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Clarification Auto Fire Sprinkler Sys Installation Requirements

Per CMS memo dated 12/15/2016

Sprinkler Requirement for Long Term Care Facilities:
On May 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published the final rule Medicare and Medicaid Programs: Fire Safety Requirements for Certain Health Care Facilities (81 FR 26872). This regulation adopted the 2012 Life Safety Code (LSC), and the 2012 Health Care Facilities Code (HCFC). The 2012 LSC requires all existing and newly constructed health care facilities including long term care facilities to be equipped with a supervised automatic sprinkler system. This regulation requires compliance with the 2010 edition of National Fire Protection Association (NFPA) 13, Installation of Sprinkler Systems.

Sprinkler Installation Requirements for Attics containing Fire Retardant Treated Wood (FRTW): The use of FRTW is allowed to be installed in a facility in concealed or attic space without the installation of an automatic sprinkler system, provided that it meets certain conditions related to access, construction type, storage and fuel fired equipment. This is a change, because FRTW was not discussed clearly with regards to concealed spaces in the 2000 edition of the LSC or the 1999 edition of NFPA 13.

CMS Memo Dated 12/9/2016

The Centers for Medicare & Medicaid Services (CMS) will not enforce the new rule prohibiting skilled nursing facilities, nursing facilities and dually-certified facilities from using pre-dispute binding arbitration agreements while there is a court-ordered injunction in place prohibiting enforcement of this provision.

Infection Control Pilot 2017

Project Overview: The Centers for Medicare & Medicaid Services (CMS) is in the second year of a three year pilot project to improve assessment of infection control and prevention regulations in Long Term Care (LTC) facilities, hospitals, and during transitions of care. All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor.

Second Year Activities: Using draft surveyor Infection Control Worksheets (ICWS) based on the new Long Term Care regulation as well as a revised hospital surveyor ICWS, 40 hospital surveys will be paired with surveys of LTC facilities, in order to provide an opportunity to assess infection prevention during transitions of care. In addition, CMS will pilot technical assistance opportunities for facilities in efforts to improve their infection control programs to meet these new regulations. The draft ICWSs are attached to provide transparency of CMS pilot expectations.

Important – CMS training for Implementation of New NH Regs

Save the Date Training for Phase 1 Implementation of New Nursing Home Regulations

Need for Training: The Centers for Medicare and Medicaid Services (CMS) is developing an online training for Regional Offices (RO), State Survey Agencies (SA), providers and other stakeholders on the new Nursing Home Regulations. – Training Content and Availability: The online training will include information about Phase 1 of new Nursing Home Regulations, and will be available to all parties starting November 18, 2016. – Mandatory Requirement: All Long Term Care (LTC) surveyors are required to complete this training in order to be able to conduct any LTC surveys after November 28, 2016.

Annual long term care survey

This is a reminder that the annual Long Term Care survey is currently underway. LTC surveys this year are due on October 28, 2016. Completion of these online surveys is mandatory. You should have been contacted multiple times with your log-in information by email from the Department (sent to the Administrator). If you did not receive these communications, or if you have any questions, please notify the Division of Health Informatics at or call 717-547-3660.

PA Message Board memo – r/t saline syringes

Along with the PAHAN bulletin, as distributed earlier, PADOH has placed this specific message on the message board:

The Pennsylvania Department of Health (PADOH), in collaboration with the Centers for Disease Control and Prevention (CDC), U.S. Food and Drug Administration (FDA), and other state health departments, is currently investigating an outbreak of Burkholderia cepacia bloodstream infections. While the investigation is still in its early stages, contaminated prefilled saline flush syringes manufactured by Nurse Assist, Haltom City, Texas have been implicated as the source. The PADOH Bureau of Laboratories performed testing of Nurse Assist 10-milliliter saline flush syringes that were obtained from a Pennsylvania long-term care facility with reported cases; all unopened syringes tested were found to have been contaminated with B. cepacia.

PADOH recommends that any health care facilities, providers, or anyone else who have received Nurse Assist prepackaged three-, five- and 10-milliliter syringes of saline flush immediately discontinue using and sequester these saline products until further notice. At this time, DO NOT discard/destroy the products. DO NOT send flushes back to suppliers. All products should be placed together in a locked office. Guidance on the sequestered saline flush syringes will be forthcoming.

Notice: Five Star Preview Reports (posted 09/20/2016)

The Five Star Preview Reports will be available on September 20th. To access these reports, select the CASPER Reporting link located on the CMS QIES Systems for Providers page. Once in the CASPER Reporting system, select the 'Folders' button and access the Five Star Report in your 'st LTC facid' folder, where st is the 2-character postal code of the state in which your facility is located and facid is the state-assigned Facility ID of your facility.

Nursing Home Compare will update with August's Five Star data on September 28, 2016.

Important Note: The 5 Star Help line (800-839-9290) will be available September 26, 2016 through September 30, 2016. Please direct your inquiries to if the Help Line is not available.

RAVEN Software for Oct 1 2016 available

October 2016

Data Collection Software: jRAVEN v1.4.0 The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. Please consult the jRAVEN Installation and User Guides for additional information.

jRAVEN v1.4.0 is now available for download under the related links section at the bottom of this webpage and includes the following enhancements to jRAVEN v1.3.0:

  • v1.14.1 of the MDS 3.0 Item Sets
  • v2.00.0 of the MDS 3.0 Data Specifications
  • v2.00.4 of the MDS 3.0 Data Specifications Errata
  • Additional Help Content
  • 'Outdated' Assessment Status
  • Informational Message Updates
  • Reporting Enhancements
  • Import functionality compliant with the MDS 3.0 Data Specifications

    For additional technical support or questions related to jRAVEN please contact the QTSO Help Desk by calling 800-339-9313 or by email to

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