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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.

Cyber Security

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

Discharge Notice Clarification

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

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

For questions related to PBJ policies, please email

PBJ website link:

2017 International Pressure Ulcer Prevalence

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.

Updated guidance- Federal Requirements for Providing Services to Justice Involved Individuals

CMS memo dated 12/23/2016: Revised to remove the requirements for, and all references to, hospital specialty units to ensure that hospitals are able to meet the unique security needs for justice involved individuals receiving treatment
*** Surveyor Guidance: The Centers for Medicare & Medicaid Services (CMS) are clarifying requirements for providing services to justice involved individuals in skilled nursing facilities (SNFs), nursing facilities (NFs), hospitals, psychiatric hospitals, critical access hospitals (CAHs), and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID).
Specifically, this guidance seeks to assure high quality care that is consistent with essential patient rights and safety for all individuals. (This policy memorandum replaces memo published 5/3/2016)

FSES update

Per CMS memo dated 12/16/2016

The Centers for Medicare & Medicaid Services (CMS) has adopted the 2012 Life Safety Code (LSC) and the 2012 Health Care Facilities Code (HCFC) through regulation (see 81 FR 26872, 5/4/16), effective July 5, 2016.
FSES Edition to be Used To Meet Fire Safety Requirements: If the FSES is being used to demonstrate compliance with the fire safety requirements, the version of the FSES for Health Care Occupancies and Board and Care Occupancies found in the 2013 edition of the Guide on Alternative Approaches to Life Safety, NFPA 101A must be used. A facility that achieves a passing score on the 2013 edition of the FSES will be considered to meet the fire safety requirements for certification and recertification with the Medicare and Medicaid programs.

Survey Start Date: CMS began surveying for compliance with the 2012 LSC and HCFC on November 1, 2016. Facilities may now use the 2013 edition of the FSES. * Time Limited Waiver for Corrective Action: Long Term Care (LTC) facilities using the FSES may be granted a time limited waiver to correct certain deficiencies.

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