CMS Midwest Division of Survey and Certification Long Term Care Provider Update 14-10

Two Survey and Certification Memos have been released since the last note:

14-37: Advance Guidance - Revisions to State Operations Manual (SOM), Appendix PP- Guidance to Surveyors for Long-Term Care (LTC) Facilities and Chapter 4 (7/3/14)

We have revised the Interpretive Guidelines and, where appropriate, Investigative Protocols for the following F Tags to incorporate Survey & Certification (S&C) policy memos issued from October 2003 through May 2014.  Specifically, the guidelines have been updated for the following F Tags:

F161 - Assurance of Financial Security

F202 - Documentation for Transfer and Discharge

F208 - Admission Policy

F221 - Physical Restraints

F278 - Accuracy of Assessment/Coordination/Certification/Penalty for Falsification

F281 - Services Provided Meet Professional Standards of Quality

F286 - Maintaining 15 Months of Resident Assessments (Use)

F332 - Medication Errors/Free of Medication Errors of 5% or Greater

F333 - Medication Errors/Residents are Free of Significant Medication Errors

F371 – Sanitary Conditions

F387 - Frequency of Physician Visits/Timeliness of Visits

F388 - Personal Visits by the Physician

F390 - Physician Delegation of Tasks in SNFs/Performance of Physician Tasks in NFs 

F425 - Pharmacy Services

F428 - Drug Regimen Review

F431 - Service Consultation/Labeling of Drugs and Biologicals/Storage of Drugs and 


F441 - Infection Control

F492 - Compliance with Federal, State and local laws and Professional Standards

F514 - Clinical Records

F516 - Resident Identifiable Information/Safeguard against loss, destruction, or 

           unauthorized use

Revisions to SOM Chapter 4:  Section 4132.1E Waiver of Program Prohibition has been revised to incorporate information consistent with CFR 483.151(c)(1).  Section 4542.2 State Agency (SA) Expenses for Training of SA Personnel has been revised to include Association of Health Facility Survey Agencies (AHFSA) to the list of annual meetings.

14-38: Rehabilitation Agencies: Fire Alarm Systems, SOM Appendix E Revision - Advance Copy (7/3/14)

The interpretive guidance for OPTs is revised to clarify the fire safety requirements.   Surveyors should review the revised Appendix E to view the requirements in their entirety.   Rehabilitation Agencies are required to have an automatic extinguishing system or an enclosure with a 1-hour fire resistance rating in hazardous areas as well as fire extinguishers, a fire alarm system, and a fire evacuation plan.  Air horns will not serve in place of a fire alarm system for Rehabilitation Agencies.   Rehabilitation Agencies cannot be certified or recertified and extension locations cannot be approved if they do not meet the minimum fire protection requirements.


Nursing Homes

The National Partnership to Improve Dementia Care in Nursing Homes is having its next call on August 19.

Culture Change

We received four documents from Pioneer Network and two from Action Pact.