Presented by:
Charlie Schlegel, Director
Division of Safety Inspection
And
Susan Williamson, Director
Division of Nursing Care Facilities

Facility and Survey 01/01/15 – 06/30/15
Facilities
703 Facilities
88,070 Beds
Surveys Completed
1,886 Total surveys
362 Re-licensure/recertification surveys (Full
Health Surveys)
564 Revisits (to all types of surveys)
1,442 On-site visits (includes complaint visits)

Facilities
703 Facilities
88,034 Beds
Surveys Completed
3,712 Total surveys
709 Re-licensure/recertification surveys (Full
Health Surveys)
1,109 Revisits (to all types of surveys)
2,805 On-site visits (includes complaint visits)

Facilities
706 Facilities
88,278 Beds
Surveys Completed
3,709 Total surveys
732 Re-licensure/recertification surveys (Full
Health Surveys)
1,076 Revisits (to all types of surveys)
2,852 On-site visits (includes complaint visits)

2012
89 Full Health Surveys were deficiency free
2013
74 Full Health Surveys were deficiency free
2014
68 Full Health Surveys were deficiency free
01/01/15 – 06/30/15
31 Full Health Surveys were deficiency free

Surveys with Scope & Severity D & Above
Standard
Surveys
Complaint
Surveys
Substandard
Quality of Care
2012 2013 2014
598 651 629
01/01/15 to
06/30/15
325
355
0
390
6
455
1
288
2

01/01/15 – 06/30/15 Frequency of DNCF Visits
Number of Visits % of PA facilities
20 +
10 to 19
6 to 9
2 to 5
1
0
0.00%
0.71%
3.98%
49.22%
28.88%
17.21%

Number of Visits % of PA facilities
20 +
10 to 19
6 to 9
2 to 5
1
0
0.28%
5.12%
18.35%
56.47%
18.92%
0.85%

• 2007 – 14
• 2008 – 22
• 2009 – 29
• 2010 – 10
• 2011– 18
• 2012 – 2
• 2013 – 2
• 2014 – 9
• 01/01/15 to
06/30/15 – 4

Pl/CMP=
Pll/CMP=
Plll/CMP=
Pl only=
Pll only=
PIV only=
CMP only=
2012
0
0
2
0
0
0
0
Pl=Provisional l license
2013
1
0
0
1
0
0
11
2014
01/01/15 to
06/30/15
0
8
4
2
1
2
0
Plll=Provisional lll license
2
0
0
6
1
0
0
Pll=Provisional ll license CMP=Civil Monetary Penalty

01/01/15 – 06/30/15 Incidents
• Total number of incident reports received:
10,845
• Most Frequently reported events:
Transfer to Hospital – 5,236
Abuse – 1,342
Other – 1,160

• Total number of incident reports received:
19,411
• Most Frequently reported events:
Transfer to Hospital – 9,822
Abuse – 2,375
Other – 2,185

• Total number of incident reports received:
19,198
• Most Frequently reported events:
Transfer to Hospital – 9,998
Abuse – 2,228
Other – 1,944

01/01/15 – 06/30/15 Complaint Data
Complaint Data
• Total received= 1,054
• Total substantiated= 314
(30%)
• Onsite investigations conducted= 89%
• Substantiated complaints with citations issued at “G” or above= 2.85%
Most Frequently Filed
• Care or Services 66.3%
• Resident Rights 15.9%
• Environment 8.4%

Complaint Data
• Total received= 1,930
• Total substantiated= 487
(25%)
• Onsite investigations conducted= 89%
• Substantiated complaints with citations issued at “G” or above= 1.5%
Most Frequently Filed
• Care or Services 66.0%
• Resident Rights 17.0%
• Environment 8.8%

Complaint Data
• Total received=1,854
• Total substantiated= 445
(24%)
• Onsite investigations conducted= 93%
• Substantiated complaints with citations issued at “G” or above= 1.8%
Most Frequently Filed
• Care or Services 65.6%
• Resident Rights 17.1%
• Environment 10.5%

2014
83 Tags Disputed
16% deleted (13)
17% revised (14)
67% upheld (56)
2013
92 Tags disputed
14% deleted (13)
7% revised (6)
79% upheld (73)
2012
48 Tags disputed
31% deleted (15)
19% revised (9)
50% upheld (24)
2011
122 Tags disputed
23% deleted (28)
11% revised (13)
66% upheld (81)
2010
108 Tags disputed
3% deleted (3)
12% revised (13)
85% upheld (92)

2014
26 Tags disputed
23% deleted (6)
4% revised (1)
73% upheld (19)
2013
14 tags disputed
7% revised (1)
86% upheld (12)
7% withdrawn (1)
2012
5 tags disputed
20% deleted (1)
80% upheld (4)

2014
1 tag disputed
100% upheld (1)
2013
10 tags disputed
100% upheld (10)

DSI Overview
• 2000 – 2012 LSC Update
• Renovation, Alteration and New Construction
Projects
• CMS S&C-13-58 – 2012 LSC Waivers
• CMS S&C-12-21 – LSC Cultural Change Waivers
• Plan of Correction and Time Limited Waivers

2012 LSC
• CMS FY2016 Draft Mission and Priority
Document to State Agencies includes:
– CMS Central Office training of states on the 2012
LSC
– CMS Central Office training of states on new rule regarding emergency preparedness

2012 LSC
• 2000 – 2012 LSC Changes
– Popular changes highlighted in CMS S&C Letters
• Patient lift and transport equipment in corridor
• Combustible decorations
• Generator load bank testing
• Sprinkler water flow devices and electric fire pumps
• LSC suites
• Door locking arrangements
• Recycling and patient record containers

2000 – 2012 LSC Changes
• Inspection and testing requirements for firerated door assemblies in accordance with
NFPA 80
• Inspection and testing requirements for smoke door assemblies in accordance with
NFPA 105

2000 – 2012 LSC Changes
• Fire-rated door assemblies
– Applies to new and existing installations
– Inspected and tested not less than annually
– Written record shall be signed and kept for inspection by the AHJ
– Functional testing by knowledgeable individuals
– Repairs shall be made “without delay”

2000 – 2012 LSC Changes
• Fire-rated door assemblies – Swinging doors
– Prior to testing, a visual inspection of both sides must be performed, to include the following:
• No holes or breaks in surfaces of door or frame
• Glazing, vision light frames and glazing beads
• No visible signs of damage to the door, frame, hinges, and hardware
• No parts are missing or broken
• Door clearances are appropriate
• Self-closing device operating properly

2000 – 2012 LSC Changes
• Fire-rated door assemblies – Swinging doors
– Visual inspection continued:
• If installed, the coordinator is working
• Latching hardware operates
• No auxiliary hardware installed that would interfere with proper door operation
• No field modifications that would void the label
• Gasketing and edge seals, if required, are inspected

2000 – 2012 LSC Changes
• Similar requirements for horizontal sliding, vertically sliding and rolling doors
• Also, similar requirements for smoke door assemblies
• Recommend that facilities begin preparing for the door testing and inspection requirements

2000 – 2012 LSC Changes
• Generator battery maintenance
• 2000 LSC references 1999 NFPA 110,
Emergency and Standby Power System
• This edition contains weekly inspection requirements, to include electrolyte levels
• Since this edition, maintenance free or sealed batteries have become more prevalent

2000 – 2012 LSC Changes
• For sealed batteries, the accepted weekly inspection, per manufacturer’s instructions and later editions of NFPA 110, is battery voltage
• It is not the intent that only non-sealed batteries be used based on the weekly inspection requirement of electrolyte levels in
1999 NFPA 110

2000 – 2012 LSC Changes
• Long story short….
• Sealed battery – battery voltage must be included in the weekly battery inspection
• Battery that is not sealed – electrolyte levels must be inspected weekly

Renovations and Construction
• 28 Pa Code § 205.4. Building plans.
• (a) There may be no new construction of a facility without the Department’s approval of final plans. There may be no alterations or additions to an existing building or conversion of a building or facility made prior to the
Department’s approval of final plans.

Renovations and Construction
• The health care facility is ultimately responsible for any renovation or construction project
• Extremely important to ensure that the architect, engineer and/or contractor receive plan approval from DOH prior to the start of any work
• Highly recommended that facilities use individuals with PA health care experience

Renovations and Construction
• What happens when you are unsure if a project would require plan review by DOH?
• Call the Central Office of the Division of Safety
Inspection at 717 787-1911
• Health Facility Plan Reviewers are available daily to field these questions

Renovations and Construction
• Plan reviewers will request a short narrative describing the proposed project
• If it is determined that the scope of work does not require a full plan review, the plan reviewer will respond to the facility with a letter for your file

Renovations and Construction
• Requesting an occupancy inspection
• DSI must survey and grant occupancy prior to the Division of Nursing Care
• DSI requires a minimum 30 day notice to schedule the occupancy survey
• DSI schedules are typically completed midmonth for the next month

Renovations and Construction
• A request that is received prior to the midmonth completion of the schedule is much easier to schedule
• A request that is received May 25 th for a requested occupancy survey on June 25 th is more difficult due to June’s schedule already being complete

Renovations and Construction
• Use one point of contact to request the occupancy survey
• This can be via email or regular mail:
– Include drawing number (H number)
– Facility ID number
– Date or date range requested
– Brief scope of project, especially if a phased project
– Point of contact information
• Keep DSI notified of any need to move the date of the occupancy survey

2012 LSC
• CMS has issued Survey & Certification Letters permitting certain provisions of the 2012 LSC through waivers
• S&C 12-21-LSC addresses cooking facilities, fixed furniture and patient lift equipment in the corridor, decorations and gas fireplaces

S&C-12-21-LSC
• Capacity of Means of Egress
– 18.2.3.4 (2) – Non-continuous projections not more than 6 inches from the corridor wall, positioned not less than 38 inches above the floor, shall be permitted.
– 19.2.3.4(2) – Where corridor width is at least 6 ft, non-continuous projections not more than 6 inches from the corridor wall, above the handrail height, shall be permitted.

S&C-12-21-LSC
Capacity of Means of Egress
– 18/19.2.3.4 (4) – Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
• The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 inches.
• The fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.

S&C-12-21-LSC
Capacity of Means of Egress
– 18/19.2.3.4 (4) (continued)
• The wheeled equipment is limited to the following:
– Equipment in use and carts in use
– Medical emergency equipment not in use
– Patient lift and transport equipment
– Note: S&C text states, “Also, previous guidance concerning “not in use” criteria found in S&C-10-
18-LSC is still applicable.”

S&C-12-21-LSC
Capacity of Means of Egress
– What has really changed?
– The only real change is that the 2012 LSC exempts patient lift and transport equipment from the “in use” provisions.
– Everything else is subject to the “30 minute rule.”
For example, computers on wheels, iv poles, dietary carts, housekeeping carts, etc.

Capacity of Means of Egress

S&C-12-21-LSC
Capacity of Means of Egress
– Where the corridor width is at least 8 ft, projections are permitted for fixed furniture, provided all the following conditions are met:
• The fixed furniture is securely attached to the wall or floor.
• The fixed furniture does not reduce the clear width of the corridor to less than 6 ft.
• The fixed furniture is located on one side of the corridor only.

S&C-12-21-LSC
Capacity of Means of Egress
• The fixed furniture is grouped such that each grouping does not exceed 50 square feet.
• The fixed furniture groupings are separated from each other by at least 10 ft.
• The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.

S&C-12-21-LSC
Capacity of Means of Egress
• Corridors must be protected throughout by a electrically supervised smoke detection system or arranged to allow direct staff supervision from a nurse station or similar space.
• The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system.

Capacity of Means of Egress

S&C-12-21-LSC
Alternative Kitchen Cooking Arrangements
• Within a fully sprinklered smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or less residents, one cooking facility shall be permitted to be open to the corridor, provided that the following requirements are met:

S&C-12-21-LSC
Alternative Kitchen Cooking Arrangements
– The portion of the nursing home must be separated from other portions of the facility by a smoke barrier.
– The cooktop or range is equipped with a range hood equal to the width of the cooking surface, with grease baffles or other clean-out capabilities.
– The range hood has a minimum airflow of 500 cfm.
– Hood is ducted to the exterior or equipped with a charcoal filter to remove smoke and odor.

S&C-12-21-LSC
Alternative Kitchen Cooking Arrangements
– The cooktop is protected by a fire suppression system listed in accordance with UL 300
(commercial) or UL 300a (residential).
– A manual release of the extinguishing system is provided.
– An interlock is provided to turn off all sources of fuel and electrical power to the cooktop when the suppression system is activated.

S&C-12-21-LSC
Alternative Kitchen Cooking Arrangements
– The use of solid fuel for cooking and deep fat frying are prohibited.
– Portable fire extinguisher is located in the kitchen area.
– A switch, which is locked or located in a restricted area, is provided to deactivate the cooktop when not under staff supervision. The switch must be on a timer, not exceeding 120 minutes, to automatically deactivate the cooktop, independent of staff action.

S&C-12-21-LSC
Alternative Kitchen Cooking Arrangements
– Procedures for the use, inspection, testing and maintenance of the cooking equipment are in accordance with NFPA 96 and manufacturer’s instructions.
– Two AC-powered photoelectric smoke alarms, interconnected and equipped with a silence feature, are located not closer than 20 feet to the cooktop.
– No smoke detector is located less than 20 feet from the cooktop.

Alternative Kitchen Cooking Arrangements

Alternative Kitchen Cooking Arrangements

S&C-12-21-LSC
HVAC – Direct-Vent Gas Fireplaces
• Direct-vent gas fireplaces shall be permitted inside of smoke compartments containing resident sleeping rooms, provided that the following criteria are met:
– No such device is located within a resident sleeping room.
– The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system, with listed quick response or residential sprinklers.

S&C-12-21-LSC
HVAC – Direct-Vent Gas Fireplaces
– Fireplace includes a sealed glass front with a wire mesh panel or screen.
– The controls for the fireplace are locked or located within a restricted location.
– Electrically supervised carbon monoxide detection is provided in the room where the fireplace is located.

Direct-Vent Gas Fireplaces

S&C-12-21-LSC
Combustible Decorations
• Combustible decorations, such as photographs, paintings, and other art, which are attached directly to walls, ceilings and non-rated doors, are permitted with the following requirements:

S&C-12-21-LSC
Combustible Decorations
– Decorations do not exceed 30% of the wall, ceiling and door areas inside any room or space in a smoke compartment that is fully sprinklered.
– Decorations do not exceed 50% of the wall, ceiling and door areas inside patient sleeping rooms, having a capacity not exceeding 4 residents, in a smoke compartment that is fully sprinklered.
– Decorations on non-fire rated doors do not interfere with the operation or latching of the door.

S&C-12-21-LSC

S&C-12-21-LSC
• S&C 12-21-LSC required that a facility request the use of the waiver (submitted to PADOH for review and then forwarded to CMS for final review and approval)
• Then the facility would be cited at each future survey and request the continuance of the waiver in the POC
• This is the typical CMS process for continuing waivers

S&C 13-58-LSC
• CMS issued S&C Letter 13-58-LSC on August
30, 2013
• This letter changes the previous S&C 12-21-
LSC guidance and adds more 2012 LSC provisions
• The 4 provisions of S&C 12-21-LSC are now categorical waivers

S&C 13-58-LSC
• What are categorical waivers?
– These waivers do not require the facility to formally request and receive prior approval from
CMS
– These waivers are not cited during the survey process
– These waivers do require notification of the intent to use the waiver
– The waivers are documented in the initial comments of all surveys

S&C 13-58-LSC
• How is notification accomplished?
– A template letter has been created for facilities
– Complete the template letter and forward to DSI
– The facility will receive a response letter for their survey file to produce at future Life Safety Code surveys

S&C 13-58-LSC
• Added provisions from the 2012 LSC available to facilities as categorical waivers:
– Medical Gas Alarm Panels
– Openings in Exit Enclosures
– Emergency Generators
– Door Locking Arrangements
– Suites
– Testing of Waterflow Devices and Pumps
– Recycling Containers

S&C 13-58-LSC
• Medical gas alarm panels
– Centralized computer system may be permitted as a substitute for one of the two master alarm panels required by 1999 NFPA 99
– Facility must fully comply with the remainder of the 1999 NFPA 99 master alarm panel requirements and Section 5.1.9.4 of 2012 NFPA 99

S&C 13-58-LSC
• Openings in exit enclosures
– Existing unoccupied mechanical spaces with firerated doors may open into an exit enclosure in accordance with Section 7.1.3.2(9)(c) of 2012
NFPA 101
– Space must only contain non-fuel-fired mechanical equipment
– No combustible storage
– Fully sprinklered building

S&C 13-58-LSC
• Emergency generators
– Annual load bank testing for diesel-powered generators reduced from 2 continuous hours to 1 hour and 30 minutes per Section 8.4.2.3 of 2010
NFPA 110
– All other testing and inspection requirements must be met

S&C 13-58-LSC
• Door locking arrangements
– Expansion of special locking arrangements to areas where the patients pose a security risk or where patients require specialized protective measures for their safety per Sections
18/19.2.2.2.2 – 18/19.2.2.2.6
– Emergency departments with secure holding rooms
– Pediatric/nursery units

S&C 13-58-LSC
• Suites
– One of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites
– One of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior
– An increase in sleeping room suite size up to 10,000 ft2
– Per Section 18/19.2.5.7 of 2012 NFPA 101

S&C 13-58-LSC
• Waterflow and pump testing
– Quarterly testing of vane-type and pressure switch type waterflow devices extended to semiannual testing per Sections 2-3.3 and 5-3.2 of 2011 NFPA
25
– Weekly testing of electric motor-driven pump assemblies extended to monthly per Sections 5.3 and 8.3 of 2011 NFPA 25

S&C 13-58-LSC
• Recycling containers
– Increase in size of containers used solely for recycling of clean waste or patient records awaiting destruction from 32 gallons to 96 gallons when outside of a hazardous storage area per
Section 18/19.7.5.7.2 of 2012 NFPA 101

POC and Time-Limited Waivers
• A typical survey track for LSC deficiencies gives facilities a maximum of 90 days to correct a deficiency prior to denial of payments for new admission (DPNA).
• Shorter survey tracks are possible if the LSC survey is pulled into a Health survey track. It is very important to communicate with your field office to understand timeframes for correction.

POC and Time-Limited Waivers
• If correction of a LSC deficiency is going to take more than 90 days, a Time-Limited
Waiver (TLW) must be requested.
• The TLW is to be requested at the Plan of
Correction (POC) of the initial LSC survey. If requested later, there is no guarantee that it will be approved by CMS within the survey track timeframe for the survey.

POC and Time-Limited Waivers
• Field offices are a great resource for what information is required within the TLW request letter and for sample letters.
• All TLW requests are reviewed by the field office and forwarded to central office.
• Upon review by central office, TLW’s can then be recommended to CMS.

POC and Time-Limited Waivers
• There is no specific timeframe that CMS responds to TLW requests. Depending on their schedule, it can be two weeks or possibly two months.
• Facilities receive a DPNA letter from CMS at 70 days in the survey track. This letter explains that DPNA begins at 90 days.

POC and Time-Limited Waivers
• While the survey is unannounced, and DOH cannot tell a facility when a revisit will occur, it is not the practice of DOH to permit a facility to reach DPNA when the facility has corrected all deficiencies within the 90-day period.
• This becomes more and more difficult when correction dates are close to the 90-day maximum, due to survey schedules.

Questions?

• DNCF 717-787-1816
• DSI 717-787-1911
• Message Board https://sais.health.pa.gov/commonpoc/Login/Login.aspx
• CMS Website www.cms.hhs.gov
• State Operations Manual http://cms.hhs.gov/manuals/Downloads/som107ap_pp_ guidelines_ltcf.pdf