Nursing Home Quality Improvement Tools and Resources

This editable tool supports nursing homes in tracking weekly and monthly tasks involving nursing home transportation vehicles.

COVID-19 Vaccination Tracking Tool

This tool supports nursing homes in tracking COVID-19 vaccine administration for residents and staff. Updated June 2021

COVID-19 Centers for Medicare & Medicaid Services (CMS) Mock Survey Tool

This tool supports nursing homes in evaluating COVID-19 infection prevention and control systems in place against CMS evaluation criteria.

F880 Meal Monitor Audit

This tool is a hand hygiene and contact precautions observation meal monitor.

Environmental Cleaning Evaluation Worksheet

Use this tool for data entry tool to record results of evaluation for each surface on the checklist for every room monitored.

Hand Hygiene

Use these tools to conduct observation audits of hand hygiene and to track compliance.

Personal Protection Equipment (PPE) Audit Tool

Use this tool to conduct observation audits for donning and doffing PPE and to track compliance. The tool includes a compliance calculator to get a compliance rate.

Ask the Experts – COVID-19

A fact sheet on COVID-19 topics including vaccine recommendations, vaccine products, special populations and vaccine safety, the Ask the Experts: COVID-19 resource published on immunize.org can be a great tool to answer questions and combat vaccine hesitancy. The link below will redirect to immunize.org.

COVID-19 Outpatient Therapeutics Clinical Decision Guide

The Administration for Strategic Preparedness and Response (ASPR), within the U.S. Department of Health and Human Services (HHS), created a clinical decision guide for COVID-19 outpatient therapeutics for those 12 years and older. The link below will re-direct to the ASPR website.

Evolution of COVID-19 Vaccines

This flyer outlines how COVID-19 vaccines have changed over time to keep up with the different variants of the novel coronavirus and includes the 2024-2025 monovalent vaccine to protect against the latest variants.

Get Recharged Now

This flyer can be hung on the wall or given to residents or their families as a reminder to find out whether they are up-to-date on their COVID-19 vaccine.

COVID-19: To Vaccinate or Not to Vaccinate?

Highlighting the importance of vaccination recommendations for COVID-19, this resource shows the continued prevalence of COVID-19 in people ages 65 years and older and how to tell if people 65 years and older are up-to-date with their COVID-19 vaccination.

Up-To-Date COVID-19 Vaccine Decision Tree

Determine if someone is up-to-date with their COVID-19 vaccinations based on criteria for the National Healthcare Safety Network (NHSN).

COVID-19 Centers for Medicare & Medicaid Services (CMS) Mock Survey Tool

This tool supports nursing homes in evaluating COVID-19 infection prevention and control systems in place against CMS evaluation criteria.

Checklist of Best Practices to Keep COVID-19 Out of Nursing Homes

This checklist supplements health care agency (Centers for Medicare & Medicaid Services [CMS], Centers for Disease Control and Prevention [CDC], etc.) guidelines to keep residents, staff and visitors safe in nursing homes.

NHSN Frequently Asked Questions (FAQs) for Long-Term Care Facilities (LTCFs)
This document outlines the process for access to the NHSN and processes for facility administrators.
Access tool

Top 10 Questions Answered on the COVID-19 Bivalent Vaccine

This resource includes 10 questions about the COVID-19 bivalent vaccine answered by Mountain-Pacific Quality Health Pharmacist (PharmD) Kyla Newland and Registered Nurse (RN) Jesse Kinsey.
View Handout

COVID-19 Vaccine Clinic Fillable Flyer Template

This flyer provides an easily customized template for advertising COVID-19 vaccination clinics. It includes fillable sections to include a specific date, time and location. The flyer also includes facts about the COVID-19 bivalent booster vaccination and general vaccine facts.

Bivalent Booster Letters

These three letters are customizable to use as a way to encourage inform long-term care management/staff, residents and their loved ones of the importance and effectiveness of the new bivalent COVID-19 immunization boosters.

COVID-19 County Transmission Level Fillable Signage

These three signs are customizable to use as a way to inform both visitors and employees to the facility what the current rate of COVID-19 transmission is in the county your facility is located in.

Managing during the Pandemic Tip Sheet

This tip sheet provides advice for health care workers to remember to care for their own physical and mental wellbeing while caring for those with COVID.

COVID-19 Resource Guide

This tool provides quick-link resources for the latest information and guidance from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).

COVID-19 Care Plan Template

This tool provides a ready-made COVID-19 care plan that is customizable to fit the facility’s specific needs and policies.

COVID-19 Nursing Home Cohorting Policy Template

This tool provides a ready-made cohorting policy that is customizable to fit the facility’s specific needs.

COVID-19 Nursing Home Visitation Policy Template

This tool provides a ready-made visitation policy that is customizable to fit the facility’s specific needs.

COVID-19 Vaccine/Booster Declination Form

Use this tool to provide nursing home staff who are declining to receive a COVID-19 vaccination series or a booster shot.

Centers for Medicare & Medicaid Services (CMS) Hotspot Referral Root Cause Analysis Fishbone Diagram

Use this tool to help find the cause of a COVID-19 outbreak.

Long-Term Care: Providing Monoclonal Antibody Therapy Safely – Webinar (6/16/21)
This interactive online event presents information to help advance the skillset of clinical staff in providing monoclonal antibody therapy.

COVID-19 Stakeholder Fireside Chats
The Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC) host a fireside chat on vaccine safety. This is part of a special series, a part of the CMS National Nursing Home Stakeholder Call Series, aimed at addressing staff questions and concerns about the new COVID-19 vaccines. Each session will be moderated by CMS with speakers from CDC and representatives of front line staff and providers.

This chat will continue to address myths surrounding vaccine danger with the following panelists:

COVID-19 Health Care Providers Fact Sheet
The Trump Administration is taking aggressive action and exercising regulatory flexibilities to help health care providers combat and contain the spread of the 2019 novel coronavirus disease (COVID-19). In response to COVID-19, the Centers for Medicare & Medicaid Services (CMS) is taking proactive steps through 1135 waivers to rapidly expand the Administration’s efforts against COVID-19.

COVID-19 Emergency Declaration Health Care Providers Fact Sheet | View Fact Sheet

COVID-19 Nursing Home Visitor Guidance

The Centers for Medicare & Medicaid Services (CMS) announced critical new measures designed to keep America’s nursing home residents safe from the 2019 novel coronavirus disease (COVID-19), based on the newest recommendations from the Centers for Disease Control and Prevention (CDC). The CMS memorandum directs nursing homes to significantly restrict visitors and nonessential personnel and restrict communal activities. The new measures are meant to protect America’s seniors, who are at highest risk for complications from COVID-19. While visitor restrictions may be difficult for residents and families, it is an important temporary measure for their protection.

CMS Announces New Measures to Protect Nursing Home Residents from COVID-19 | View Press Release (Updated 9/23/22)
Memo Nursing Home Guidance QSO-20-39-NH | View Memo (Revised 5/08/23)

COVID-19 Resident/Family Handouts
Nursing homes have proven to be especially susceptible to COVID-19 outbreaks, as residents are at high-risk for being affected and experiencing complications and even death. Despite facility efforts to develop and follow responsible infection prevention policies and procedures, the pandemic still puts nursing home residents and staff at risk. These handouts provide helpful information for residents and families to help prevent infection, spread, hospitalizations and deaths.

COVID-19 Training for Nursing Home Staff & Management

This resource includes directives from CMS for scenario-based training, fundamentals of COVID-19 prevention for nursing home management training and Agency for Healthcare Research and Quality (AHRQ), Extension for Community Healthcare Outcomes (ECHO) and Institute for Healthcare Improvement (IHI) training.
View Handout

Social Connecting while Physical Distancing: Engaging Nursing Home Residents during COVID-19 – Webinar (6/25/20)

This interactive, peer-to-peer, information-sharing, online event presents innovative ways for nursing homes to engage residents in meaningful activities during the COVID-19 pandemic, while combating social isolation and adhering to state and federal regulations.
View Recorded Webinar

You Get What You Get If You Don’t Disinfect

This resource is from the Wyoming Department of Health and offers best practices on how to properly disinfect, respiratory hygiene and isolation precautions.
View Handout

Infection Prevention and Control

Sepsis Awareness and Prevention (6/20/2024)
Access the recording
Access the slides

SBAR Communication for Possible Sepsis

Nursing Home Sepsis Gap Analysis

Know the Signs of Sepsis flyer

Resident and Family Guide to Understanding Sepsis

Skilled Nursing Facility (SNF) Sepsis Care Kit

Oral Health in Nursing Homes

An annual training for certified nursing assistants (CNAs) and other nursing home staff on dental health. This webinar demonstrates proper cleaning techniques for teeth and dentures, how to recognize common dental issues in residents and how to avoid those issues, or address them after they arise. This webinar is presented by Dr. Mark Thoreson and was recorded by Mountain Pacific on March 26, 2024.

Visitor Signage Aligning with the End of the Public Health Emergency

Facility Respiratory Infection Status for Visitors (customizable): Access the sign

Facility Respiratory Infection Status for Health Care Workers (customizable): Access the sign

Facility Visitation Guidelines (customizable): Access the sign

CDC Cover Your Cough: Access the flyer

CDC Provider Factsheet: Access the flyer

Ohana Pacific Health (OPH) Cover Your Cough: Access the flyer

OPH Please Wear Masks: Access the flyer

OPH Visitor Restrictions: Access the flyer

OPH Wash Your Hands: Access the flyer

Vaccine Clinic Fillable Flyer Template

This flyer provides an easily customized template for advertising vaccination clinics. It includes fillable sections for a specific date, time and location. The flyer also includes facts about adult immunizations.

Nursing Home Infection Control and Prevention Training Options
Access Resource

Urinary Tract Infection (UTI) Resources

Urinary Tract Infection (UTI) Signs and Symptoms Assessment Access Resource

Risk Factors for Urinary Tract Infections (UTIs) Access Resource

Urinary System and Your Health Access Resource

Enhanced Barrier Precautions (EPBs) Risk Assessment Tool

Centers for Medicare & Medicaid Services (CMS) issued new guidance on EBPs in nursing homes effective April 1, 2024. This risk assessment tool is meant to help guide staff while balancing the homelike environment for the residents.

Enhanced Barrier and Contact Precautions Flowchart for Nursing Homes

Enhanced Barrier Precautions Risk Assessment Enhanced Barrier Precautions (EBPs) Quick Guide Tool

The document was designed for use as either a one-page guide or to be cut into fourths and used as easy-access pocket cards.

EBPs Quick Guide Badge Cards

This quick reference tool was designed to be printed double-sided, cut and laminated to fit behind either a vertical or horizontal identification badge.

Barrier Precautions Comparison Sheet
Access Resource

Which Disinfectants Kill COVID-19?
This infographic, produced by the U.S. Environmental Protection Agency (EPA) , walks through how to tell if the disinfectant product(s) being used are effective against COVID-19 and how to use the List N tool on the EPA website to find out which product(s) should be used to fight COVID-19.

Fit Testing Name Badge Card Templates
Access Templates

Infection and Sepsis Zone Tool
Use this zone tool to conduct a daily assessment.
See Tool

Infection and Sepsis Zone Tool – Badge Cards
Use this zone tool to conduct a daily assessment. This quick reference tool was designed to be printed double-sided, cut and laminated to fit behind either a vertical or horizontal identification badge.

Nursing Home Top 10 Infection Control Deficiencies
Find top infection control deficiencies and suggestions on how to remediate each issue in this tip sheet.
See Tool

Infection Prevention Quick Guide and Checklist
New to the world of infection prevention or looking for infection prevention resources? This guide can help!
See Tool

Long-Term Care Healthcare Associated Infections (HAI) and Immunization Reporting Tool
This template assists with infection and immunization reporting.
See Tool

NHSN Reporting Requirements – Webinar (6/24/2021)
Review of NHSN reporting requirements for long-term care facilities, including the COVID-19 vaccination module, with Tom Vincent, Data Analyst, Mountain-Pacific Quality Health, and Erika Baldry MPH, CIC, Communicable Disease Epidemiologist and Montana HAI Program Coordinator.
See Webinar
See Webinar Slide Deck

NHSN Frequently Asked Questions (FAQs) for Long-Term Care Facilities (LTCFs)
This document outlines the process for access to the NHSN and processes for facility administrators.
Access tool

CDC Long Term Care Antibiotic Stewardship
Access Webpage

Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes

This toolkit catalogs many solutions designed at the state level to protect vulnerable nursing home residents during the coronavirus disease 2019 (COVID-19) pandemic. This information was collected by a variety of partners, including Centers for Medicare & Medicaid Services (CMS) contractors of the Quality Improvement Organization (QIO) Program.

Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes | View Toolkit

Early Recognition of Sepsis in Long-Term Care – Webinar (9/19/18)
This 30-minute presentation will describe the development of the Nevada Sepsis Coalition Toolkit for skilled nursing facilities and provide an overview of the individual tools in the toolkit. The Sepsis Toolkit is designed to support skilled nursing facilities in early recognition and intervention for signs and symptoms of sepsis in residents.
See Webinar

Montana Antimicrobial Stewardship Resources
The Montana Antimicrobial Stewardship (ABS) Collaborative is a group effort to create a statewide Antimicrobial Stewardship Program (ASP) implementation plan. Our goal is to collaborate, assist and offer resources, expertise and tools through multiple programs for use by Montana inpatient and outpatient facilities.
Learn More

National Healthcare Safety Network (NHSN)
National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection tracking system. NHSN provides facilities, states, regions and the nation with data needed to identify problem areas, measure progress of prevention efforts and ultimately eliminate healthcare-associated infections.
Access Website Here

Resources for Self-Isolation and Self-Quarantine

These resources are designed to aid case investigators and contact tracers in asssessing ability to safely isolate or quarantine at home and the need for additional social support.

The Germinatr – Short Video

It's Worth a Shot Series

It’s Worth a Shot – COVID-19 Vaccination and Booster 2024 Series

A weekly educational session to discuss COVID-19 boosters and vaccines.

It’s Worth a Shot – COVID-19 Vaccination and Booster 2023 Series

A weekly educational session to discuss COVID-19 boosters and vaccines.

It’s Worth a Shot – COVID-19 Vaccination and Booster 2022 Series

A weekly educational session to discuss COVID-19 boosters and vaccines.

SOS - Sharing Out Suggestions for Compliance Care Coordination and Reducing Readmissions

Malnutrition: How to Nourish for Increased Quality of Health – Webinar (12/06/2023)

Head-to-Toe Health Assessment Tool
This tool provides a quick reference guide to completing a comprehensive resident assessment. The document was designed for use as either a one-page guide or to be cut into fourths and used as easy-access pocket cards.

Reducing Emergency Department Visits and 30-Day Readmission (May 2023)

Presented by Dr. Douglas Kuntzweiler, this presentation discusses how to reduce resident visits to the emergency department as well as how to reduce the rate of 30-day readmissions.

COPD Booklet
A practical guide to living with Chronic Obstructive Pulmonary Disease
See Booklet

Transitions of Care Toolkit

How to Refer – Reference Partner Cards
Access Cards

COPD Zone Tool
See Tool

Skilled Nursing Facility Rehospitalization Risk Assessment
See Tool

Heart Disease Zone Tool
See Tool

Herramienta de manejo de la salud cardiovascular
Ver herramienta

Living with Heart Failure Booklet
A Guide to Keeping a Strong and Steady Beat
See Booklet

Resident Information Booklet
Go to the hospital or stay here?
See Booklet
See Two-page Tear-off

Skilled Nursing Facility (SNF) Resident Pre-Admission Checklist
See Tool

S.B.A.R.
A structured resident safety communication technique designed to convey a great deal of information in a succinct and brief manner.
See Tool

Best Practices for Pain Management and prevention of Re-admission Webinar
Access Webinar

Hawaii Long-Term Care Workgroup
The following resources offer education and awareness around providing care during the COVID-19 outbreak, according to the Hawaii Department of Health (DOH) and Centers for Disease Control and Prevention (CDC) guidelines:

Interfacility Transfers
PreAdmission Huddle Equipment – Special Care Needs for SNF Residents
See Tool

Nursing Home Kickoff – Webinar (July 2020)
During this webinar, Mountain-Pacific Quality Health Program Director Mary Erickson presents our nursing home initiatives, including the new goals and objectives for Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) work. Topics covered include infection prevention and support, prevention of emergency room and hospital visits/readmissions, improving resident access to behavioral health, changes to recruitment and participation and changes to Mountain-Pacific staff.
Access Recording | View the Slides

SNF Transfer Checklist
See Tool

Welcome to the Reducing Preventable Admissions/Readmissions Nursing Home Collaborative: Understanding Changes in Readmission Measures in Nursing Homes – Webinar (9/7/2018)
See Webinar – 49 min

Staffing Resources

Staff Training Tracker for Facility Use

Creating a Culture of Staff Empowerment – Webinar (2/7/2018)
Nursing home leaders will share strategies to boost staff empowerment, increase ownership and accountability, engage staff in quality improvement and promote the retention of quality staff. Discover how staff empowerment and an organizational culture can improve the overall quality of care, environment and enhance the quality of life for both staff and residents alike.
See More

Employee Retention: Tips for Leaders
Employee turnover is costly and time-consuming. It creates stress for existing employees and scheduling havoc. Keeping good employees should be a leadership priority.
Access Tool Here

Peer Coach Training Materials
As a Peer Coach, you will serve as an integral part of the nursing home care community to promote quality improvement and provide support for those participating in the National Nursing Home Quality Care Collaborative.
Access Tool Here

Staffing Turnover
Access Tool Here

Tips for Success: Consistent Assignment
Access Tool Here

Tips for Success: Huddles
Access Tool Here

Tips for Success: Leadership Presence
Access Tool Here

Tips for Success: Staff Stability
Access Tool Here

Emergency Preparedness

Safe Evacuation Table Top Exercise for Long Term Care Facilities

This guidebook will help Long Term Care facilities (LTC) evaluate their preparedness plan for an evacuation. This guidebook contains all the materials necessary to conduct a simulated evacuation using a type of exercise called a tabletop exercise (TTX). No actual patient movement is involved.

Nursing Home Emergency Preparedness Checklist for Updated Guidance

In light of the coronavirus disease 2019 (COVID-19) public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) has updated the Emergency Preparedness Interpretive Guidelines to further expand on best practices, lessons learned and planning considerations for emerging infectious diseases (EID).

Nursing Home Emergency Procedures Flipchart

You can customize this tool to help with your emergency preparedness.

Emergency Preparedness Plan Template

Use this template to help with your emergency planning.

Emergency Preparedness Plan: After-Action Template

This tool can be used to evaluate the effectiveness and efficiency of an emergency preparedness plan.

Health Care Disaster Preparedness through Lessons Learned – Webinar

Resources for Resident Management

Culturally and Linguistically Appropriate Services (CLAS) Checklist
Access Tool Here

Wyoming Culture Change Webinar Series

Building culture change through community is only of many goals of the Wyoming Culture Change Coalition. Hosted by Carmen Bowman, Wyoming Culture Change Grant Project Coordinator, this webinar series focuses on a variety of topics impacting nursing home residents, staff and communities. Funded by the Wyoming State Survey Agency and the Centers for Medicare & Medicaid (CMS) Region VIII-funded CMP Grant, all content is shared by Mountain-Pacific with permission.

Approaches to Quality Sleep Culture – Webinar (7/10/2019)
See Webinar

APY Reduction Packet
Questions to Ask before Starting Antipsychotic Medications
Access Tool Here

Changes in Condition: Diabetes and Hypoglycemia – Webinar (2/1/2019)
See Webinar – 55 min
See Slide Deck

CMS Hand in Hand: A Training Series for Nursing Homes
CMS Hand in Hand: A Training Series for Nursing Homes
Access Link Here

College Students and Professionals in Nursing Homes
Do you have problems with your students leaving while the dorms are closed for summer and holidays? Are your residents lonely and wish they had people who just had time to “be” with them? Check out these innovative living arrangements being utilized in other states and countries. Visionary – absolutely! The gap between our youth and elders is larger than ever and we are an aging society with need outgrowing resources. Outside of the box thinking is needed to solve our challenges and reunite our youth and elders.

3/3/16 – Video: “Why These Millennials Live in a Retirement Home,” posted by Seeker Stories (from Finland)
See Video – 3 minutes 8 seconds

12/12/14 – Video: “Dutch Retirement Home Breaks Boundaries and Age Divide,” posted by AFP news agency (from Holland)
See Video – 2 minutes 36 seconds

Article: “College Students Are Living Rent-Free in a Cleveland Retirement Home” by Smithsonian.com
Research shows that the unique arrangement could have health benefits for the elderly.
Cleveland: See More – 2 minutes

Creating a Memory Box
Creating a Memory Box for Residents with Dementia
Access Tool Here

Bowel and Bladder Incontinence Toolkit
This toolkit helps you complete a thorough assessment of, manage and monitor urinary incontinence among your long-term care residents.
Access Tool Here

Five Senses and Dementia
Using the Five Senses to Support Residents with Dementia
Access Tool Here

Incontinence Toolkit
Access Tool Here

INTERACT® Tools for the Early Recognition and Management of UTIs, CAP and Sepsis – Webinar (11/2/2018)
See Webinar – 1 hr 35 min

Music and Memory – How can this help your residents?
4/2/12 – Video: “Seniors Fall in Love with iPods at Retirement Home,” a news segment posted by Music & Memory
This WGAL news story features seniors benefitting from the services of Music & Memory.
See Video – 3 minutes

Nursing Homes: Resolving Ethical Dilemmas in Advance Care Planning – Webinar (9/14/2017)
See Webinar

Opioid Use in Long-Term Services and Supports | Online Modules
Access eight modules that each take about 20 minutes to complete. Instructions for delivering the modules as a group educational activity are included in the tool. Modules cover the following topics:

Pain Assessment in Advanced Dementia (PAIN AD) Tool
Access Tool Here

Pain Management in the Elderly – Webinar (1/9/2018)
Presentation by Steven Atkinson PA-C, MS
See Webinar Presentation – 1 hour 33 minutes
See Presentation Slides

Reducing Heart Failure Related Readmissions for Nursing Homes 2. Anticoagulants for Nursing Homes – Webinar (1/18/2019)
See Webinar – 52 min

Resident Information Booklet
Go to the hospital or stay here?
See Booklet
See Trifold Pamphlet
See Two-page Tear-off

Shodair Trauma-Informed Culture – Webinar (9/16/2020)

This one-hour overview of the Sanctuary model is designed to help participants better understand trauma-informed cultures. This webinar looks at why a trauma-informed culture matters and tools that can be used to cultivate resilience within the workplace.
See Video
See Slides

Teach Back Training
See Website

Trauma-Informed Care in Long-term Care – Webinar (5/16/2019)
See Video

Trauma-Informed Care – Nursing Home TIC Talks – Webinar (9/14/2020)

Mountain-Pacific Quality Health’s Trauma-Informed Care (TIC) Talk features a review of the basics of TIC and how it impacts health both physically and mentally. Viewers will also learn how the Community Resiliency Model (CRM) relates to TIC and how to stay “resilience-focused.” For information more CRM training options, please contact us.
See Video
See Slides

Video: Clinical Laboratory Tests, What do the Results Mean? (1/29/2019)
Empowering nurses to participate in antimicrobial stewardship programs is the missing link in strengthening antimicrobial stewardship and improving patient care. It has been found that nurses are generally not comfortable with microbiology reports. Tune in to learn how to interpret lab results to improve patient care and antimicrobial stewardship in your community.
See Video

Video: “How to De-escalate a Difficult Situation” by Teepa Snow, posted by My Alzheimer’s Story (8/15/15)
This video offers ten ways to de-escalate a crisis.
See Video – 4 minutes 56 seconds

Video: “What Is Validation? Interview with Naomi Feil” by Ed Feil (5/15/2012)
Naomi Feil explains what validation is and why it is important to restore dignity and self-worth by using this technique.
See Video – 4 minutes 3 seconds

Resources for QAPI and MDS

MDS Updates for the 2025 Fiscal Year – Webinar (9/3/2024)

A webinar discussing changes to the MDS ahead of the release on October 1, 2024.
See Webinar
See Slide Deck

MDS Warning and Error Messages on the Final Validation Report – Webinar (4/30/2024)

Jennifer LaBay, RN, discusses common error messages when submitting the final validation report within MDS.
See Webinar
See Slide Deck

Wyoming GWEP Newsletter – Quality Assurance and Performance Improvement (QAPI) Resources
Many of our partners and the Centers for Medicare & Medicaid Services offer QAPI tools
and resources. We have assembled a list for you to access as needed, depending on
where you are with your QAPI efforts.
Access Resource

Overview of the Minimum Data Set Changes: Sections D, K and O
Jennifer LaBay, RN, details the changes to Sections D, K and O of the MDS ahead of their October 1, 2023 release.
See Webinar
See Slide Deck

Introduction to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) Process – Webinar (5/2/2023)
Jennifer LaBay, RN, provides an overview of the RAI as it relates to MDS mandates.
See Webinar
See Slide Deck
Access the Minimum Data Set (MDS) Version 3.0

Sections K and M: Navigating the MDS to Ensure Accurate Nutrition, Wound Assessment and Coding – Webinar (9/20/2022)
Jennifer LaBay, RN, goes into Sections K and M of the Minimum Data Set (MDS), focusing on nutrition and wound assessment.
See Webinar
See Slide Deck

Storytelling through MDS – Webinar (5/26/2022)
Paula Konomos, RN, dives into the importance of the Minimum Data Set (MDS) and how data tells a story.
See Webinar
See Slide Deck

ARD Management: Making Molehills Out of Mountains – Webinar (4/28/2022)
Assessment reference date (ARD) management is a HUGE responsibility for MDS coordinators. During this webinar, you will learn how to break down the complexities of ARD management into simple processes for nurse assessment coordinators (NACs). This session is taught by the American Association of Post-Acute Care Nursing (AAPACN) development specialist Jessie McGill, RN, RAC-MT, RAC-MTA.
See Webinar
See Slide Deck

Back to Basics: Section GG – Webinar (9/22/2021)
Jessie McGill, RN, RAC-MT, RAC-MTA with American Association of Post-Acute Care Nursing will discuss section GG performance scales, tasks and subtasks, supporting documentation requirements for section GG and the differences between the performance periods on the OBRA and PPS assessments for section GG data collection.
See Webinar
See Slide Deck

Taking a “Shot” at the Influenza/Pneumococcal Vaccination Quality Measures – Webinar (6/9/2021)
Subject matter expert Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC, shared influenza and pneumonia vaccine process strategies and resources.

5-Star and Publicly Reported Quality Measure Update – Webinar (4/21/2021)
Subject matter expert Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC, shared updates to the five-star rating system and publicly reported quality measures.

Influenza and Pneumonia Immunization MDS Coding Tip Sheet – Handout (4/28/2021)
This tool is for nursing home Minimum Data Set (MDS) coordinators and those who support entering the MDS data. Use this information as a quick reference in addition to your Resident Assessment Instrument (RAI) manual and Quality Measures (QMs) Users Manual to accurately code influenza and pneumococcal vaccinations.

Minimum Data Set (MDS) Significant Change – Webinar (3/24/2021)
Mountain-Pacific Quality Health and the Wyoming Office of Healthcare Licensing and Survey co-hosted the webinar with Jane Belt, RN, MS, RAC-MT, RAC-MTA, QCP. Discussion and key topics focused on how to:

Are you ready for the October 1, 2019 PDPM – Webinar (9/11/2019)
Access Recording

Change Package
This change package is intended for nursing homes participating in the National Nursing Home Quality Care Collaborative, led by the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs), to improve care for the millions of nursing home residents across the country. The Collaborative will strive to instill quality and performance improvement practices, eliminate Healthcare-Acquired Conditions (HACs) and dramatically improve resident satisfaction by focusing on the systems
that impact quality such as: staffing, operations, communication, leadership, compliance, clinical models, quality of life indicators and specific, clinical outcomes (targeted focus on inappropriate antipsychotics in persons living with dementia, falls, pressure ulcers, physical restraints, urinary tract infections and health care-acquired infections).
Access Tool Here

CMS QAPI Resources
The Centers for Medicare & Medicaid Services (CMS) strives to provide nursing home providers with access to resources (materials or websites) to support QAPI implementation. Follow this link to those CMS resources.
Access Tool Here

Continuing the Quality Improvement Journey – Webinar (4/12/2017)
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Data Basics: Quality Measure Report Moving Forward – Webinar (6/18/2020)

Mountain-Pacific Quality Health’s data analyst Tom Vincent dives into the following topics: five-star rating changes; quality measure score/rating; Mountain-Pacific’s Quality Measure reports. Learn more about Mountain-Pacific’s nursing home initiative goals and the changes in quality measures.
See Video

Engaging Staff in QAPI – Webinar (5/10/2018)

Webinar with Deb Fournier, MSB, CPHQ, ML NHA, chief operations officer for Maine Veterans’ Homes. Hosted by HealthInsight Nevada.
See More

Honoring Choices: Engaging Providers in Advanced Care Planning – Webinar (12/1/2017)
This webinar defines advanced care planning, discusses how to integrate planning into care and shares how advanced care planning is being handled in Wisconsin through the medical society through a program called “Honoring Choices Wisconsin.”
See More

How to Access CASPER Report
See Tool

ICAMP – Immunization Champions, Advocates & Mentors Training Program
This national webinar on the Immunization Champions, Advocates & Mentors Program (ICAMP) was presented by The Gerontological Society of America (GSA). ICAMP is intended to mobilize and assist health care professionals in their efforts to increase adult immunization rates and to reach the ultimate destination: the achievement of Healthy People 2020 goals for adult immunization. ICAMP provides tools and resources that align with the National Vaccine Advisory Committee (NVAC) Standards for Adult Immunization Practice which includes assessing patients, making a strong recommendation, administering or referring, and documenting.
See Video and Slides

MDS 3.0 RAI Manual Updates: What Changed for October 1 (10/20/2016)
This year’s MDS 3.0 RAI User’s Manual update was packed full of changes, from a new item set (the Medicare Part A PPS Discharge Assessment), to the new section GG on the MDS (section GG!). These changes are big! This session will focus on detailing the rules according to final instructions from CMS. We’ll discuss clarifications and changes from CMS on how to accurately capture items in section GG such as “usual performance,” “helper” and when to complete the end of Medicare Part A Assessment. In addition to covering the big changes, the session will clarify the numerous miscellaneous changes to chapters 2 and 3, including MDS sections C, J, M and others.
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MDS Coding Webinar Series