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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

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.

Society of Healthcare Human Resources Professionals in Pennsylvania (SHHRPP) conference

We are excited to open registration for this year's conference for the Society of Healthcare Human Resources Professionals in Pennsylvania (SHHRPP) on October 12th and October 13th. This year's con

ference promises to be a special one with a fantastic educational program and great social and networking opportunities at the Toftrees Golf Resort, State College, Pennsylvania. Please see attached brochure including the agenda and registration form.

The Keynote Speaker Thursday will be Michael A. Aitken, SHRM's Vice President Government Affairs, with over 25 years of experience working on workplace and workforce issues, Mike is a leading authority on issues important to the human resource profession. As one of SHRM's primary spokespeople, Mike is regularly interviewed by the media and sought out as a speaker for business audiences. Other speakers are Arthur W. Breese, Director of Diversity, Geisinger Health Care System; W. Scott Hardy, Ogletree, Deakins, Nash, Smoak & Steward, P.C.; Thomas Cummins, CCP, Gallagher Surveys; Lynn C. Outwater, Attorney at Law, Jackson Lewis, P.C. and Kathie Simpson, PNAP Executive Director.

The educational value of this program is outstanding—members can participate in this two day conference at this resort for $150 – the early-bird special—much less for many one-day conferences and even webinars. SHHRPP is able to offer this outstanding conference at this great rate because of the generosity of sponsors and exhibitors.

In addition, Toftrees Golf Resort is offering a discounted rate for the SHHRPP room block at $109.00 per night. The rate is available for the SHHRPP room block on Wednesday, October 11, Thursday, October 12 and Friday, October 13th. To reserve a room at this rate, we strongly suggest that you contact the resort as soon as possible because October is a busy time for Penn State football games. Please click on the following link to reserve a room at Toftrees Golf Resort. You can also register on line for the conference at

Toftrees State College Hotel Location: Toftrees Golf Resort is located just off Route 322 and I-99 in State College, Pennsylvania; just one exit from Penn State University, Beaver Stadium and the Bryce Jordan Center. This State College hotel is in a peaceful and beautiful wooded area, but still is just less than two miles from great shopping and dining.

HOTEL NEAR UNIVERSITY PARK AIRPORT (SCE): Located just 3 miles away, Toftrees Golf Resort is the closest hotel/resort to the airport. The University Park Airport provides direct flights to and from Philadelphia, Washington D.C., and Detroit with services from Delta, United, and US Airways. A complimentary airport shuttle is available upon request for resort guests.

If you have any questions, please feel free to contact me at or


Thank you, Peggy Maxwell

SHHRPP Conference Coordinator

The New NAB Study Guide Is Available

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

CMS memo 7/7/2017 Revision of CMP Policies

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

CMS memo 6/30/2017 Revisions to SOM Appendix PP for Phase 2, F-tag revisions and related issues

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.

CMS memo 6/16/2017 re Reasonable Assurance

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:


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