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RAI Spotlight Vol 11 issue 1
We are pleased to provide the latest issue of the RAI Spotlight, and hope that the information contained will be useful to you. Details are included about the teleconference on Further MDS Updates scheduled for October 13, 2016.
The latest issue of the RAI Spotlight will appear on the DOH Message Board for only 60 days.
The four most recent issues may be found in the Bulletins section of the Nursing Facility Report Portal (NFRP) (https://cmi.panfsubmit.com). If you are interested in an older issue, please contact the Myers and Stauffer help desk at 717-541-5809. A generic form to request a CD of any teleconference may be found in the Resources section of the NFRP.
Final MDS 3.0 item sets for 10-1-16 posted
From the MDS 3.0 Technical Information website below.
A new version (v1.14.1) of the MDS 3.0 item sets was posted. This version is scheduled to become effective October 1, 2016. The item sets should be considered final.
NOTE: The item sets are included in two (2) zip files found at the bottom of this web page download section.
Protecting Resident Privacy and Prohibiting Mental Abuse
Freedom from Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). Facility and State Agency Responsibilities: This memorandum discusses the facility and State responsibilities related to the protection of residents. Specifically, at the time of the next standard survey for both the Traditional survey and QIS, the survey team will request and review facility policies and procedures that prohibit staff from taking, keeping and/or distributing photographs and recordings that demean or humiliate a resident(s).
CMS Memo Dated 7/29/2016
Refer to the below link for CMS memo dated 7/29/2016 re Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies in Nursing Homes.
PA Dept. of Health – Division of Nursing Care Facilities
Nursing Home Survey Observations
DOH surveyors have observed issues with Reliant mechanical lifts. Facilities should read and follow the owner’s manual for proper operation and safety procedures. Specifically note weight limitation and do not use as a transport device. Facilities have been identified to be in an immediate jeopardy situation when it has been observed that the lifts do not have the correct clips. Facilities should inspect the lifts to determine whether their lifts have the correct clips and, if not, request them from the manufacturer, putting the lift out of service until they are obtained and documenting this monitoring process.
Surveyors have also seen increased instances of unresolved narcotic count discrepancies/losses, dosage errors with medications, resident elopements and instances when a two-person transfer is noted in the care plan but a one-person transfer was attempted and resulted in a fall with injuries.
Facilities are reminded that the Older Adults Protective Services Act (OAPSA) which was amended by Act 13 of 1997 mandates reporting suspected abuse to the local agency on aging and DOH. If the suspected abuse is sexual abuse, serious physical or bodily injury or suspicious death the law requires additional reporting to the PA Department of Aging (PDA) and local law enforcement.
Dementia Care in Nursing Homes
The link below is to CMS letter dated 6/3/2016 re report of results of the Focused Dementia Care Surveys FY 2015
Life Safety Surveys
The link below is to CMS letter dated 6/20/2016 referencing the adoption of the 2012 Life Safety Code and 2012 Health Care Facilities Code effective 7/5/2016 for surveys beginning 11/1/2016
Nursing Home Enforcement Report 2006-2014
CMS published the link on 6/3/2016 that includes Nursing Home Enforcement Actions from 2006-December 31, 2014
Payroll-Based Journal – LTCF Manual
Link is for the current April 2016 CMS policy manual on electronic staffing data submission.
Nursing Home Action Plan FY 2016-2017
CMS memo dated 5/20/2016 related to the Nursing Home Action Plan FY 2016-2017 that outlines 5 actionable strategies to improve nursing home safety and quality.
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