Responding to a Legal Record Request

LTC Clarified: Weekly News, Insights & Connections

Written By:

Janine Lehman, RN, RAC-CT, CLNC

Director of Clinical Services

Proactive LTC Consulting

Receiving a legal record request can be a fear-provoking experience. It’s easy to assume the worst-case scenario is unfolding. However, legal record requests are submitted for many different reasons. When staff have been trained on proper procedures, it can help to alleviate stress and to ensure an effective response.

This 2-day intensive workshop is designed for Skilled Nursing Facility (SNF) Infection Preventionists (IPs) and healthcare professionals responsible for infection prevention and control (IPC) programs. Learn More

This 5-week intensive series offers long-term care professionals an in-depth understanding of the regulatory requirements and process involved when an Immediate Jeopardy (IJ) has been cited. Tips and strategies will be shared for writing an IJ Removal Plan and subsequent PoC, and for preparing for the IJ

removal and revisit surveys that will follow. Sessions 3 through 5 will focus on the most commonly cited IJ issues: Abuse, Infection Control, and Accidents/Incidents with best practices for risk reduction in these areas. Learn More

Ask Proactive!

Q: A resident had a fall at home resulting in multiple fractures. The resident was admitted to our facility following hospitalization and surgery. Would orthopedic aftercare be an appropriate primary diagnosis?

Written By:

Susan Pokorny, RN, GERO-BC, RAC-CT, RAC-CTA

MDS Consultant

Proactive LTC Consulting

Get the Answer

Upcoming Training Events

SEPTEMBER: Check out upcoming webinars in September!

QM Intensive: Using Data to Drive Improvement - Webinar

This session focuses on Quality Measure (QM) data analysis and using data to drive clinical and operational improvements. Presented by Shelly Maffia. Learn More

Understanding the MDS (For DONs and non-MDS Leaders) - Webinar

Participants will explore the relationship between clinical assessment, interdisciplinary collaboration, and MDS coding, as well as the resulting clinical and reimbursement outcomes. Presented by Eleisha Wilkes. Learn More

Infection Preventionist Virtual Workshop for Skilled Nursing Facilities - Webinar

RAC-CTA - Webinar

Take your experience to a higher level with the RAC-CTA certification. Presented by Christine Twombly in partnership with AAPACN. Learn More

Quality That Pays: How Clinical Excellence Drives Reimbursement - Webinar

This session will take place at the IHCA Annual Convention & Expo. Break down how everyday clinical practices directly impact reimbursement, quality measures, Five-Star ratings, and Medicaid add-on programs. Presented by Sarah Becker. Learn More

Ongoing Survey & Audit Preparedness - Webinar

Dive into proven strategies for maintaining compliance and excellence, with practical insights for anticipating and managing survey scrutiny from an MDS perspective. Presented by Eleisha Wilkes & Amy Stewart. Learn More

ICD-10 Coding Refresher - Webinar

This program will include information regarding the Official ICD-10 Coding Guidelines, best practices for accurate ICD-10-CM code assignment, how to avoid common coding mistakes, and the importance of principal diagnosis identification. Presented by Shelly Maffia. Learn More

In the News

Updated Five Star Cut Point Tables and Full Statement of Deficiencies

August 2026 updates to the Five Star Cut Point Tables and Full Statement of Deficiencies were posted and may be accessed here.

SNF Data Validation Process FAQs Updated

The SNF Data Validation Process audits accuracy of the MDS based QMs used in the SNF VBP and QRP programs. The SNF Data Validation Process FAQs were updated this month with new clarifications on facility notification of selection via email in addition to the iQIES notice and that notifications are expected to be released in February, May, August and November each year. In addition to other updates, CMS clarified that summary outcome reports would be released annually vs. the previous guidance of within 3 months of the submission deadline. Contact Proactive for assistance in responding to SNF Validation Process audits.

Contact Proactive LTC CareConnect for same-day access to seasoned clinical experts providing guidance to stabiliaze situations, reduce risk and move forward with confidence.

Learn more about our team

Proactive’s nurse, MDS, therapist, and operations consultant team includes SNF experts with backgrounds as DON, Operations Director, Clinical Reimbursement Director, Clinical Trainer, Surveyor, and Compliance Officer. Contact us to learn more about support options.

Our Services

Nurse Consulting	Interim MDS	Mock Survey
Legal Nurse Consulting	MDS Consulting	Medical Review
QAPI	5-Star	Regulatory Support
PDPM and CMI Audits	Infection Prevention & Control	Reimbursement Consulting
Training	Compliance Programs	Home Health Consulting