8/20/2026:

McKnight’s Long-Term Care News: SNF AUDIT ENVIRONMENT ESCALATES: FORMER PROSECUTOR WARNS ‘NOBODY’S SAFE’

Long-term care operators are facing an unprecendented, aggressive regulatory environment where minor documentation oversights can rapidly escalate into multimillion-dollar liabilities, according to healthcare defense attorney Alyssa Friedman.

“What used to be a little problem that was to be solved with $10,000 or $20,000 in takebacks - they’re now taking the molehill and making it into the mountain,” she said at Zimmet Healthcare Services Group conference last week. “The minute you get the records request, it could go from a request for 10 charts to a $30 million problem.”

A central driver of this inflated financial risk is the expanding reliance on statistical extrapolation the CMS and the HHS Office of Inspector General.

Article can be found at https://lnkd.in/gmtidS43 (REPOSTED FROM INDEED WEBSITE 8/20/26)

10/1/2026 Latest SNF ADR News and Guidance

SNF ADR activity is intensifying post‑2025 “5‑Claim Probe,” with Targeted Probe & Educate (TPE) now triggering 20–40 claim ADRs in 45 days for facilities with ≥60% error rates Proactive LTC Consulting+1.

Current Landscape

• The SNF 5‑Claim Probe & Educate ended June 30, 2025, but many facilities face a surge in Additional Documentation Requests (ADRs) under the Targeted Probe & Educate (TPE) process Proactive LTC Consulting.

• CMS guidance suggests 100% error rates (5/5 claims in error) are prioritized, but TPEs are now being initiated for facilities with ≥60% error rates Proactive LTC Consulting+1.

• Facilities with sub‑par probe outcomes are likely to face expanded focus and higher‑volume ADRs — often 20–40 claims within 45 days Proactive LTC Consulting.

Common ADR Denial Drivers Proactive LTC Consulting

• Missing or incomplete documentation for the full admission‑to‑discharge period.

• Late, missing, or invalid physician certifications/recertifications.

• Missing hospital documentation for qualifying stays.

• Documentation not supporting billed PDPM HIPPS codes (e.g., Section GG, Section I, active diagnoses).

Best Practices for SNF ADR Management Proactive LTC Consulting+2

1. Dedicated ADR Team – Assign clear roles for identifying notices, gathering records, drafting responses, and submitting packets.

2. Standardized ADR Packet Template – Include labeled sections for hospitalization records, MDS assessments, physician orders, nursing notes, MAR/TAR, therapy, etc.

3. Front‑Load Clinical & Coding Review – Engage MDS and clinical experts to validate HIPPS codes before submission.

4. Submission Log – Track ADR receipt date, due date, submission date, confirmation, and outcome; note favorable/partial/denied determinations.

5. Retention of All Records – Keep complete packets and correspondence for audit trails and appeals.

Appeals Process Awareness www.myhbconsulting.com

If a claim is denied after ADR response, SNFs must navigate Medicare’s five‑level appeals process (redetermination → reconsideration → administrative law judge → federal court), with strict deadlines and review standards at each stage www.myhbconsulting.com.

Key Takeaway

Expect more aggressive, high‑volume ADRs post‑probe — facilities should now treat ADRs as a core compliance and revenue‑protection function, with proactive readiness, organized documentation, and timely, complete responses to avoid denials and costly appeals Proactive LTC Consulting+2.

8/10/2026:

QIPP Year 10

Texas Health and Human Services/(HHS) and TMHP published the State Fiscal Year (SFY) 2027 Quality Incentive Payment Program (QIPP Year 10) facility-level baselines, program-wide benchmarks, and quarterly targets on August 10, 2026. QIPP 10 officially begins on September 1,2026.

8/10/2026: Component 2 Workforce Metrics

Quality metrics remain unchanged from QIPP 9, but the three Component 2 workforce metrics will now be divided evenly instead of previous allocations.

8/10/2026: Quarter 1 Data Window

Performance data tracking for Quarter 1 covers July through September 2026, coinciding with the program launch.

9/3/2026 Why falls may be the best bellwether for staffing, operational performance

As federal regulators put more emphasis on #falls — even using them to help determine the worst nursing homes in the nation — industry insiders are revealing what those fall-related injuries and even near misses indicate about quality of care.

Increasingly, they’re seen as a window into #staff coverage, communication, and care planning and delivery. And not just by patients.

Insights from AAPACN's Quality Virtual Conference and a new data analysis from Covr are revealing why falls matter not just to individual residents, but to the overall performance of skilled nursing and long-term care organizations.

Jessie McGillLauren Stenson, RN, DNP, CNDLTC, QCP, DNS-CT#skillednursing#nursinghomes#LTC#postacutecare#workforce#fallrisl#seniors

https://lnkd.in/g-s3KAjD

FY 2027 SNF Reimbursement & MDS Industry Updates

CMS finalized its FY 2027 SNF Prospective Payment System (PPS) rule on July 30, 2026, with a 2.4% Medicare payment increase, QRP reforms, and a long-term all-payer MDS mandate. The rule takes effect October 1, 2026

• 2.4% increase in SNF Medicare Part A payment rates for FY 2027, based on a 3.3% market basket increase minus a 0.9% statutory productivity adjustment

• Aggregate increase: ~$882–$888 million in Medicare Part A payments 

• Impact varies by facility type: hospital-based SNFs ~+2.9%, rural ~+2.7%, freestanding urban ~+2.3% 

• SNF Value-Based Purchasing (VBP) will reduce aggregate payments by ~$203.6M in FY 2027 

Quality Reporting Program (QRP) Changes

• Removal of two COVID-19 measures starting FY 2028:

  1. COVID-19 Vaccination Coverage Among Healthcare Personnel

  2. COVID-19 Vaccine: Percent of Patients/Residents Up to Date

• Estimated annual cost savings: ~$8.3M 

• Tighter data submission window for QRP data starting FY 2029 

MDS & All-Payer Data Requirements

• All-payer MDS mandate: Facilities must submit MDS assessments for all covered skilled residents regardless of payer starting with the FY 2031 SNF QRP 

• This will expand MDS reporting beyond current Medicare-only requirements, affecting staffing, software, and annual cost reporting

• CMS is signaling increased focus on MDS accuracy, PDPM coding, and documentation to support reimbursement and compliance. 

Patient Driven Payment Model (PDPM)

• CMS solicited stakeholder input on measuring and addressing case-mix growth; no immediate changes to PDPM CMI values, but future adjustments may be considered

Practical Implications for SNFs

• Finance & Reimbursement: Model the 2.4% rate update at the facility level, factoring in case mix, occupancy, and payer mix. Monitor VBP performance for potential payment reductions

• Clinical & MDS Teams: Prepare for expanded MDS reporting timelines and accuracy requirements; ensure documentation supports both care and reimbursement

• Quality Teams: Update workflows to remove COVID-19 measures from FY 2028 reporting cycles

• Operations: Plan for increased administrative and IT capacity to handle all-payer MDS submissions starting FY 2031 

Bottom line: While the 2.4% payment increase is modest, the long-term MDS and QRP changes will significantly impact SNF operations, compliance, and revenue. Facilities should start preparing now for the expanded data requirements and quality reporting reforms.

Texas State RAI Coordinator Information:

TX Holly Sanchez RAI_MDS@hhs.texas.gov‍ ‍

TX MDS Coding/Clinical Questions RAI_MDS@hhs.texas.gov

9/3/26 Supportive documentation for MDS coding focus!!!

Expanding MDS reporting changes coming for 2029!!!

With greater scrutiny of case-mix growth and coding, nursing homes should be strengthening documentation. Moreover, operators should also prepare now for expanded MDS reporting requirements beginning in 2029.

https://lnkd.in/p/gaRqQ_uR

10/27/2026‍ ‍CMS Releases Updated MDS 3.0 RAI User’s Manual: Key Clarifications Effective 10/1

by Proactive LTC Consulting

CMS has released the final MDS 3.0 RAI User’s Manual v1.20.11, effective October 1, 2026.

This update includes important coding refinements that affect documentation, interdisciplinary communication, PDPM accuracy, and audit readiness. The change tables contain meaningful clarification in areas where teams commonly face uncertainty, including wounds, pain, interviews, isolation, respiratory therapy, and state-specific requirements.

The key takeaway from this release is that accurate MDS coding begins with timely, consistent, interdisciplinary documentation.  Let’s review the primary updates:

Section M: Important wound-coding clarifications

Several of the most operationally significant changes are in Section M: Skin Conditions.

CMS clarifies that when a pressure ulcer/injury was documented on admission, subsequently closes, and later opens again, it is not coded as present on admission. Facilities should ensure wound records clearly establish the wound’s status and progression over time.

CMS also distinguishes advanced wound treatment from surgical wound care. Applying an advanced wound-care dressing or skin substitute to a pressure ulcer/injury does not make it a surgical wound. A pressure ulcer becomes a surgical wound when it is excised and closed with a flap and/or graft.

In addition, adhesive bandages and wound-closure strips are not considered dressings for M1200 coding. Wound-care documentation, treatment administration records, and MDS review processes should be aligned with these definitions.

CMS further reinforces that residents with diabetes may have pressure, venous, arterial, or diabetic neuropathic ulcers. The MDS should reflect the wound’s primary etiology; diabetes alone does not determine how an ulcer is coded.

Pain Coding Requires Clear Support in the Clinical Record

CMS added useful direction for J0100, Pain Medication and Non-Medication Intervention.

For scheduled pain medication, the medical record must support that the medication was actually received.  For PRN pain medication, the record may support that the medication was received or that it was offered and declined.

For non-medication pain interventions, the intervention must be scheduled as part of the care plan, documented as actually provided, and assessed for effectiveness.

This is a good opportunity to review whether pain assessments, care plans, treatment documentation, and MDS coding tell the same story.

 BIMS and PHQ Interviews: Code the Interview Closest to the ARD

CMS clarified the process when multiple interviews are completed during the look-back period. If more than one BIMS or PHQ-2 to 9 interview occurs during the look-back period, code the assessment using the interview completed closest to the ARD.  Teams should have a reliable process for tracking completed interviews and communicating the applicable interview result to the MDS coordinator before the assessment is finalized.

 Shortness of Breath: Do Not Require the Resident to Perform the Activity

For J1100, Shortness of Breath While Lying Flat, CMS clarifies that if a resident reports avoiding a position or activity—such as lying flat—because of shortness of breath, staff should not require the resident to perform that activity.

This supports a resident-centered assessment process and reinforces the need to document the resident’s report and the supporting clinical assessment.

 Isolation and Respiratory Therapy Remain Highly Specific

The revised guidance for O0110M1, Isolation or Quarantine for Active Infectious Disease, reinforces that isolation coding requires all applicable criteria to be met. The resident must have an active, highly transmissible or epidemiologically significant infection; be on transmission-based precautions beyond standard precautions; be alone in the room—not cohorted with another resident; and remain in the room while services are brought to them.

For O0390D, Respiratory Therapy, only time spent with the resident by a respiratory therapist or respiratory nurse counts toward the 15-minute threshold on at least one day of the look-back period. Routine or prophylactic incentive spirometry that does not require skilled respiratory judgment does not qualify, even when nursing staff assist. Metered-dose and dry-powder inhaler administration also is not included in respiratory-therapy minutes.

 State Requirements Cannot Change Federal MDS Coding

CMS clarified an important point for multi-state organizations and facilities with state-specific requirements. States may add federal comprehensive assessment items to Quarterly and/or PPS item sets. However, because these remain federal MDS items, state requirements cannot replace, modify, or add to CMS item definitions, coding instructions, coding tips, or response options.

This clarification can be particularly helpful during coding reviews and audits: while states and payers may have separate assessment or documentation expectations, federal MDS items must still be coded using the CMS instructions in the RAI Manual.

 Race and Ethnicity: Flexibility for Subsequent Assessments

CMS added flexibility for A1005, Ethnicity, and A1010, Race. Facilities do not need to repeat these questions on every assessment. If the resident was asked within the prior year, the prior response may be used. If it has been a year or more, the resident should be asked again.

 PDPM and Chapter 6 Clarifications

CMS updated Chapter 6 language to include “asthma, chronic obstructive pulmonary disease, or chronic lung disease and shortness of breath when lying flat” within the Special Care High discussion. This clarification is important when teams are evaluating the applicable criteria and supporting the related PDPM nursing classification.

CMS also now consistently refers to the PDPM depression end split as “signs and symptoms of depression.” The underlying PDPM logic has not changed, but consistent terminology helps teams connect clinical documentation and the BIMS/PHQ process to the nursing case-mix classification.

Finally, the manual reinforces that bowel and bladder toileting programs do not require day-and-minute documentation for restorative-nursing coding. Clinical documentation should still clearly demonstrate that the individualized program was provided.

 Additional Reminders

CMS reinforced that I2300, UTI, has its own coding criteria and does not use the general active-diagnosis seven-day look-back period.

The manual also adds information related to resident transfers during a natural disaster or other public-health emergency. Emergency-preparedness teams should review the updated direction, including when to seek guidance from CMS, the State Agency, and the Medicare Administrative Contractor.

 What Facilities Should do Now

Before October 1, facilities should:

• • Download the updated RAI Manual and chapter/section change tables.

  • Educate MDS, nursing, wound-care, infection-prevention, therapy, respiratory, and care-planning teams on the changes relevant to their roles.

  • Audit current processes for pressure injuries, pain interventions, interviews, isolation, respiratory therapy, and restorative programs.

  • Update internal tools, education materials, and audit criteria as needed.

  • Reinforce that accurate coding begins with timely, consistent, interdisciplinary documentation.

These clarifications may seem technical, but they address exactly the types of questions that can lead to inaccurate coding, unsupported reimbursement, denials, or avoidable disputes. The updated manual and change tables are available on the CMS MDS 3.0 RAI Manual page.

8/25/2026: RISK BASED SURVEY (RBS)

The RBS (Risk Based) survey will be implemented nationwide beginning September 8, 2026. CMS is providing SAs and CMS Locations information related to training and implementation to prepare for the RBS launch in August and September 2026. High Performing Facility Icon: 🏆CMS will place an icon on Nursing Home Care Compare website identifying facilities that qualify for the RBS which indicates a higher level of performance. The icon will remain on the nursing home’s profile page until the facility is no longer eligible for the RBS.

Reference: QSO-26-14-NH https://cstu.io/19e18d‍ ‍(Reposted from MDS Consultants 8/4/2026 post on LinkedIn website)

Item description

8/20/2026:

MDS CONSULTANTS ARTICLE- PBJ PROVIDERS AND VENDORS:

CMS has posted Payroll-Based Journal (PBJ) resources for the internet Quality Improvement and Evaluation System (iQIES) on the QIES Technical Support Office (QTSO) website. You can find the iQIES Staffing Data Submission PBJ User Manual and the PBJ Error Message Reference Guide in the iQIES Payroll-Based Journal (PBJ) Manuals topic under the Reference & Manuals section. Provider link: https://cstu.io/7a466a iQIES Manuals: https://cstu.io/81767b

For additional assistance email the iQIES Service Center at iqies@cms.https://cstu.io/38f017 or contact the iQIES Service Center at (800) 339-9313, Monday through Friday, 8:00 AM - 8:00 PM ET.

You may also request assistance via secure chat or schedule a call through CCSQ Support Central, Monday - Friday 9:00 AM - 5:00 PM ET

(Reposted from Indeed on 8/14/26 - Published by MDS Consultants)

8/20/2026:

MDS CONSULTANTS ARTICLE- PBJ REPORTS AVAILABLE IN IQIES

The reports guide provides detailed inforamtion on user-requested Payroll-Based Journal (PBJ) reports available in iQIES was posted on 8/14/26. The reports are organized in alphabetical order by report name. Each report is set up as follows:

• Report Name and Purpose

• Run Report Criteria

• Sample Report

• Report Details

Details at https://lnkd.in/gzGF4Rkv and https://lnkd.in/gpSf9cFVtem description

10/1/2026

CMS Releases Updated MDS 3.0 RAI User’s Manual: Key Clarifications Effective 10/1

by Proactive LTC Consulting | Sep 23, 2026

CMS has released the final MDS 3.0 RAI User’s Manual v1.20.11, effective October 1, 2026.

This update includes important coding refinements that affect documentation, interdisciplinary communication, PDPM accuracy, and audit readiness. The change tables contain meaningful clarification in areas where teams commonly face uncertainty, including wounds, pain, interviews, isolation, respiratory therapy, and state-specific requirements.

The key takeaway from this release is that accurate MDS coding begins with timely, consistent, interdisciplinary documentation.  Let’s review the primary updates:

Section M: Important wound-coding clarifications

Several of the most operationally significant changes are in Section M: Skin Conditions.

CMS clarifies that when a pressure ulcer/injury was documented on admission, subsequently closes, and later opens again, it is not coded as present on admission. Facilities should ensure wound records clearly establish the wound’s status and progression over time.

CMS also distinguishes advanced wound treatment from surgical wound care. Applying an advanced wound-care dressing or skin substitute to a pressure ulcer/injury does not make it a surgical wound. A pressure ulcer becomes a surgical wound when it is excised and closed with a flap and/or graft.

In addition, adhesive bandages and wound-closure strips are not considered dressings for M1200 coding. Wound-care documentation, treatment administration records, and MDS review processes should be aligned with these definitions.

CMS further reinforces that residents with diabetes may have pressure, venous, arterial, or diabetic neuropathic ulcers. The MDS should reflect the wound’s primary etiology; diabetes alone does not determine how an ulcer is coded.

Pain Coding Requires Clear Support in the Clinical Record

CMS added useful direction for J0100, Pain Medication and Non-Medication Intervention.

For scheduled pain medication, the medical record must support that the medication was actually received.  For PRN pain medication, the record may support that the medication was received or that it was offered and declined.

For non-medication pain interventions, the intervention must be scheduled as part of the care plan, documented as actually provided, and assessed for effectiveness.

This is a good opportunity to review whether pain assessments, care plans, treatment documentation, and MDS coding tell the same story.

BIMS and PHQ Interviews: Code the Interview Closest to the ARD

CMS clarified the process when multiple interviews are completed during the look-back period. If more than one BIMS or PHQ-2 to 9 interview occurs during the look-back period, code the assessment using the interview completed closest to the ARD.  Teams should have a reliable process for tracking completed interviews and communicating the applicable interview result to the MDS coordinator before the assessment is finalized.

Shortness of Breath: Do Not Require the Resident to Perform the Activity

For J1100, Shortness of Breath While Lying Flat, CMS clarifies that if a resident reports avoiding a position or activity—such as lying flat—because of shortness of breath, staff should not require the resident to perform that activity.

This supports a resident-centered assessment process and reinforces the need to document the resident’s report and the supporting clinical assessment.

Isolation and Respiratory Therapy Remain Highly Specific

The revised guidance for O0110M1, Isolation or Quarantine for Active Infectious Disease, reinforces that isolation coding requires all applicable criteria to be met. The resident must have an active, highly transmissible or epidemiologically significant infection; be on transmission-based precautions beyond standard precautions; be alone in the room—not cohorted with another resident; and remain in the room while services are brought to them.

For O0390D, Respiratory Therapy, only time spent with the resident by a respiratory therapist or respiratory nurse counts toward the 15-minute threshold on at least one day of the look-back period. Routine or prophylactic incentive spirometry that does not require skilled respiratory judgment does not qualify, even when nursing staff assist. Metered-dose and dry-powder inhaler administration also is not included in respiratory-therapy minutes.

State Requirements Cannot Change Federal MDS Coding

CMS clarified an important point for multi-state organizations and facilities with state-specific requirements. States may add federal comprehensive assessment items to Quarterly and/or PPS item sets. However, because these remain federal MDS items, state requirements cannot replace, modify, or add to CMS item definitions, coding instructions, coding tips, or response options.

This clarification can be particularly helpful during coding reviews and audits: while states and payers may have separate assessment or documentation expectations, federal MDS items must still be coded using the CMS instructions in the RAI Manual.

Race and Ethnicity: Flexibility for Subsequent Assessments

CMS added flexibility for A1005, Ethnicity, and A1010, Race. Facilities do not need to repeat these questions on every assessment. If the resident was asked within the prior year, the prior response may be used. If it has been a year or more, the resident should be asked again.

PDPM and Chapter 6 Clarifications

CMS updated Chapter 6 language to include “asthma, chronic obstructive pulmonary disease, or chronic lung disease and shortness of breath when lying flat” within the Special Care High discussion. This clarification is important when teams are evaluating the applicable criteria and supporting the related PDPM nursing classification.

CMS also now consistently refers to the PDPM depression end split as “signs and symptoms of depression.” The underlying PDPM logic has not changed, but consistent terminology helps teams connect clinical documentation and the BIMS/PHQ process to the nursing case-mix classification.

Finally, the manual reinforces that bowel and bladder toileting programs do not require day-and-minute documentation for restorative-nursing coding. Clinical documentation should still clearly demonstrate that the individualized program was provided.

Additional Reminders

CMS reinforced that I2300, UTI, has its own coding criteria and does not use the general active-diagnosis seven-day look-back period.

The manual also adds information related to resident transfers during a natural disaster or other public-health emergency. Emergency-preparedness teams should review the updated direction, including when to seek guidance from CMS, the State Agency, and the Medicare Administrative Contractor.

What Facilities Should do Now

Before October 1, facilities should:

• • Download the updated RAI Manual and chapter/section change tables.

  • Educate MDS, nursing, wound-care, infection-prevention, therapy, respiratory, and care-planning teams on the changes relevant to their roles.

  • Audit current processes for pressure injuries, pain interventions, interviews, isolation, respiratory therapy, and restorative programs.

  • Update internal tools, education materials, and audit criteria as needed.

  • Reinforce that accurate coding begins with timely, consistent, interdisciplinary documentation.

These clarifications may seem technical, but they address exactly the types of questions that can lead to inaccurate coding, unsupported reimbursement, denials, or avoidable disputes. The updated manual and change tables are available on the CMS MDS 3.0 RAI Manual page.

8/4/2026: FY 2027 SNF VBP Program August 2026 Performance Score Reports Now Available

The August 2026 Performance Score Reports (PSRs) for the fiscal year (FY) 2027 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) are now available to download via the Internet Quality Improvement and Evaluation SNF System (iQIES). SNFs may submit requests for corrections to their performance score and ranking up to 30 days following the date of report release.

8/21/2026: IS YOUR SNF READY FOR DATA VALIDATION AUDITS?

CMS recently updated its Skilled Nursing Facility Data Validation Process FAQs, providing additional guidance on what providers can expect if selected for review.

Although selection is random, every SNF should understand the process and be prepared to respond if chosen.

The purpose of this audit is to verify the accuracy of the MDS data behind SNF QRP and VBP quality measures.

Validation results themselves are informational only, but failing to submit the requested records triggers a 2% Annual Payment Update reduction under the SNF QRP.

Three changes stand out:

1. Quarterly selection is now explicit. CMS will notify selected SNFs in Feb, May, Aug and Nov.

2. The 45-day clock remains the critical operational requirement. Selected SNFs have 45 calendar days to submit requested medical record documentation supporting up to 10 MDS assessments. The submission deadline is 11:59 pm on day 45, subject to the business-day exception outlined by CMS.

3. CMS is formalizing the feedback process. Data Validation Summary Reports will now be released annually, and CMS states that the validation team cannot provide case=specific explanations for findings. The reports are informational, and SNFs are not penalized based on the validation results themselves. The penalty is tied to failure to comply with the submission requirements, which can result in a 2% SNF QRP Annual Payment Update reduction.

4. CMS has moved the Help Desk to a CMS email address, added same-day email notification when selection letters are posted in iQIES, and explicitly addresses what happens when PHI is inadvertently sent by email.

   For SNFs, this is increasingly less about waiting for a selection notification and more about being ready when it arrives.

   8/2026 FAQ Update found at Skilled Nursing Facility Validation Program: Frequently Asked Questions