July 11, 2018
Regulatory Resources and Updates for Care Centers
On July 11, 2018 by Jonathan Lips
The Centers for Medicare & Medicaid Services (CMS) and the Minnesota Department of Health (MDH) issued a number of regulatory updates in the two weeks since we last published Advantage. Care centers will want to take note of these items:
MDH to Host Statewide Call on July 16
MDH will sponsor a statewide Nursing Home Regulatory telephone conference call on Monday, July 16 from 11 a.m. to Noon. An agenda will be posted here when available. MDH is pleased to offer a new statewide call system that does NOT require any registration. There is no limit to the number of participants. This new system enables MDH to archive a recording of the call, which will be posted on MDH website for 90 calendar days. To participate, call 844-302-0362 and use event number 793733705.
CMS Addresses Legionella Testing Questions
In welcome news, CMS has updated its Quality, Safety & Oversight memorandum concerning Legionella. Ever since CMS established the requirement last year for care centers to have water management programs addressing Legionella, there has been uncertainty about whether providers must test their water for the presence of the pathogen itself.
This memorandum states clearly that “CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. … LTC surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use.”
For additional guidance about when a facility might choose to conduct testing, see this Centers for Disease Control and Prevention Frequently Asked Questions page.
Liquid Oxygen Update
As anticipated (see our June 19 Advantage article), CMS has provided written guidance to MDH clarifying that existing care centers may store and use liquid oxygen in resident rooms without having to meet a fire-resistance enclosure rating.
What follows is a communication from the CMS Region V office in Chicago to MDH:
“CMS recently had a meeting between central office and the regional offices to discuss the applicability of NFPA 99 Section 11.7.4, 2012 Edition. During that meeting, it was pointed out that part of the requirements at 11.7.4 are separation requirements that include fire barriers that have a minimum of a 1 hour fire resistance rating. Therefore, this code section only applies to new construction after CMS adopted the LSC, 2012 Edition and NFPA 99, 2012 Edition. As a reminder, the regulation was published and effective July 5, 2016. Details were provided in S&C 16-29-LSC. Furthermore, it was stated in that memo that NFPA 99, 2012 Edition adopted only TIA 12-2, 12-3, 12-4, 12-5 and 12-6. NFPA recently released TIA 12-8 that pertains to NFPA 99 Section 11.7.4, but it is not enforceable by CMS, because that TIA was not one that was adopted on July 5, 2016. CMS would need to formally adopt that TIA before it is enforceable as a Federal requirement. To summarize, NFPA 99, 2012 Edition, Section 11.7.4 only pertains to new construction after the adoption of that edition on July 5, 2016. Also, TIA 12-8 that pertains to this code section has not been adopted through the rulemaking process and is not enforceable during a Federal survey. You will receive something from CMS if there are any changes to this guidance in the future.”
Frequently Asked Bed Rail Questions
CMS has prepared a Frequently Asked Questions document concerning bed rails, which addresses questions arising under F604, F700 and F909. CMS intends to post the document on its website within the next month; meanwhile, members may access the document by clicking here.
Immediate Jeopardy Removal Process
MDH has developed a document that surveyors will use any time they identify an Immediate Jeopardy situation. This one-page summary describes the process by which a care center submits a removal plan and MDH verifies the facility has implemented the plan.
Consistent with the CMS State Operations Manual Chapter 7, the MDH guidance emphasizes that a plan of correction should be deferred until after the immediate jeopardy has been removed and the facility receives its 2567 Statement of Deficiencies.