Every March, the National Association of Councils on Developmental Disabilities (NACDD) and its partners collaborate to lead Developmental Disabilities Awareness Month (DDAM), an annual campaign highlighting how people with and without disabilities form strong communities together. Established in 1987 by President Ronald Reagan, Developmental Disabilities Awareness Month highlights the importance of fostering a society where people with disabilities are empowered to contribute to their communities. NACDD’s 2025 theme, We’re Here All Year, focuses on how people and programs are always contributing, not just during this observance.
Category: Gero Nurse Prep
Simplifying Oxygen Signage Requirements
Managing life safety compliance is a complex, multi-faceted task. It requires knowledge in multiple codes, utilization of the proper code editions, and determination of which requirements are applicable to your building. This blog post will break down the requirements around oxygen signage.
The Healthcare Facilities Code® (NFPA 99) contains most of the requirements related to oxygen systems, storage and signage. CMS has adopted the 2012 edition of NFPA 99. Oxygen signage requirements fall into two categories: signage for oxygen storage and signage when oxygen is in use.
When oxygen cylinders or containers are stored within an enclosure, a precautionary sign is required on the door or gate that is readable from a distance of five feet away. The signage must include the following wording:
This requirement is intended to apply to rooms and enclosures where multiple cylinders are being stored. It is not necessary to place signage everywhere an oxygen cylinder is located in a building. For example, cylinders available for emergency use on carts, at nurse stations, and staged in small quantities are not subject to oxygen storage signage requirements.
The signage requirements that apply when oxygen is being utilized in the building depend on the facility’s smoking policy. A facility that prohibits smoking is only required to provide precautionary signage at the building’s major entry points. However, a facility that allows smoking must provide precautionary signage wherever supplemental oxygen is in use, including the aisles and walkways leading to such areas. In all cases, the signage must be readable from a distance of five feet away. The annex section of NFPA 99 suggests signage be no smaller than 8 X 11 inches and include the following wording and symbol:
Finally, if liquid oxygen is used in the building and transfilling occurs – where liquid oxygen is transferred from a base reservoir container to portable liquid oxygen containers – signage must be posted at the transfilling location indicating that transfilling is occurring and smoking is not permitted in the immediate area.
The detailed requirements for oxygen signage can be found in Chapter 11 (Gas Equipment) of NFPA 99. NFPA provides a free viewer where you can access codes and standards on their website. Hardcopy and user-friendly on-line subscriptions are also available for a fee at www.nfpa.org.
AHCA is always available to support members with life safety compliance questions. Inquiries can be emailed to emergencyprep@ahca.org.
Now Available: ICD-10-CM Code Update Files
The Centers for Disease Prevention and Control (CDC) posted the updated ICD-10-CM code files to address revisions to the ICD-10-CM Official Guidelines for Coding and Reporting and other typographical errors. These updates are effective April 1, 2025. The CDC has announced there are no new ICD-10-CM codes effective April 1, 2025.
While there are no new ICD-10-CM codes, there is a significant update to the guidelines for coding COVID-19. The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
The following changes are noted in the guidelines for coding confirmed cases of COVID-19, effective April 1, 2025:
- Code only a confirmed diagnosis of the COVID-19 (U07.1) as documented by the provider (physician or other qualified health care practitioner legally accountable for establishing the patient’s diagnosis). The current guidance that documentation of a positive test is a confirmed diagnosis will no longer be in effect beginning April 1.
- For asymptomatic residents who test positive for COVID-19, query the medical provider as to whether or not the resident has COVID-19. The guidance notes that false positives are possible, and it is the medical provider’s responsibility to confirm and document a diagnosis.
This will result in a significant change in which residents will have the code U07.1 added to their medical records beginning April 1, 2025. These changes, however, do not impact NHSN reporting at this time. We will continue to monitor for any changes to NHSN reporting in the future and will provide updates if and when appropriate. Please send any questions to regulatory@ahca.org.
Now Available: 2025 National Skilled Nursing Care Week® Planning Guide, Resources, and Products
The American Health Care Association (AHCA) is excited to announce the launch of the 2025 National Skilled Nursing Care Week® (NSNCW) Planning Guide, promotional resources, logos/graphics, and products! These materials, available at NSNCW.org, are designed to assist in planning, promoting, and celebrating NSNCW and will provide you with all you need to make this week memorable for your residents, staff, and volunteers.
Begin your NSNCW 2025 preparations today and help us create a week filled with unforgettable moments! We look forward to celebrating with everyone and spreading joy throughout your communities May 11 through May 17, 2025.
HOW TO PARTICIPATE
Here are some ideas on how you can start planning your NSNCW celebrations now.
- Use the Planning Guide to plan your activities for the week. Or use them to help come up with your own unique celebrations!
- Begin planning how you will promote NSNCW activities with those outside your building. Use materials in the promotional toolkit to reach out to media, local and national elected officials, and your surrounding community to spread the word.
- Use the NSNCW graphics and logos to promote NSNCW in your newsletters and other materials.
- Visit NSNCW.org for a wide selection of Tapestry of Life themed gifts and decorations to help you celebrate the week. Be sure to order early!
Don’t forget to share! Be sure to tell us how your staff, volunteers, residents, and families are celebrating. Share your inspiring stories, photos, videos, and other content with AHCA/NCAL at storiesofcare@ahca.org. Remember to tag @NationalSkilledNursingCareWeek on Facebook and in any NSNCW-related posts and use #NSNCW.
ABOUT THE THEME
Tapestry of Life highlights the meaningful stories that make up each person’s journey in skilled nursing care. From residents and families to caregivers and staff, everyone adds a unique thread that is woven into this vibrant tapestry. This theme celebrates the connections, resilience and strength that unite us all. Learn more about NSNCW.
Join the Free COE-NF Behavioral Health Action Network Spring Series
Beginning in March 2025, the Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) will host a three-part series of virtual one-hour sessions.
These sessions are FREE to attend! Learn best practices from other nursing facilities and behavioral health subject matter experts. With the support of COE-NF behavioral health specialists, you will be able to implement the learnings in your facility.
Who Should Attend:
This series will improve the behavioral health knowledge and skill set of all staff working in CMS-certified nursing facilities across the United States.
Series Topics:
- Part 1: Incorporating behavioral health & substance use disorder (SUD) into Individualized Assessment & Person-Centered Care
- Part 2: Engaging with Residents: Effective Communication Skills
- Part 3: De-Escalating Aggressive Behavior and Crisis Situations with Residents
Sessions
Registration is required. Select only one cohort session from the list below to register.
Cohort 1 – all sessions at 12 pm EST
- Part 1: Tuesday, March 4, 2025
- Part 2: Tuesday, March 18, 2025
- Part 3: Tuesday, April 1, 2025
Cohort 2 – all sessions at 10 am EST
- Part 1: Thursday, March 6, 2025
- Part 2: Thursday, March 20, 2025
- Part 3: Thursday, April 3, 2025
Cohort 3 – all sessions at 2pm EST
- Part 1: Wednesday, March 12, 2025
- Part 2: Wednesday, March 26, 2025
- Part 3: Wednesday, April 9, 2025
Cohort 4 – all sessions at 4pm EST
- Part 1: Thursday, March 13, 2025
- Part 2: Thursday, March 27, 2025
- Part 3: Thursday, April 10, 2025
For more information, please call 1-844-314-1433 or email coeinfo@allianthealth.org.
How to Structure Your Compliance Program
Nursing, assisted living, and post-acute facilities have long been an area of scrutiny by the Office on Inspector General (OIG) as they are high-risk areas. It is important that an organization have a formal compliance program as proactive and preventive; a structure to address issues; and as a mitigating factor should compliance violations be identified by regulatory agencies.
OIG recognizes a common structure for compliance programs centered around seven elements. They are:
- Written policies, procedures, and standards of conduct
- How accessible are they to all employees?
- How often are they reviewed?
- What is the process/procedure for review and approval?
- Are they written in understandable language?
Find out more by going to https://www.providermagazine.com/Articles/Pages/How-to-Structure-Your-Compliance-Program.aspx
Do You Maintain a Compliant Fire Safety Plan?
Fire safety is a critical component of any healthcare organization’s overall safety program. As such, healthcare providers are required to develop facility-specific fire and evacuation procedures, provide fire safety training, and conduct regularly scheduled fire drills.
Most facility fire procedures correctly focus on the critical actions to take upon discovery of a fire. These actions are often simplified into an acronym such as RACE (rescue, alarm, contain, evacuate) or something similar. However, the Life Safety Code® requires some very specific information to be included in a healthcare occupancy’s fire safety plan. Review your fire safety plan and fire procedures against these nine (9) required components to ensure they are comprehensive and compliant with Section 19.7.2.2 of the Life Safety Code® (2012 edition) and CMS tag K-711.
- Use of Alarms: Upon discovery of a fire, procedures should direct staff to quickly activate the fire alarm system via the closest manual pull station. In addition to building-wide notification, activation of the fire alarm will likely initiate a variety of automatic actions such as door release, HVAC shutdown, and fire department notification.
- Transmission of Alarms to the Fire Department: Your fire alarm system most likely maintains some direct connection to ensure the fire department is automatically notified when the alarm is activated. This is commonly accomplished via the use of a central monitoring service. However, there are a handful of other arrangements that lead to the same outcome. Ensure your procedures specifically spell out how alarms are transmitted to the fire department.
- Emergency Phone Call to Fire Department: Although the fire alarm system is required to automatically contact the fire department, a direct phone call to the fire department (usually via 911), is an extremely important step. Not only does it serve as a back-up communication, but it allows the facility to provide details regarding the situation directly to emergency personnel. Specific information can be extremely valuable to dispatchers and firefighters and may have a direct impact on the emergency response. Make sure your procedures include a back-up phone call and clarify who is to make the back-up call on all shifts.
- Response to Alarms: It is important that procedures clarify who should respond to the fire area when. For example, during normal business hours, there are often additional staff in the building available to respond to alarms. However, in the evening and overnight, it may be necessary for additional clinical staff to report to the fire area to ensure there are enough hands to implement the procedures. Procedures should detail roles for all staff upon activation of the alarm.
- Isolation of the Fire: Health care occupancies are specifically designed to contain smoke, thereby limiting its ability to travel throughout the building. Closing doors, and keeping them closed, is a critical step in limiting smoke travel. Staff procedures should clarify their role in closing the door to the fire room along with the remaining doors in the building.
- Evacuation of Immediate Area: Quick removal of the occupants of the fire room is essential. Procedures should place emphasis on evacuation of the fire room followed by closure of the fire room door to keep smoke from spreading.
- Evacuation of the Smoke Compartment: Extended evacuation beyond the fire room is an important decision to be made and depends on a few factors. Procedures should clarify when it is appropriate to evacuate the remainder of the smoke compartment, order of evacuation, and the evacuation destination. Evacuation floorplans are often a helpful visual reference that clarify smoke barrier boundaries, evacuation direction, and fire department entry.
- Preparation of Floors and Building for Evacuation: While the initial point of focus is the immediate fire area, staff should simultaneously be taking action throughout the remainder of the building as well. This includes preparing for possible extended evacuation of the fire floor, floors above or below, or possibly the entire building. Procedures should outline who will determine the need for further evacuation, how it will be communicated, and what the extended evacuation process will entail. This may include vertical evacuation techniques for multi-story buildings.
- Extinguishment of Fire: It may be appropriate for staff to extinguish a fire. Procedures should clarify the situations, methods, and supporting equipment available for fire suppression.
Fire drills serve as an opportunity to evaluate staff knowledge and test staff implementation of the fire safety plan. Fire drills are required to be conducted quarterly on each shift with the drill times and conditions varied. Drills conducted between 6:00am and 9:00pm should include the activation of the building fire alarm system. Otherwise, overnight fire drills are permitted to use a coded announcement instead of audible alarms. It is not the intent of fire drills to excite or disturb residents. Detailed fire drill requirements are found in Section 19.7.1 of the Life Safety Code® (2012 edition) and referenced in CMS tag K-712.
Knowledge of applicable codes and standards is your best tool for ensuring life safety compliance. You can purchase a copy of the Life Safety Code® (NFPA 101) online at www.nfpa.org. The AHCA/NCAL website is also a good source for on-going fire safety education, tools, and resources.
Are Your New Admissions Vaccinated?
Vaccination against influenza (flu), COVID-19, and RSV reduces the likelihood of serious illness, hospitalization, or even death in long term care residents. LTC providers play an important role in protecting their residents by promoting vaccination against these viruses. And while influenza and COVID-19 vaccine are ideally administered in the fall, there is no wrong time to get vaccinated against these viruses.
This blog post serves as a reminder of the importance of promoting vaccination against respiratory viruses for newly admitted residents, offering actionable insights to strengthen your approach to infection prevention efforts.
Why is Vaccination Crucial for New Admissions?
Residents of nursing homes are at an increased risk of severe illness from respiratory infections due to factors such as age and underlying health conditions. Vaccination is one of the most effective ways to prevent the spread of respiratory viruses, particularly when new residents may not yet have immunity to certain viruses circulating in the community or within the facility itself.
By prioritizing vaccination for new admissions, you not only protect the health of individual residents but also contribute to the overall safety and well-being of your facility.
Best Practices for Promoting Vaccination in New Admissions:
- Incorporate Vaccination into Admission Protocols
When new residents are admitted, ensure that vaccination is part of the standard intake procedure. This means reviewing their vaccination history, checking for any necessary vaccines, and administering them as soon as possible.
- Educate Residents and Families
Many families may not fully understand the importance of vaccinations, especially when it comes to respiratory viruses. Provide clear and concise information about the benefits of vaccination and how it protects not only the individual but the entire community within your nursing home. Check out the AHCA/NCAL #GetVaccinated website for resources to support these conversations.
- Ensure Accessibility
Make the vaccination process as easy as possible. This could involve offering vaccines on-site or coordinating with local health providers for timely administration.
- Document and Follow-Up
Keep accurate records of vaccinations administered and follow up with residents who may have missed their vaccines at the time of admission. Regularly review resident records to ensure they stay up-to-date on necessary immunizations.
- Promote a Culture of Prevention
Foster an environment where vaccination and disease prevention are seen as routine, essential parts of resident care. This will not only increase vaccination rates but also contribute to a culture of health and well-being within your facility.
Conclusion: A Commitment to Safety
Promoting vaccination for new admissions is one of the simplest and most effective ways to prevent the spread of respiratory viruses in your nursing home. This not only protects their health but also safeguards the larger community of residents and staff. By making vaccination a top priority during the admission process, you’re taking a crucial step in the fight against respiratory illnesses and ensuring your facility remains a safe haven for all who call it home.
Polypharmacy Is a Problem in Senior Care
Polypharmacy, the concurrent use of multiple medications by a patient, is a growing concern in senior care. As the elderly population continues to grow, so too does the prevalence of chronic conditions that require pharmaceutical intervention. However, while medications can be life-saving, the indiscriminate use of multiple drugs often leads to adverse effects, drug interactions, and diminished quality of life for seniors.
Addressing polypharmacy is not just a medical issue; it’s a critical aspect of providing holistic, patient-centered care that respects the complexities of aging.
Read the full article at https://www.providermagazine.com/Articles/Pages/Polypharmacy-Is-a-Problem-in-Senior-Care.aspx
CMS Posts Updated Five-Star Quality Rating Program Technical User’s Guide
The updated Nursing Home Care Compare Technical Users’ Guide has been posted on the Centers for Medicare and Medicaid Services’ (CMS’) Five Star Quality Rating System Page.
Effective with the January 2025 refresh (expected on January 29th), CMS will unfreeze four quality measures (QMs) that were frozen beginning with the April 2024 refresh. These measures were updated to accommodate recent changes to the Minimum Data Set (MDS). Please refer to the CMS Memorandum QSO-25-01-NH for more information about these updates.