CMS Nurse Aide Training and Competency Evaluation Program Waiver and Appeal Requirements
The Centers for Medicare & Medicaid Services (CMS) is providing clarification regarding existing statutory and regulatory authority regarding waivers and appeals of NATCEP/CEP prohibition or loss.
CMS revised Policies for Immediate Imposition of Federal Remedies
This policy memo replaces S and C: 16-31-NH released July 22, 2016 and the revision on July 29, 2016:
Revisions to Chapter 7 of the State Operations Manual (SOM) (Attachment):
The Centers for Medicare & Medicaid Services (CMS) has revised guidance relating to the Immediate Imposition of Federal Remedies. Other sections of Chapter 7 have been revised to ensure consistency with these revisions.
Major revisions include:
We specify that when the current survey identifies Immediate Jeopardy (IJ) that does not result in serious injury, harm, impairment or death, the CMS Regions may determine the most appropriate remedy;
We clarified that Past Noncompliance deficiencies as described in SS7510.1 of this chapter, are not included in the criteria for Immediate Imposition of Remedies;
For Special Focus Facilities (SFFs), we now exclude any S/S level "F" citations under tags F812, F813 or F814 from the tags that require immediate imposition of remedies.
This memo is being released in draft. We seek comment on this policy by December 1, 2017
Program Memorandum No. 2017-04
Pressure Injury Reporting Online Education Now Available
On January 1, 2018, the new standards for Final Guidance for Pressure Injury Reporting Requirements under the Medical Care Availability and Reduction of Error (MCARE) Act will go into effect. This final guidance includes five principles that were jointly approved by the Pennsylvania Patient Safety Authority and the Pennsylvania Department of Health.
Training is now available for all acute care licensed facilities in Pennsylvania. Patient Safety Officers, their designees, and others involved with event determination should complete training prior to January 1, 2018. If there are others within your organization who would benefit from completing this curriculum, please forward this invitation to them.
Program Memorandum No. 2017-04 describes the registration and sign-in process to access this education curriculum.
When you are ready to begin the curriculum, register or login at
http://ecrilearning.ecri.org/PAPSRS_ACUTE. It is recommended that you save this link to your favorites in your Internet browser. The link is also provided in the "Resource" tab on PA-PSRS.
The Pennsylvania Patient Safety Authority
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Electronic Staffing Submission
Per CMS memo dated 9/25/2017
CMS will begin posting Payroll-Based Journal public use files which will be accessible at https://data.cms.gov/ on November 1, 2017.
The Nursing Home Compare website indicates whether providers have submitted data by the required deadline, and if providers have submitted, complete, incomplete, or inaccurate data.
We are updating the data submission specifications to give providers the ability to link employee IDs for an employee that has changed employee IDs within a facility and will post an updated PBJ policy manual and related information by October 1, 2017 at
Quality and Certification Oversight Reports (QCOR) website launch
Per memo dated 8/22/17: The Centers for Medicare & Medicaid Services (CMS) is releasing information related to the new QCOR website in an overarching initiative for increased transparency.
The following resuscitation reminders should be reinforced in facility CPR policies, procedures, and training.
It is recommended that 911 be called unless a "Do Not Resuscitate" (DNR) order is written by the resident's physician.
The 2015 American Heart Association Guidelines Update for CPR and ECC (Emergency Cardiac Care) provide the following advice regarding "Shock First vs CPR First":
"For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use."
It is also recommended that nursing facility CPR efforts should not cease until:
- an obvious sign of life, such as breathing, is observed,
- an AED is available and ready to use,
- EMTs provide relief, or
- a physician orders that efforts be terminated.
Further, it is important that the facility establish and use a mechanism to quickly identify a resident's choice for a DNR (Do Not Resuscitate) or full code. Some facilities have an indicator on the resident's armband while others have a designation placed in the resident's room. Regardless of the method, care should be taken to safeguard resident confidentiality.
There are many other parameters/guidelines for CPR, and we share the following links as additional references:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf(Surveyor guidelines referencing CPR in nursing facilities start on page 18)
Any questions or comments regarding the above should be directed to the Division of Provider Services, Bureau of Quality and Provider Management at 877-299-2918.
A listserv has been established for ongoing updates on the CHC program. It is titled OLTL-COMMUNITY-HEALTHCHOICES, please visit the ListServ Archives page at http://listserv.dpw.state.pa.us to update or register your email address.
Please share this email with other members of your organization as appropriate. Also, it is imperative that you notify the Office of Long-Term Living for changes that would affect your provider file, such as addresses and telephone numbers. Mail to/pay to addresses, email addresses, and phone numbers may be updated electronically through ePEAP, which can be accessed through the PROMISe provider portal. For any other provider file changes please notify the Bureau of Quality and Provider Management Enrollment and Certification Section at 1-800-932-0939 Option #1.
To ensure you receive email communications distributed from the Office of Long-Term Living, please visit the ListServ Archives page athttp://listserv.dpw.state.pa.us to update or register your email address.
Nominate a Patient Safety Champion
Nominations are currently being accepted for the 2018 I Am Patient Safety contest. This statewide contest recognizes and celebrates healthcare staff and/or facilities for their commitment to patient/resident safety. New this year is a category specific to long-term care. Please review the information packet and nominate a patient safety champion!
JoAnn Adkins, RN, BSN, CIC, FAPIC
Senior Infection Prevention Analyst
Pennsylvania Patient Safety Authority
Nursing Home Enforcement - Frequently Asked Questions
Fire and Smoke Door Annual Testing
CMS memo dated 7/2/17 noted that In health care occupancies, fire door assemblies are required to be annually inspected and tested in accordance with the 2010 National Fire Protection Association (NFPA) 80.
In health care occupancies, non-rated doors assemblies including corridor doors to patient care rooms and smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105. Non-rated doors should be routinely inspected as part of the facility maintenance program.
Full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018.
Life Safety Code (LSC) deficiencies associated with the annual inspection and testing of fire doors should be cited under K211 - Means of Egress - General.