdisciplinary team members will put these new standards into practice in order to continue their efforts to improve quality of life for those living in nursing homes across the country.

    New Dining Practice Standards 8-26-11

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  • OSHA Press Release 2011

    Wednesday January 4, 2012

    OSHA to Focus on Nursing Home

    The Occupational Safety and Health Administration will soon launch the National Emphasis Program on Nursing Homes and Residential Care Facilities. This is in response to what OSHA sees as higher than average incidents of occupational injuries and illnesses among health care support workers. Through this initiative, they will increase inspections of these facilities, focusing on back injuries from resident handling or lifting patients; exposure to bloodborne pathogens and other infectious diseases; workplace violence; and slips, trips and falls.

    See OSHA Press Release 2011 for more details.  

    OSHA Publishes New and Updated Materials on Worker Safety and Health

    The Occupational Safety and Health Administration (OSHA) recently published new and updated educational brochures on a number of topics including workers' rights, employers' rights following an OSHA inspection, as well as how to protect workers from hazards in the construction, general and maritime industries. OSHA's Worker' Rights booklet describes the rights to which workers are legally entitled under the Occupational Safety and Health Act. The booklet, Employer Rights and Responsibilities Following an OSHA Inspection, reviews what happens after an inspection and is provided to employers during an OSHA inspection. The agency also recently published an updated Construction Industry Digest, and a new Small Entity Compliance Guide for Respiratory Protection Standard, Laboratory Safety Guidance, a series of new QuickCards and new publications to help protect construction, general industry and shipyard workers. Please call 1-800-321-OSHA or (202) 693-1999 to order copies or visit OSHA's Publications page: http://www.osha.gov/pls/publications/publication.AthruZ?pType=AthruZ)  to order online.

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  • Outbreak of Contagious Disease or Condition Among Assisted Living Residents

    Monday February 27, 2012

    Once an outbreak has been identified, it is important the facility take the appropriate steps to contain it. State, local and county health departments offer guidance and regulations regarding responding to and reporting outbreaks.  This information is often received in advance of an outbreak and included in the infection prevention and control program. Plans for containing outbreaks usually include efforts to prevent further transmission of the infection while considering the need of all residents and staff.

    We suggest that you review the Regulations in Assisted Living and Specialty Care Assisted Livings to ensure Regulatory Compliance. This information can be found in: Alabama Assisted Living Rules and Regulations 420-5-4-.05 Records and Reports andAlabama Specialty Care Assisted Living Rules and Regulations 420-5-20-.05 Records and Reports.

    It is important that all infection prevention and control practice reflect current Centers for Disease Control guidelines.

    Each facility should refer to their specificState:

    • Rules and Regulations; and
    • State and local health departments for reporting guidelines and recommendations.
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  • Infection Control and the Norovirus

    Monday February 27, 2012

    Due to the recent reported cases of the Norovirus in nursing homes and assisted living facilities it is important that we remember what the facility's role and responsibility is regarding infection control.

    Under the guidance for Surveyors in the State Operations Manual, F-441Infection Control, states; Recognizing and Containing Outbreaks An outbreak is typically one or more of the following:

    • One case of an infection that is highly communicable;
    • Trends that are 10% higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or
    • Occurrence of three or more cases of the same infection over a specified length of time on the same unit or other defined areas. 

    Once an outbreak has been identified, it is important the facility take the appropriate steps to contain it.  State health departments offer guidance and regulations regarding responding to and reporting outbreaks.  This information is often received in advance of an outbreak and included in the infection prevention and control program. Plans for containing outbreaks usually include efforts to prevent further transmission of the infection while considering the need of all residents and staff.

    It is important that all infection prevention and control practice reflect current Centers for Disease Controlguidelines.

    Component of an infection Prevention and Control Program

    • Policies and procedures
    • Infection Preventionist
    • Surveillance( process and outcome)
    •  Documentation
    • Monitoring
    • Data Analysis
    • Communicable Disease Reporting
    • Education
    • Antibiotic Review

    Facilities should review the complete guidance under CFR §483.65 Infection Control F441 for more details.

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  • HHS Announces Intent to Delay ICD-10 Compliance Date

    Tuesday February 21, 2012

    As part of President Obama's commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10). 

    The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 - a delay of two years from the compliance date initially specified in the 2008 proposed rule.  HHS will announce a new compliance date moving forward.

    "ICD-10 codes are important to many positive improvements in our health care system," said HHS Secretary Kathleen Sebelius.  "We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system."

    ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10.  Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

    All HHS press releases, fact sheets and other press materials are available at: http://www.hhs.gov/news.

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  • Norovirus Update

    Tuesday February 21, 2012

    Healthcare facilities, including nursing homes and hospitals, are the most commonly reported settings for norovirus outbreaks in the United States. The virus can be introduced into healthcare facilities by infected patients/residents--who may or may not be showing symptoms--or by staff, visitors, or contaminated food products. Outbreaks in these settings can be quite long-sometimes lasting months-and illness can be more severe, occasionally even fatal, in hospitalized or nursing home patients than for otherwise healthy persons.

    Noroviruses are responsible for about half of all reported outbreaks of gastroenteritis (vomiting, diarrhea, and stomach cramping caused by inflammation of the stomach and intestines). While the vast majority of norovirus illnesses are not part of a recognized cluster, outbreaks provide important information on how the virus is spread and, therefore, how best to prevent infection.  Norovirus outbreaks occur throughout the year, but over 80% of them occur during November-April. In addition, norovirus outbreaks tend to increase periodically when new strains of the virus appear. The virus can be spread through food, water, by touching things that have the virus on them, as well as directly from person to person. There is no long-lasting immunity to norovirus; thus, outbreaks can affect people of all ages and in a variety of settings

    Due to the recently reported outbreaks of the norovirus in Long Term Care and Assisted Living facilities we have attached several CDC norovirus related documents.

    For more information we encourage you to visit the CDC web site at: http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm

    Norovirus-Guideline for Healthcare Settings-2011

    Norovirus Worksheet

    Norovirus Poster

    Norovirus Comm Framework

    Norovirus Case Fact Sheet

    NoroVirus-Management of Outbreaks in Healthcare Settings

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  • Centers for Medicare and Medicaid Services is Considering Extending its Timeline for ICD-10 Code Conversion Compliance

    Wednesday February 15, 2012

    Healthcare providers could get some regulatory deadline relief soon. The acting head of the Centers for Medicare and Medicaid Services said today the agency is considering extending its timeline for ICD-10 code conversion compliance.

    Under current ICD-10 rules, healthcare providers, payers, and others have until Oct. 1, 2013 to switch over their claims, billing, and other systems from current ICD-9 to ICD-10 codes for medical diagnosis and inpatient procedures. The transition from ICD-9 to ICD-10 involves expanding medical diagnosis codes from the current 14,000 to more than 67,000, and procedure codes from 13,000 to 85,000.

    Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services, told a conference of the American Medical Association (AMA) that her agency could delay adoption of the ICD-10 system. Current law calls for physicians to adopt the new codes next year.

    "I'm committing today to work with you to re-examine the pace at which we implement ICD-10," she said to loud applause. "I want to work together to ensure that we implement ICD-10 in a way that [meets its] goals while recognizing your concerns."

    Critics - including the AMA - say switching to ICD-10 coding will require doctors' offices to deal with some 68,000 codes, more than five times the current 13,000. The change, according to the AMA, would cost medical practices anywhere between $83,290 and more than $2.7 million, depending on size.

    Speaking to reporters after her prepared remarks, Tavenner said her office would formally announce its intention to craft new regulations "within the next few days."

    LTC Provider University will provide updates when they become available.

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  • CMS Allows Physician Assistants to Perform SNF Level of Care Certification and Recertifications

    Monday February 13, 2012

    On January 13, 2012 CMS published a pair of transmittals that revise Chapter 8, section 40.1 of the Medicare Benefit Policy Manual to add physician assistants to the list of practitioners that can perform the required initial certification and periodic recertifications of the need for skilled nursing facility (SNF) level of care. 

    On January 13, 2012 CMS   issued Transmittal 153, entitled -"Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications".  The transmittal provides guidance on the ability of physician assistants to perform level of care certifications and recertifications in skilled nursing facilities. The guidance implements Section 3108 of the Affordable Care Act.  According the guidance, a physician assistant may now perform the certification or recertification if the physician assistant collaborates with the physician but does not have a direct or indirect employment relationship with the facility.  


    Please review the following two attachments for details.

    Physician Assistants January 13, 2012

    Physician Assistants Flyer


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  • CMS Updates Information Related To Reporting Reasonable Suspicion of a Crime

    Monday February 13, 2012

    The Centers for Medicare and Medicaid Services (CMS) has recently issued an updated S&C memo on reporting the reasonable suspicion of a crime.

    This memorandum informs SAs of the new section 1150B of the Act, which was established by section 6703(b)(3) of the Affordable Care Act and is entitled "Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities." In order to promote timely application of the protections offered by section 1150B of the Act for LTC facility residents, CMS is explaining now the current obligations of LTC facilities to comply with the law as it is plainly written, without any delay that might be occasioned by waiting for any administrative rule-making process that might further clarify application of the law.

    The updates appear in the Definitions and Questions and Answers sections.

    In the definitions, the terms "agent" and "contractor" are further defined in Appendix One. These definitions will assist providers in determining who is included in "covered individuals."  

    In the Q&A section of the memo, additional clarity is provided regarding the role of the facility in reporting the suspicion of a crime. It should be noted that this memo specifically states that a facility may report of a reasonable suspicion of a crime directly to the state survey agency and law enforcement on behalf of covered individuals. Additionally, the Q&A section provides clarity about the impact of this requirement on ICFs/MR.  

    Please see the attached S&C letter for more detailed information.

    Reporting Suspicion of Crime 20Jan2012 update

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  • How to Protect Your Facility by Having Third Party Contracts in Place

    Friday March 16, 2012

    According to F500, if the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement, agreement or contract.  The arrangement, agreement, etc. pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility and the timeliness of the services. 

    Therefore the facility is required to have contracts with all third party vendors that provide contract services.  Contracts should include at a minimum:

    •  Clarification of services/scope of work
    • Timeliness of the services
    • Payment arrangements of the services/compensation
    • Clarification of reporting/documentation requirements, if applicable
    • Staff training requirements, screening, licensure, etc., if applicable
    • Contract terms
    • Period of agreement
    • Termination of agreement

    From the risk management perspective, the following terms should be included in the contract: 

    • Independent Contractor provision - this agreement clarifies that the contractor is not a facility employee and therefore not subject to the facility's worker's compensation benefits or professional liability insurance coverage. 
    • Hold Harmless/Indemnification provision - this agreement clarifies that one or both parties agree to not hold the other responsible for damages.  This agreement indemnifies one or both parties by agreeing to not hold the other responsible for any legal liability or looses as a result of a specified incident or action. 
    • Insurance coverage by both parties - this clause states that each entity will carry their own general/professional liability insurance. This provision without a hold harmless/indemnification clause is only helpful if both the facility and the 3rd party contractor are co-defendants. In other words, if the 3rd party contractor is not a party to a claim against the facility, the 3rd party contractor's liability insurance will not hold harmless or indemnify the facility.

    In the event an incident/event occurs in which a vendor employee is involved and a claim arises, the outcome may depend upon the terms of the contract. 

    The facility may want to consult with Corporate Counsel on the appropriate wording for contracts.

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  • Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response During Disasters

    Wednesday April 25, 2012

    Federal regulations require that Medicare and Medicaid certified nursing homes have written emergency plans and provide employees with emergency preparedness training. In a 2006 report about nursing homes that experienced hurricanes, the Office of Inspector General (OIG) found that emergency plans lacked many provisions recommended by experts. In response, CMS issued guidance checklists for emergency planning of health care facilities, long-term care (LTC) ombudsman programs, and State survey agencies (SA). The OIG conducted this study released April 2012 to assess emergency preparedness and response of nursing homes that experienced more recent disasters.

    For this study, the OIG analyzed national survey data to determine compliance with Federal regulations. They also conducted site visits to 24 selected nursing homes that experienced floods, hurricanes, and wildfires in 2007-2010. They interviewed nursing home administrators and staff, local emergency managers, and representatives from State LTC ombudsman programs and SAs. They also compared the emergency plans of each selected nursing home to the CMS checklist for health care facilities.

    The OIG found that most nursing homes nationwide met Federal requirements for written emergency plans and preparedness training. However, they identified many of the same gaps in nursing home preparedness and response that were found in the 2006 report. Emergency plans lacked relevant information including only about half of the tasks on the CMS checklist. Nursing homes faced challenges with unreliable transportation contracts, lack of collaboration with local emergency management, and residents who developed health problems. LTC ombudsmen were often unable to support nursing home residents during disasters; most had no contact with residents until after the disasters. SAs reported making some efforts to assist nursing homes during disasters, mostly related to nursing home compliance issues and ad hoc needs.

    The OIG made three recommendations to CMS and one recommendation to Administration on Aging (AoA). CMS agreed with their recommendations to revise Federal regulations to include specific requirements for emergency plans and training, update the State Operations Manual to provide detailed guidance for SAs on nursing home compliance with emergency plans and training, and promote use of the checklists. AoA also agreed with their recommendation to develop model policies and procedures for LTC ombudsmen to protect residents during and after disasters.

    The top 10 disaster prone states, as ranked by historical statistics on disaster declarations are Texas, California, Oklahoma, New York, Florida, Louisiana, Alabama, Kentucky, Arkansas and Missouri.

    Sources: Department HHS Office of Inspector General; CMS; Long Term Care Ombudsman

    The National Long Term Care Ombudsman Resource Center link: http://www.ltcombudsman.org/issues/emergency-preparedness

    Office of Inspector General April 2012 Report:

    Nursing Home Emergency Preparedness and Response Report 2012

    OIG Memo to CMS April 13, 2012:

    OIG Emergency Memo April 13-2012

    CMS Emergency Preparedness Checklist:

    CMS Emergency Preparedness for Every Emergency checklist revised Sept 2009

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  • Pain vs. Behaviors

    Monday April 23, 2012

    It has been recently noted after review of numerous medical records a common trend has been identified.  Residents with impaired cognition are exhibiting behaviors i.e. screaming out, resisting care, removing clothes etc.  The residents are being assessed for behavioral interventions and some resident are being placed on psychoactive medications while pain is the cause of the resident's behaviors. Residents were not consistently assessed for pain during the behavioral assessment phase to rule out pain.  Facilities may want to review current systems and processes to ensure there is an evaluation of the resident for pain with the onset and/or increase in behaviors.   This will also help in the prevention of unnecessary drugs.  See article below.

    Management of Pain In Persons With Dementia  

    Pain is a common medical condition in older persons; especially residents in long term care (LTC) settings. Pain is defined as a sensory and emotional experience associated with actual or potential tissue damage. Chronic persistent pain occurs in 24% of LTC residents while only 29% are free of all pain. Most, i.e., 74%, demented nursing home residents have some pain and the majorities, i.e., 70%, are untreated or under-treated.

    Pain can have multiple origins; however, discomfort produced by musculoskeletal disease is the most common problem in the older person, e.g., arthritis 42%, bone fracture 12%. Untreated or under-treated pain can produce significant suffering as well as agitation and behavioral problems in persons with dementia. Regular administration of acetaminophen can reduce agitation in more than one-half of agitated, demented patients with pain.  

    Assessment and management of pain is an important responsibility of any clinical management team. Dementia patients are less likely to receive analgesics despite the fact that they experience suffering equal to cognitively intact individuals.  

    Source: Richard E. Powers, MD (2008) - Bureau of Geriatric Psychiatryhttp://www.alzbrain.org/

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  • Employee Rights Notice Posting

    Monday April 23, 2012

    April 30, 2012 is the new deadline for nearly all nursing facilities and assisted living communities to display posters informing employees of their rights under the National Labor Relations Act (NLRA), according to the National Labor Relations Board.  The notice should be posted in a conspicuous place, where other notifications of workplace rights and employer rules and policies are posted. Employers also should publish a link to the notice on an internal or external websites if other personnel policies or workplace notices are posted there.                         

    You may download and print the notice using the links below. You may also call 202-273-0064 and copies will be mailed to you free of charge.


    The poster is required to be 11 x 17 inches, in color or black-and-white. When printing to full size, be sure to set your printer output to 11 x 17. Or you may print the two 8.5 x 11 pages and tape them together.

    English Posters

    English Employee Rights Poster 11 x 17  English Employee Rights Poster 8-5 x 11

    Spanish Posters

    Spanish Employee Rights Poster 11 x 17

    Spanish Employee Rights Poster 8-5 x 11

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  • National Plan to Address Alzheimer’s Disease

    Wednesday April 11, 2012

    On January 4, 2011, President Barack Obama signed into law the National Alzheimer's Project Act (NAPA), requiring the Secretary of the U.S. Department of Health and Human Services (HHS) to establish the National Alzheimer's Project. The law also establishes the Advisory Council on Alzheimer's Research, Care, and Services and requires the Secretary of HHS, in collaboration with the Advisory Council, to create and maintain a national plan to overcome Alzheimer's disease (AD).

    Building on the preliminary work on this plan, on February 7, 2012, the Obama Administration announced a historic $156 million investment to tackle Alzheimer's disease.

    The draft of the National Plan is being submitted to the Advisory Council for consideration and input. It was also be open for public comment through March 30, 2012.

    To read the draft in its entirety click on the following link:

    Draft National Alzheimer's Plan 2012

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  • NCCAP National Examination

    Monday April 9, 2012

    The National Certification Council of Activity Professionals has implemented an examination that all NEW applicants must complete in order to apply for national certification at the ADC or ACC level(s) effective January 1, 2012. Please note that is will not affect those individuals already certified at any level with NCCAP prior to December 31, 2011.

    The test consists of questions from the nine topic areas and the 163 competencies defined in the MEPAP curriculum. Completion of the Modular Education Program for Activity Professionals, 2nd Edition will prepare the applicant for the exam. There will be 50 questions on the test and applicants will have one (1) hour to complete the test. Applicants must make a 70% to pass the exam. Comira and ACT testing centers will administer the examination and they are located throughout the United States and Canada.

    For additional information regarding the new testing policy and procedure please contact the NCCAP office or visit their web site at www.nccap.org

    Source: National Certification Council for Activity Professionals

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  • Disparities/Minority Health: Lower flu vaccination rates for black nursing home residents a cause for concern

    Monday April 9, 2012

    The average flu vaccination rate among nursing home residents nationwide was 72 percent during the 2005-2006 flu season. This was well below the Healthy People 2010 goal of 90 percent. A new study found that black nursing home residents have lower flu vaccination rates than their white counterparts. It found that over three consecutive flu seasons (2006-07, 2007-08, and 2008-09), the odds of being vaccinated were 14-16 percent lower for blacks than for whites within the same facility.This difference persisted even after excluding residents who were either offered but declined vaccination, or were vaccinated outside the facility.

    The Brown University researchers also found that nursing homes with high proportions of black residents had lower vaccination rates for both blacks and whites than did facilities with lower proportions of black residents. These facilities generally have a high proportion of Medicaid residents. Therefore, they have less revenue and fewer opportunities to cross-subsidize care with income from more profitable Medicare and private-pay patients.

    The researchers suggest that low revenue, insufficient staffing, and poor-quality performance may all contribute to the lower vaccination rates in these facilities. They also point out that blacks are consistently more likely than whites to refuse flu vaccinations when offered. To completely eliminate racial differences in flu vaccination rates, educational programs that focus on elderly blacks and their families may be necessary, suggest the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS16094).

    Source: Agency for Healthcare Research and Quality  http://www.ahrq.gov/research/apr12/0412RA23.htm

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  • End of Life Care During the Last Days and Hours

    Tuesday April 3, 2012

    The Registered Nurses Association of Ontario (RNAO) and the guideline development panel have compiled a list of implementation strategies to assist health-care organizations or health care providers that are interested in implementing this guideline.  

    According to the RNAO, this nursing best practice guideline is a comprehensive document, which provides resources necessary for the support of evidence-based nursing practice. The document must be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This guideline should not be applied in a "cookbook" fashion, but rather as a tool to enhance decision-making in the provision of individualized care. In addition, the guideline provides an overview of appropriate structures and supports necessary for the provision of best possible care.  

    The purpose of this best practice guideline is to provide evidence-based recommendations for Registered Nurses and Registered Practical Nurses on best nursing practices for end-of-life care during the last days and hours of life. The guideline does not replace consultation with palliative care specialists, who can support nurses to provide quality end-of-life care. The guideline is intended to be a resource to nurses who may not be experts in this practice area. It is acknowledged that individual competencies vary between nurses and across categories of nursing professionals. The inclusion of recommendations on clinical, education, organization and policy topics makes this guideline applicable to nurses in all domains and settings of practice  

    Source: Agency for Healthcare Research and Quality

    End of Life Care During the Last Days and Hours

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  • Antipsychotic Drugs Might Raise Heart Attack Risk: Study

    Monday April 2, 2012

    WEDNESDAY, March 28 (HealthDay News) -- Antipsychotic drugs can raise the risk of heart attack in older patients with dementia, a new study suggests.

    It's common to prescribe antipsychotics to older patients with dementia to control symptoms such as agitation, hallucinations and aggression. Previous studies have found that this use of the drugs may be linked to an increased risk of stroke and death from all causes.

    But until now, the risk of heart attack associated with the use of antipsychotic drugs in older people with dementia had been "poorly examined," wrote study author Dr. Antoine Pariente, of Universite Bordeaux Segalen in France, and colleagues.

    They looked at nearly 11,000 patients, aged 66 and older, in Quebec who were being treated with cholinesterase inhibitors for dementia and were also prescribed antipsychotics.

    Within a year of starting treatment with the antipsychotics, 1.3 percent of the patients had a heart attack. Compared to those not taking antipsychotics, the risk of heart attack among those taking them was 2.19 times higher for the first 30 days, 1.62 times higher for the first 60 days, 1.36 times higher for the first 90 days, and 1.15 times higher for the first year.

    "Our study results indicate that the use of [antipsychotic medications] is associated with a modest increase in the risk of [heart attack] among community-dwelling older patients with treated dementia," the researchers wrote. "The increased risk seems to be highest at the beginning of treatment and seems to decrease thereafter, with the first month of treatment accounting for the highest period of risk."

    The study, which found an association between antipsychotic use and heart attack but did not prove cause-and-effect, appeared online March 26 in the Archives of Internal Medicine.

    "Because [antipsychotic] use is frequent in patients with dementia ... the increased risk of [heart attack] may have a major public health effect, which highlights the need for communicating such risk and for close monitoring of patients during the first weeks of treatment," the authors concluded in a journal news release.

    Further research is required to learn more about why the use of antipsychotic drugs in dementia patients may increase the risk of heart attack, Dr. Sudeep Gill and Dr. Dallas Seitz, of Queen's University in Kingston, Ontario, Canada, wrote in an accompanying editorial.

    "Meanwhile, physicians should limit prescribing of antipsychotic drugs to patients with dementia and instead use other techniques when available, such as environmental and behavioral strategies, to keep these patients safe and engaged," they suggested.

    While the study found an association between antipsychotic drugs and heart attack risk, it did not prove a cause-and-effect relationship.

    SOURCE: JAMA/Archives journals, news release, March 26, 2012

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  • OSHA - Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents

    Wednesday May 30, 2012

    The purpose of Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents is to provide general policies and procedures that apply when workplace violence is identified as a hazard while conducting an inspection under a national, regional or local emphasis program and when responding to incidents of workplace violence, especially when conducting inspections at worksites in industries with a high incidence of workplace violence.  

    Workplace violence is recognized as an occupational hazard in some industries and environments which, like other safety issues, can be avoided or minimized if employers take appropriate precautions. At the same time, it continues to negatively impact the American workforce. Workplace violence has remained among the top four causes of death at work for over fifteen years, and it impacts thousands of workers and their families annually.  

    Research has identified factors that may increase the risk of violence at worksites. Such factors include working with the public or volatile, unstable people. Working alone or in isolated areas may also contribute to the potential for violence. Handling money and valuables, providing services and care, and working where alcohol is served may also impact the likelihood of violence. Additionally, time of day and location of work, such as working late at night or in areas with high crime rates, are also risk factors that should be considered when addressing issues of workplace violence.

    Click the link below for the complete report:

    Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents

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  • The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

    Tuesday May 29, 2012
    The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools. Many nursing facilities have fall programs in place, but recognize that there is always room for improvement. While not all falls and injuries can be prevented, it is critical to have a systematic process of assessment, intervention and monitoring that results in minimizing fall risk.
    Click the following file to read the entire Falls Management Program:    The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

    Source: Agency for healthcare Research and Quality (AHRQ)

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  • Identifying Medications that Older Adults Should Avoid or Use with Caution

    Friday May 25, 2012

    For more than 20 years, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults has been the leading source of information about the safety of prescribing drugs for older people. To help prevent medication side effects and other drug-related problems in older adults, the American Geriatrics Society (AGS) has updated and expanded this important resource. The expanded AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults identifies medications with risks that may be greater than their benefits for people 65 and older.

    This summary is from the full report titled, AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. It is in the March 2012 issue of the Journal of the American Geriatrics Society (JAGS). The report is authored by the American Geriatrics Society    

    Click Link Below for Summary: Beers Criteria - Updated 2012

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  • Free Online Training for MDS 3.0 Section M: Skin Condition

    Thursday May 10, 2012

    Free Online Training for MDS 3.0 Section M: Skin Condition

    This FREE video and handouts of the pressure ulcer assessment and coding training session for MDS 3.0 Section M: Skin Condition was delivered in Las Vegas on August 10, 2010.  It was posted online by the Centers for Medicare and Medicaid Services (CMS) on January 20, 2011.  This lecture was part of the CMS sponsored introduction to MDS 3.0.  If you still want access to the information it is posted on YouTube! The link is posted below with the slides/handouts.

    You can view the slides/handouts, watch the video, and get free in-depth training on this important topic for resident assessment in long-term care.  The lecture is 1 hour and 42 minutes long and reviews all aspects of prevention, wound identification, staging, and coding, including sample coding challenges and wound quiz. 

    You Tube link to video:



    MDS 3.0 Training Slides 2 Section M

    MDS 3.0 Section M Study Aid

    MDS 3.0 Training Slides Section M

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    Friday June 29, 2012

    Dementia Incidences to Triple Says World Health Organization

     The World Health Organization has released data on the current state of dementia care worldwide and the prevalence of the disease, both currently and in the future. Among other findings, researchers predict the number of people with dementia worldwide to triple by 2050.

    The World Health Organization compiled the results of a number of studies in a new report about the prevalence, effects, and implications of dementia. According to the report, in 2010 35.6 million people worldwide had dementia, a number expected to nearly double every 20 years. In 2010 the worldwide costs of dementia were estimated to be 604 billion US dollars, a number also expected to grow over the coming years. Despite the high social and financial costs, only eight countries have national programs to address dementia.

    The report emphasizes that a variety of services, including caregiver support programs, residential care communities, and palliative care options, are needed to serve those with dementia. High-income countries are generally able to provide more options for citizens, but the report makes it clear that even high-income countries have room for improvement. For example, seven out of eight survey respondents from high-income countries report that their country provides support for residential care, but many of these countries do not provide sufficient care. Poland, for instance, only reported one community specifically designed for individuals with dementia.

    Read the full report: Dementia: A Public Health Priority


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  • Revised Guidance for Tag F492

    Monday June 18, 2012

    Current guidance in Appendix PP of the State Operations Manual for Tag F 492, 42 CFR §483.75(b) and (c) States that this tag should be cited only when the authority having jurisdiction has both made a determination of noncompliance and has taken a final adverse action as a result. There has been confusion as to whether this requirement may be cited when a facility simply does not meet a State regulation. This memorandum clarifies and revises the Centers for Medicare & Medicaid Services (CMS) guidance to Surveyors in Appendix PP of the SOM regarding citations under Tag F492.

    June 1, 2012 CMS issued a revision and clarification to the Interpretive Guidance for F492. The effective date of this memo is immediately. These changes will be incorporated into the next revision of Appendix PP of the SOM. Please read the attached document for details.

    Revised Guidance for F492

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  • Disaster Planning Information

    Tuesday June 5, 2012

    All long term care providers and operators have an obligation to prepare for potential disasters. Each facility is unique with regard to the types of residents/clients served, geographical location, types of disasters to plan for and proximity to local assistance. Preparation, education, and practice are the keys to a well-managed event involving a catastrophic occurrence that comes with little or no warning.  

    We have recently added numerous documents, forms, and guides to assist health care facilities in this planning process. These forms are located behind the "Risk Management Resource Center" door. We remind all facilities that any workable disaster plan must be tailored to the individual facility. It is advised that a committee be formed to develop and analyze all material for the manual, as well as provide regular reviews and updates.  The following documents posted are:

    • Nursing Home Incident Command System (NHICS)
      • Guidebook
      • Incident Management Team
      • Position Crosswalk
      • Quick Guide to Job Responsibilities
      • Incident Briefing & Operational Log
      • Incident Objectives
      • Organization Assignment List
      • Incident Communications Plan
      • Staff Injury Plan
      • Organizational Chart
      • Incident Message Form
      • Facility System Status Report
      • Personnel Time Sheet
      • Volunteer Staff Registration
      • Master Emergency Admit Tracking Form
      • Master Resident Evacuation Tracking Form
      • Procurement Summary Report
      • Resource Accounting Record
      • Facility Resource Directory
      • Master Facility Casualty Fatality Report
      • Resident Evacuation Tracking Form
      • Incident Action Safety Analysis
      • Emergency Water Supply Planning Guide
      • National Criteria for Evacuation Decision - Making in Nursing Homes
      • Caring for Vulnerable Elders During A Disaster - Hurricane Summit

    Listed below are links to also assist you in locating additional information that you may require:  



    Homeland Security:


    American Red Cross Preparedness Fast Facts: http://www.redcross.org/portal/site/en/menuitem.86f46a12f382290517a8f210b80f78a0/?vgnextoid=92d51a53f1c37110VgnVCM1000003481a10aRCRD  

    Kentucky All Hazards Long Term Care Planning & Resource Manual: http://www.kahsa.com/Kentucky-All-Hazards-Long-Term-Care-Planning-%26-Resource-Manual-p-373.html  

    California Association of Health Facilities - Disaster Preparedness Program: http://www.cahfdisasterprep.com/PreparednessTopics.aspx  

    Florida Health Care Association - Emergency Preparedness Tools: http://www.fhca.org/facility_operations/emergency_preparedness_tools/ http://www.fhca.org/emerprep/index.php  

    National Nurse Emergency Preparedness Initiative:


    Texas Health Care Association-Disaster Preparedness Tools: http://www.txhca.org/disasterpreparedness.htm

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  • CMS Use of Insulin Pens

    Friday June 1, 2012

    The Centers for Medicare & Medicaid Services (CMS) has recently received reports of use of insulin pens for more than one patient, with at least one 2011 episode resulting in the need for post-exposure patient notification. These reports indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients. Insulin pens are meant for use by a single patient only. Each patient/resident must have his/her own. Sharing of insulin pens is essentially the same as sharing needles or syringes, and must be cited, consistent with the applicable provider/supplier specific survey guidance, in the same manner as re-use of needles or syringes.

    The Centers for Disease Control and Prevention (CDC) has also become increasingly aware of reports of improper use of insulin pens, which places individuals at risk of infection with pathogens including hepatitis viruses and human immunodeficiency virus (HIV). This notice serves as a reminder that insulin pens must never be used on more than one person.

    Follow the link to visit the CDC page on Injection Safety:


    CDC Insulin Pen Poster:

    Clinical Reminder for Use of Insulin pen

    CMS Survey & Certification letter on Insulin pens:

    Use of Insulin Pens May 18 2012

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  • The Sorrow of Suicide – National Institute of Health

    Wednesday July 11, 2012

    Suicide is tragic. It cuts a life short, and it devastates the family, friends and loved ones left behind. Those who survive a suicide attempt might end up with severe disability or other injuries. The children of people who die by suicide are more likely to later die by suicide themselves. With such extreme consequences, why would anyone make the dire decision to choose death over life?

    That's a question scientists have been struggling to answer for decades. "When you're in a suicidal state, you're kind of closing down your options. You see it as the only solution. You're not really able to entertain other ideas," says Dr. Jane Pearson, who heads a suicide research consortium at NIH. "What's the science behind that? What's happening in the brain that leads people to think so dysfunctionally?"

     Recognizing those at risk is essential. Suicide is the 10th leading cause of death nationwide, and it's the 3rd leading cause of death among adolescents. Nearly 37,000 Americans died by suicide in 2009, according to the U.S. Centers for Disease Control and Prevention. More than half of those deaths were from firearms.

    People of all genders, ages and ethnicities are at risk for suicide. Women are more likely than men to attempt suicide, but men are more likely to die by suicide. That's because men often choose deadlier methods, such as firearms or suffocation.

    "The highest risk groups are older men," says Pearson. "In fact, white men who are 85 and older have a rate of suicide that's 4 times the national average."

    To read the entire NIH report in this attachment.

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  • QAPI CMS Survey and Certification Letter – June 2012

    Monday July 9, 2012

    Memorandum Summary

    • Quality Assurance and Performance Improvement (QAPI) Activities:  Section 6102(c) of the Affordable Care Act mandates the Centers for Medicare & Medicaid Services (CMS) to establish standards and provide technical assistance to nursing homes on the development of best practices relating to QAPI. The CMS put forth several initiatives to implement these provisions that include:
    • Refinement of QAPI Tools and Resources:  Ongoing development of QAPI tools and resources that nursing homes may use to design and implement an effective QAPI program.
    • Launch of a QAPI Demonstration:  Demonstration project in 17 nursing homes in 4 States to test tools and resources and provide technical assistance to nursing homes in QAPI implementation.
    • Rollout of QAPI materials:  CMS will release materials later this calendar year that will support nursing homes in QAPI implementation.
    • Draft of the QAPI Regulation:  CMS is in the process of drafting a new QAPI regulation.
    • Launch of the Nursing Home Quality Improvement Questionnaire:  The CMS has launched a nursing home quality improvement questionnaire using an independent contractor. The data collection period is from June 25 through September 28, 2012.
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  • Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotics Drugs

    Tuesday July 24, 2012

    This study used a random sample of records from a previous Office of Inspector General (OIG) study of elderly nursing facility residents with Medicare claims for atypical antipsychotic drugs between January and June 2007. They reviewed the records for evidence of compliance with Federal requirements for resident assessments and documentation of decision-making. They also reviewed the records for evidence of compliance with Federal requirements for care plan development and implementation.

    Nearly all records reviewed (99 percent) failed to meet one or more Federal requirements for resident assessments and/or care plans. The resident assessment and care plan process involves four steps. One-third of records reviewed did not contain evidence of compliance with Federal requirements regarding resident assessments, the first step. Further, for 4 percent of records, nursing facility staff did not document consideration of the Resident Assessment Protocol for psychotropic drug use as required, the second step. Ninety-nine percent of records did not contain evidence of compliance with Federal requirements for care plan development, the third step. Finally, 18 percent of records reviewed did not contain evidence to indicate that planned interventions for antipsychotic drug use-the fourth step-actually occurred.

    Please read the following attachments for more details and CMS response to the report.

    OIG Report Care Plans for Residents Receiving Atypical Anitpsychotic Drugs

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  • Interventions to Reduce Acute Care Transfers

    Tuesday August 14, 2012

    INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change n resident condition.  The INTERACT program is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.

    The INTERACT goal is to improves care and reduce the frequency of potentially avoidable transfers to the acute hospital. Transfers to the hospital can be emotionally and physically difficult for residents, and result in numerous complications of hospitalization, and they are costly.

    In the plans for health care reform, Medicare may financially reward facilities with lower hospitalization rates for certain conditions. By improving the identification, evaluation, and communication about changes in resident status, some, but not all acute care transfers can be avoided.

    The attached pdf Transitions and Long-Term Care: Reducing Preventable Hospital Readmissions Among Nursing Facility Residents explains what INTERACT is and how to use the quality improvement tool.

    Reducing Preventable Hospital Readmissions Among Nursing Facility Residents 

    TheINTERACT web site; www.interact2.net is a free web site for facility use in decreasing acute care transfers. The web site contains information about INTERACT, INTERACT II Tools, Educational Resources, and Links to Other Resources.

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  • Important Reminder About Medicare Secondary Payer Laws

    Wednesday September 5, 2012

    Please read the following reminder regarding the Medicare Secondary Payer Act. Medicare Secondary Payer Act Reminder

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  • 2012 CMS Nursing Home Action Plan

    Wednesday September 5, 2012
    On August 28, 2012 the Centers for Medicare and Medicaid Services (CMS) released their 2012 Nursing Home Action Plan. The plan is organized into 5 actionable strategies:
    1. Enhance Consumer Engagement.
    2. Strengthen Survey Processes, Standards, and Enforcement.
    3. Promote Quality Improvement.
    4. Create Strategic Approaches through Partnerships.
    5. Advancing Quality through Innovation and Demonstration. 
    Details include planned updates to Nursing Home Compare, improving fire safety, revising surveyor guidance, QIS, civil money penalties, culture change activities, QAPI, Care Transitions, Health Facility Acquired Infections (HAIs), and initiatives for reducing re-hospitalizations and use of anti-psychotics.  The plan is based on a 3-part plan created by the agency to improve the U.S. health care system:
    1. Improving the individual experience of care.
    2. Improving the health of populations.
    3. Reducing the per-capita cost of care of populations.
    Complete 2012 Nursing Home Action Plan: 2012-Nursing-Home-Action-Plan
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  • Partnership to Improve Dementia Care in Nursing Homes

    Wednesday September 5, 2012
    In 2012, CMS launched the Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for nursing home residents with dementia-related behaviors. The goals of this initiative include a focus on person-centered care and the reduction of unnecessary antipsychotic medication use in nursing homes and eventually other care settings as well.

    CMS is using several approaches to successfully implement this initiative. CMS is developing and conducting trainings for nursing home providers, surveyors, and consumers. We are conducting research, raising public awareness, using regulatory oversight, and public reporting to increase transparency.

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  • Risk Management Certification Program - Register NOW!

    Friday September 7, 2012

    Registration is now open for the 2012 CQRMS Training Program.  If you would like more information about this program please contact Nancy Lee (contact information listed in the brochure).

    Seating is limited, early registration is recommended.

    Registration brochure: 2012 CQRMS web brochure

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  • Hand Hygiene

    Friday September 14, 2012

    Hand Hygiene (HH) has always been a concern in long term care facilities and recently, in some states, there has been an increase in the number of citations being written related to HH. A recent article published in the Journal of Applied Gerontology, titled "Hand Hygiene Deficiency Citations in Nursing Homes" addresses this area of concern.

    Click on the link below to take you to the article.


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  • Transitioning to the ICD-10 - Hospitals

    Friday September 14, 2012

    The healthcare industry faces enormous pressure to transform the delivery system from acute centric care into more cost effective care across the preventative, chronic, acute, and long-term continuum. The marketplace is demanding that providers align, and that change is implemented aggressively. The current industry backdrop is an environment where the cost of drugs, supplies, technologies and staffing are increasing, competition from entrepeneurs who capture opportunities in attractive niches is intensified, and consumer interest in public scorecards on hospital and physician safety, quality, and satisfaction has risen. All the while reimbursement rates from third party payors (Medicare, Medicaid, and Commercial Health Plans) is trending downward.

    To continue reading this article, click the link below:

    Transition to ICD 10

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  • Antipsychotic Alert

    Tuesday September 18, 2012

    Please see the two attachments regarding a recent lawsuit involving alleged off-labeled use of an antipsychotic and a press release from the U. S. Department of Justice in which a company maintained specialized sales force to market drug for off label purposes; Targeted elderly dementia patients in nursing homes.  

    Alert-CMS Initiative for the Use of Antipsychotics subject of lawsuit
    U.S.  Department of Justice Press Release

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