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Attention NAB Members and Stakeholders:
The new NAB exam study guide is now available. The new guide is online only, and covers the NAB Core exam and each of the line of service exams (NHA, RCAL and HCBS).
The guide can be purchased for $150 at
Revisions to CMP Tool:
When noncompliance exists, enforcement remedies, such as civil money penalties (CMPs), are intended to promote a swift return to substantial compliance for a sustained period of time, preventing future noncompliance.
To increase national consistency in imposing CMPs, the Centers for Medicare & Medicaid Services (CMS) is revising the CMP analytic tool in the following areas which are further explained within this policy memorandum:
Past Noncompliance; Per Instance CMP is the Default for Noncompliance Existed Before the Survey; Per Day CMP is the Default for Noncompliance Existing During the Survey and Beyond;
Revisit Timing; and Review of High CMPs.
This policy memo replaces S&C Memo 15-16-NH: The prior versions of the CMP Tool are obsolete, as of the effective date of this memo, July 17, 2017
Revised Interpretive Guidance: In September 2016, the Centers for Medicare & Medicaid Services (CMS) released revised Requirements for Participation under the Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities rule.
CMS is releasing revised Interpretive Guidance to be effective November 28, 2017.
Revised F Tags: The revisions to the regulations caused many of the prior regulatory citations to be re-designated. As such, CMS was required to re-number the F-Tags used to identify each regulatory part. Those new F-Tags are described here.
Training Resources: CMS is providing several training resources on our website and on an MLN Connect call on July 25, 2017 from 1:30 to 3:00pm EST.
Enforcement and Nursing Home Compare Considerations: To address concerns related to the scope and timing of the changes, CMS will be providing limited enforcement remedies for certain Phase 2 provisions and will be holding constant the Nursing Home Compare health inspection rating for one year.
Reasonable assurance will be applied to providers and suppliers once a termination action has been initiated by a State Survey Agency and the entity was allowed to terminate Medicare participation voluntarily before the termination action was made effective.
See Section 2016 and 2017 of the State Operations Manual (SOM).
PADONA Invitation to take part in important survey on antimicrobial stewardship and infection control practices
PADONA is requesting your assistance by participating in this voluntary survey, an important first step in our effort to better understand the status of antimicrobial stewardship programs and infection control practices that currently exist in Pennsylvania LTCFs. Although it’s voluntary, a high participation rate would enable a meaningful needs assessment of what is happening. Attached is a letter of request from Nkuchia M. M’ikanatha, DrPH, MPH, who is spearheading this effort. The link to the survey is below:
Yesterday, two healthcare facilities in Pennsylvania were infected with ransomware. The Pennsylvania Department of Health encourages all healthcare facilities to remain vigilant and follow proper information system security protocols. Please see the attached information alert and HHS update below regarding yesterday's attack, and forward this information to your IT staff where appropriate. If your facility finds yourself the victim of a cybersecurity attack, please notify your local FBI office and the Pennsylvania State Police fusion center.
Refer to below link for CMS memo dated 6/2/2017
Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk.
Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression.
Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities.
Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.
Facility Requirements to Prevent Legionella Infections: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.
Refer to link below for CMS memo dated 6/2/2017
Advanced Copy of Interpretive Guidelines: The Centers for Medicare & Medicaid Services (CMS) is releasing a new Appendix Z of the State Operations Manual (SOM) which contains the interpretive guidelines and survey procedures for the Emergency Preparedness Final Rule.
Affects all 17 providers and suppliers: Appendix Z applies to all 17 providers and suppliers included in the Final Rule.
Implementation Issues, Long-Term Care Regulatory Changes: Substandard Quality of Care (SQC) and Clarification of Notice before Transfer or Discharge Requirements
Mandatory staffing data submission through the Payroll-Based Journal began July 1, 2016.
Providers are reminded that they have until the 45th day after the end of each quarter to submit data.
To help providers improve their submissions, the Centers for Medicare & Medicaid Services (CMS) is providing feedback on each facility's data through their monthly Provider Preview reports. The Nursing Home Compare website now reflects whether providers have submitted data by the required deadline. Additionally, providers that have not submitted any data for two consecutive deadlines will have their overall and staffing star ratings suppressed.
- Tuesday, April 18, 2017 8-4 Pennsylvania Regulations and Administration – Chris Donati, NHA 7 CEUs
- Wednesday, April 19, 2017 8-4 Federal Regulations Part I – Joseph Townsend, NHA 7 CEUs
- Thursday, April 20, 2017 8-4 Federal Regulations Part 2 – Joseph Townsend, NHA 7 CEUs
For registration, please go to ContEd.pcom.edu and click on "VIEW CATALOG"
Each review course is listed and priced individually by date in our catalog. You may sign up for one course individually for $200.00 or you may purchase the full 3 course program for 550.00.
Refer to below link for CMS memo dated 3/2/2017 re Special Focus Facility program Updates :
Total SFF slots and candidates for each State: The number of designated slots and candidates for FY 2017 (see Appendix A) will not change from those effective since May 1, 2014.
Initial selection notice: The State Survey Agency (SA) must notify the provider in writing of their SFF selection and conduct a meeting (either onsite or via telephone) with the nursing home's accountable parties, and the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO), if the RO wants to be included.
Graduation from the SFF program: Once an SFF has completed two consecutive standard surveys with no deficiencies cited at a scope and severity of "F" or greater (or "G" or greater for Life Safety Code (LSC) deficiencies), and has had no complaint surveys with deficiencies at "F" or greater (or "G" or greater for Life Safety Code (LSC) deficiencies) in between those two standard surveys, the facility will graduate from the SFF program. However, if the only deficiency preventing graduation is an "F" level deficiency for food safety requirements (42 CFR SS483.60(i) Tag F371), the RO has discretion to allow the facility to graduate from the SFF program. F371 deficiencies at a "G" level or greater will prevent the facility from graduating from the SFF program.
Authority for termination: Consistent with longstanding authority, the CMS ROs may use discretionary termination for SFFs (or any facility) if necessary to protect resident health and safety.
Recommendations for Providers and Suppliers for Cyber Security: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.
The link is CMS memo of 1/13/2017
A Discharge Notice Clarification was posted to the Message Board yesterday that included the following message:
" CFR 483.15 (c)(3) Notice before transfer, was included in the updates to the Federal Regulations that were effective November 28, 2016. This requirement related to the notification of transfer or discharge, now includes an additional requirement for the facility to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
Additionally, CFR 483.15 (c)(5) Contents of the notice continues to require that the notice contain the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman (this is not new).
In collaboration with the office of the State Long Term Care Ombudsman, the Department of Health will review this requirement to ensure that the discharge notices contain all components outlined in the regulation including the contact information for the local and State ombudsman program, but, the notices are mailed, emailed, or faxed to the State Office, not to the local programs.
Attached is some helpful information put together by the PA Office of the Long-Term Care Ombudsman to assist facilities with compliance with this regulatory requirement."
The attachment is the information by the PA Office of the Long-Term Care Ombudsman titled, "NH Regs-Clarification on Discharge Notices."
Staffing Data Submission Reminder: As of July 1, 2016, electronic submission of staffing data through the Payroll-Based Journal (PBJ) is mandatory for all Long Term Care Facilities. You have up to 45 days after the end of the quarter to submit data for Federal Fiscal Quarter 1 (October 1, 2016-December 31, 2016.) The final submission file for this quarter is due on February 14, 2017. We encourage facilities to submit early to avoid system delays.
Please note that an updated policy manual and FAQ are now posted on the PBJ website.
For questions related to software or technical requirements, please emailNursingHomePBJTechIssues@cms.hhs.gov
For questions related to PBJ policies, please email NHstaffing@cms.hhs.gov
This is a free prevalence that gives nursing homes the opportunity to assess the prevalence of pressure ulcers in their facility and benchmark against other similar facilities. It is free until January 13.
PADONA is not endorsing the company or the program, but are making this opportunity available to you.
Whether you are interested in becoming a member, exhibitor, sponsor, scholarship recipient, etc, we will answer all of your questions. Lets schedule your free consultation.