You Asked: What information must be documented on our fire drill form to meet Ohio Administrative Code 3701-17-25?
ODH Answered: Each fire exit drill must include a written record and evaluation, and the following elements are required to be documented and kept on file for three years:
- · Date and time the drill occurred.
- · Employee attendance, identifying which staff participated.
- · Verification that the fire alarm signal was transmitted to the fire department or monitoring station.
- · Confirmation that receipt of the alarm signal was verified.
- · Simulation of emergency fire conditions, note that movement of infirm or bedridden residents is not required.
- · Training format used, such as hands-on, demonstration, or discussion based.
- · Evaluation of the drill’s effectiveness, including any gaps identified or follow-up actions needed.
- · Notation if an overnight drill (9 p.m. to 6 a.m.) used a coded announcement rather than an audible alarm.
- · Confirmation that alarms were reset following the drill.
These elements ensure the facility can demonstrate compliance, staff preparedness, and continuous improvement in emergency response procedures. Top Enrollment is now open for the Winter 2026 session of the Core of Knowledge, a program designed for Administrators-in-Residence that fulfills the academic requirement set by the Board of Executives of Long-Term Services and Supports (BELTSS) for qualifying to sit for the state licensure board examination to become a Licensed Nursing Home Administrator (LNHA).
The three-week course will be held January 12–30, 2026, Monday through Thursday, at the OCLC Conference Center. This is one of only two opportunities to complete the required coursework in 2026.
The deadline to register is December 5, 2025. Learn more and register for the 2026 Winter Core of Knowledge. For additional information, contact Corey Markham at cmarkham@leadingageohio.org. The next Governance Webinar Series begins January 8, 2026. The four-part series, held each Thursday in January from 2 to 3 p.m., is designed for executives, leadership teams, and board members interested in examining the partnership between leadership and the board for long-term sustainability and organizational strength.
Sessions include Recruiting for Mission, Onboarding for Impact on January 8; Inspiring Why: Engaging Boards in Meaningful Philanthropy on January 15; Ready by Choice, Not by Chance: Strategic Affiliation Planning on January 22; and Governing in the Age of AI: Legal Considerations for Aging Services on January 29.
Member registration is $119 per person. Full details and registration are available here. LeadingAge Ohio has partnered with E&M Consulting, Inc. to produce a Membership Directory and Resource Guide for LeadingAge Ohio members to easily connect with other provider and business members. Be sure to visit your Company Profile, accessible by designated organization users, to ensure your organization’s information is up to date before the beginning of the new year.
The publication will be available in both print and digital formats and will be mailed to all LeadingAge Ohio members in early 2026.
If your organization is interested in advertising within the directory, contact E&M Consulting at advertising@eandmsales.com.
Questions about your organization’s Company Profile may be sent to Molly Homan at mhoman@leadingageohio.org. Top LeadingAge Ohio, together with the Ohio Health Care Association and the Ohio Assisted Living Association, recently engaged the Governor’s office regarding the Personal Needs Allowance increase enacted through the state operating budget, House Bill 96. While the increase is intended to support individuals with limited income, it appears to exclude residents of assisted living communities. This omission has raised immediate concerns for providers who support individuals relying on Medicaid’s assisted living benefit.
On November 19, LeadingAge Ohio met with Aaron Mabe, who leads health policy work within Governor DeWine’s office. Mabe shared that the administration is aware of the issue and has been in dialogue with Ohio Department of Aging Director Ursel McElroy. He noted that discussions had paused while broader budget implementation activities were under way, but the matter remains on the administration’s agenda.
The conversation was constructive, with Mabe indicating that state officials plan to confer with both the Ohio Department of Aging and the Ohio Department of Medicaid to identify a path toward possible resolution. He emphasized that the administration would reconnect with the associations as next steps take shape.
LeadingAge Ohio will continue to monitor these discussions closely and will keep members informed as the administration clarifies how the Personal Needs Allowance applies to assisted living residents and whether legislative or administrative action will be required to ensure equitable treatment across care settings.
For questions, please contact Eli Faes at efaes@leadingageohio.org. A new proposal in the Ohio General Assembly, House Bill 521, titled the Ohio Nurse Workforce and Safe Patient Act, would create mandatory registered nurse staffing ratios in hospitals and introduce a new statewide nurse staffing committee structure. While the legislation is designed primarily for acute care settings, several provisions reference units that include long-term care beds, skilled nursing beds, and special skilled nursing beds, prompting questions about whether any LeadingAge Ohio members could be subject to the bill.
The bill applies to any facility that meets the statutory definition of a hospital, which is an institution providing inpatient medical or surgical services for more than 24 hours. It also expressly includes long-term acute care hospitals and hospital units that hold skilled nursing or long-term care beds. Facilities excluded from the bill’s staffing mandates include freestanding inpatient rehabilitation facilities, freestanding birthing centers, and psychiatric hospitals operated by the Department of Behavioral Health.
Based on this structure, the bill does not appear to apply to traditional nursing homes, residential care facilities, or assisted living communities. However, it may affect hospital-based post-acute units, including hospital-owned skilled nursing, transitional care, or swing-bed units that are licensed or designated as hospital beds. The references to skilled nursing beds appear limited to settings operated under a hospital license. At this time, the bill does not appear to extend its staffing ratios to freestanding long-term care providers.
For providers that operate hospital-based skilled nursing units—particularly those within rural hospitals, which receive extended implementation timelines—the proposal creates new ratios for these units. The bill establishes a 1:5 registered nurse–to–patient ratio for any unit identified as skilled nursing. Hospitals would be prohibited from counting charge nurses or other supervisory nurses toward this ratio and would be required to maintain shift-by-shift staffing documentation accessible to staff and the public. Compliance would be monitored through semi-annual audits conducted by the Ohio Department of Health.
If you have questions about how your licensure status may interact with the bill language, contact Eli Faes at efaes@leadingageohio.org. The Ohio Department of Aging has highlighted new guidance from the Ohio Department of Medicaid as PASSPORT providers prepare for the January 1, 2026 requirement that all claims for services subject to Electronic Visit Verification include a matching EVV record at submission. Claims without a corresponding record will be denied.
To support providers ahead of this change, the Ohio Department of Medicaid is offering two virtual training sessions in December that review EVV basics and outline the updated claims validation process. Session details and registration are available on the Ohio Department of Aging’s website. These trainings supplement, but do not replace, the EVV instruction required under Ohio Administrative Code 5160-32-04 for agencies and independent providers seeking a Medicaid ID number.
Providers unable to attend may access daily office hours and upcoming “Get Ready for Claims Matching” programming. Questions can be directed to InteragencyPolicy@medicaid.ohio.gov. ODH is collecting Ohio IDs (OHIDs) from providers regulated under Chapter 3740 of the Ohio Revised Code as it transitions to its new Certification, Licensure, and Survey Systems (CLASS) platform. Background information is posted on ODH’s CLASS system information page, and providers can submit their OHID through the ODH OHID Survey. The survey remains open.
Why it matters:
CLASS will become the central system for licensure and survey activity. Ensuring correct OHID mapping now will prevent access issues later, particularly for organizations that interact with multiple state agencies.
What to do:
• Review ODH’s CLASS overview.
• Complete the OHID survey as soon as possible.
• Share survey instructions with staff who manage licensing or survey correspondence. Top The U.S. Department of Health and Human Services has repealed major provisions of the federal Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule, reversing staffing mandates that had been finalized in 2024 by the Centers for Medicare & Medicaid Services.
The decision, announced December 2, follows HHS’ determination that the rule placed disproportionate pressure on nursing homes in rural and Tribal communities and risked limiting access to care. HHS concluded that the rule’s one-size-fits-all requirements were not feasible for many communities facing persistent workforce shortages. Tribal leaders also raised concerns regarding insufficient consultation during the original rulemaking process, emphasizing the significant implications these requirements would have had for long-term care facilities serving Tribal elders.
HHS indicated that the repeal reflects the administration’s commitment to regulatory approaches that maintain both safety and access, noting that rigid federal staffing ratios could unintentionally restrict services in areas already struggling to recruit and retain nursing staff.
Read the press release from LeadingAge here. Staff for Senator Ron Wyden, chair of the U.S. Senate Finance Committee, recently met with LeadingAge to discuss how Institutional Special Needs Plans, or ISNPs, structure their contracts with nursing homes and how those arrangements may influence outcomes for people enrolled in the plans. Senator Wyden’s team is seeking direct feedback from nursing homes about their experiences with the ISNP model. Responses will remain off the record.
LeadingAge has outlined background on the request and the specific questions under review in its recent article. Nursing homes interested in providing input or learning more may contact Nicole Fallon at nfallon@leadingage.org. Top Under §483.10(h) F583, residents have the right to personal privacy during all aspects of care and daily routines. Surveyors will expect facilities to demonstrate that staff consistently protect resident privacy by removing residents from public view, ensuring privacy curtains are fully drawn, doors are closed when appropriate, and draping or clothing is used to prevent unnecessary exposure during care.
This includes avoiding practices that compromise privacy, such as performing blood glucose checks or other personal care tasks in common areas or in view of other residents. Facilities should ensure that catheter bags are kept discreetly covered with dignity bags, and that any signage related to a resident’s care needs is not openly displayed where it can be viewed by others unless the resident or their representative has specifically requested it.
Surveyors will also interview residents and staff to assess whether privacy practices are consistently followed and understood. They may observe care interactions to verify personal care is provided away from public view and that staff actively support resident dignity through appropriate privacy measures and respectful approaches to care.
In addition, if concerns are identified, surveyors will review facility policies and procedures to determine whether they clearly outline expectations for maintaining privacy during care delivery and whether staff have been trained to meet those standards. The final STAT: Survey Tips and Tactics webinar of the year will take place on December 10 at 11 a.m. December’s program concentrates on bowel and bladder care planning and continence management, an area where surveyors frequently identify gaps related to assessments, individualized toileting programs, restorative nursing practices, and documentation that supports the care each resident receives.
Learn more and register here. The Beneficiary and Family Centered Care–Quality Improvement Organization (BFCC-QIO), previously known as Livant,a has rebranded as Commence Health, following its integration with DOMA and Advanta Government Services. The unified organization will continue to provide the same QIO services and support while operating under its new name and digital presence.
Commence Health’s updated website, available at the Commence Health QIO portal, includes access to all BFCC-QIO service areas. Providers and individuals can use the site to locate information about services, check the status of an appeal, or submit an appeal online.
The BFCC-QIO’s responsibilities and processes remain unchanged under the new brand. Questions about the transition or requests for additional information may be directed to Commence Health at communications@Commence.ai. For those SNFs that have not yet submitted their Form CMS-855A revalidation application or, as applicable, SNF Attachment, this is an important reminder that you must do so by January 1, 2026 (previously August 1, 2025). Failure to do so could result in the stay or deactivation of your Medicare enrollment. CMS has released the MDS 3.0 Quality Measures User’s Manual v18.0 along with a full set of updated supporting files, all effective January 1, 2026. These materials outline the detailed specifications for the MDS-based quality measures included in the Nursing Home Quality Initiative and reflect several measure changes for the upcoming year. The complete file set is available in the Downloads section of the CMS Nursing Home Quality Measures webpage.
What’s new
- The MDS 3.0 QM User’s Manual v18.0 includes updated measure specifications and a Notable Changes section that highlights revisions from version 17.0, including the respecification of the Long Stay Antipsychotic Measure and modifications to functional measures following the removal of item O0400 from MDS version 1.20.1.
- The Risk Adjustment Appendix File provides updated logistic regression coefficients that support risk-adjusted measures within the Nursing Home Quality Initiative beginning January 1, 2026.
- CMS has issued refreshed claims-based technical specifications for Nursing Home Compare, including an updated 2025 Claims-based Measures Technical Specifications document and its accompanying appendix.
- The SNF QM User’s Manual v7.0, effective October 1, 2025, is included in the file set along with its Risk Adjustment Appendix. These documents incorporate the functional measure changes tied to the removal of item O0400.
Why it matters
- The updated manual and risk adjustment files will guide quality measure reporting for the 2026 program year.
- Changes to the functional and antipsychotic measures may influence future performance trends, public reporting, and quality improvement priorities.
- Providers should review the revised measure specifications early to ensure internal processes and MDS workflows are aligned with the 2026 expectations.
Members with specific technical questions are invited to reach out to Stephanie DeWees at SDeWees@leadingageohio.org for support. CMS has released the December 2025 Quarterly Confidential Feedback Reports for the FY 2027 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program. Reports are now available through the iQIES system and include baseline results for all eight measures that will be used to calculate incentive payments beginning October 1, 2026.
What’s in the report
- Facility-level results for the baseline period of all eight SNF VBP measures, including readmissions, hospitalizations, infections, staffing turnover, total staffing hours, discharge function, discharge to community, and long-stay falls with major injury.
- These baseline results will be used to score performance and determine incentive payments for the FY 2027 program year.
- Performance-period data will be released in the June 2026 Quarterly Confidential Feedback Reports.
Why it matters
- FY 2027 marks the first year of the expanded SNF VBP program, now assessing eight measures rather than four.
- The baseline report allows organizations to understand how they will be scored under the expanded model and identify areas needing attention before performance-period results are released.
- SNFs have 30 days, until January 1, 2026, to request corrections. CMS will consider correction requests only for calculation errors made by CMS or its contractors.
How to request corrections
- Submit correction requests to SNFVBPquestions@cms.hhs.gov with the subject line “SNF VBP Review and Correction Inquiry.”
- Include the facility name, CMS Certification Number (CCN), description of the requested correction, and the reason for the request.
Accessing your report
- Reports are available only in iQIES. SNFs can download their report by logging in, navigating to My Reports, and opening the MDS 3.0 Provider Preview Reports folder.
- Providers needing assistance may contact the QIES/iQIES Service Center at (800) 339-9313 or iqies@cms.hhs.gov.
More details on the SNF VBP program, including measure specifications and program updates, are available on the CMS SNF Value-Based Purchasing webpage. Top Top Maple Knoll Village has been named Retirement Community of the Year in the 2025 Greater Cincinnati Nonprofit of the Year Awards. The announcement, shared through Maple Knoll Communities’ recent LinkedIn post, highlights the organization’s continued commitment to creating a welcoming, person-centered environment where older adults can live, grow, and thrive. The recognition reflects the contributions of residents, families, volunteers, and the staff whose work strengthens Maple Knoll’s mission and its presence in the Cincinnati region. LeadingAge Ohio congratulates Maple Knoll Village on this achievement and celebrates the visibility it brings to Ohio’s nonprofit aging services sector. Top LeadingAge Ohio holds valuable education webinars and in-person events throughout the year. Opportunities are added weekly. See the complete Schedule of Events. Top
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