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News from PADONA

PADONA along with LeadingAge PA will be offering an educational series on Requirements of Participation for Nursing Homes, Phase 2 (RoPs), beginning Tuesday January 9th and then continuing biweekly on Tuesdays at 11:00am. This hour long series will help you gain an understanding of the Regulatory Requirements, discuss how to use the Critical Pathways to assure compliance and improve survey results, and Review examples of Practical Applications to achieve Regulatory Compliance. In the first session, Baker Tilly’s Director Clinical Advisory Services, Sophie Campbell will discuss Nursing Services – Sufficient and Competent Staff. Please look for the registration in coming weeks.

CMS Phase 2 Enforcement updates posted 11/24/2017

  • Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements: CMS will provide an 18 month moratorium on the imposition of certain enforcement remedies for specific Phase 2 requirements. This 18 month period will be used to educate facilities about specific new Phase 2 standards.
  • Freeze Health Inspection Star Ratings: Following the implementation of the new LTC survey process on November 28, 2017, CMS will hold constant the current health inspection star ratings on the Nursing Home Compare(NHC) website for any surveys occurring between November 28, 2017 and November 27, 2018.
  • Availability of Survey Findings: The survey findings of facilities surveyed under the new LTC survey process will be published on NHC, but will not be incorporated into calculations for the Five-Star Quality Rating System for 12 months. CMS will add indicators to NHC that summarize survey findings.
  • Methodological Changes and Changes in Nursing Home Compare: In early 2018, NHC health inspection star ratings will be based on the two most recent cycles of findings for standard health inspection surveys and the two most recent years of complaint inspections.

CMS Launch of Long-Term Care Survey memo dated 11/24/2017

  • The new computer-based LTCSP will be effective November 28, 2017.
  • Appendix P will no longer be available: Beginning with surveys occurring on November 28, 2017, Appendix P will no longer be accessible. The LTCSP procedure guide will replace Appendix P as the procedural and technical guide for conducting LTC standard surveys. Chapter 7 of the State Operations Manual (SOM) will be revised to include survey policy.
  • Survey Resources: A link to resources surveyors will need to conduct LTC surveys will be made available on November 17, 2017. Surveyors must download items included on this link to their survey laptops by November 28, 2017.

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 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.

Thank you,

The Pennsylvania Patient Safety Authority

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 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

CPR Reminder

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: 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 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 at 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!

Nominations must be submitted by October 2, 2017.

JoAnn Adkins, RN, BSN, CIC, FAPIC

Senior Infection Prevention Analyst

Pennsylvania Patient Safety Authority

NH enforcement

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.

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