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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:


News from PADONA – 06/28/17 – ADV – Pennsylvania Healthcare Facilities Infected with Ransomware

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.

Ransomeware Info

PA Dept of Health

Requirement to Reduce Legionella Risk in Health Care Facility Water Systems

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.

Appendix Z: Emergency preparedness – Final Rule

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.

CMS memo dated 5/12/2017

Implementation Issues, Long-Term Care Regulatory Changes: Substandard Quality of Care (SQC) and Clarification of Notice before Transfer or Discharge Requirements

Electronic Staffing Submission – PBJ Update 4/21/2017

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.

PCOM announces the Nursing Home Administration (NHA) Review Course

  • 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 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.

For questions, contact Ilene Warner-Maron, PhD RN NHA at or 215 871-6618

Special Focus Facility program Update

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.

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