ANNOUNCED SURVEYS - If a facility has completed construction or renovations, they notify the Division of their readiness for an inspection. Thus, the facility is aware that the Department will be conducting a visit. Visits are conducted for purposes of determining occupancy requirements. These are the only visits announced by the Division of Safety Inspection.
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) [Formerly HEALTH CARE FINANCING ADMINISTRATION (HCFA)] - The federal agency responsible for overseeing the Medicare and Medicaid programs.
CERTIFICATION SURVEY - Once the facility has been given a license to operate in the Commonwealth of Pennsylvania, they can voluntarily participate in the Medicare and/or Medicaid Programs. If they choose to participate, the Division conducts an initial certification survey to determine compliance with the federal requirements. Participation in these programs allows Medicare and Medicaid recipients to obtain services once the facility has been determined to be a qualified provider.
COMPLAINT SURVEY - An unannounced survey completed to investigate a complaint filed against a facility. Residents, family members, members of the public, etc., may file a complaint with the Department of Health. Complaints are kept confidential unless directed otherwise.
COMPLIANCE - The facility meets the requirements needed to participate in the Medicare/Medicaid programs.
CONSTRUCTION TYPES - The following list contains the construction designations contained in the National Fire Protection Association's Life Safety Code, NFPA #101. The information noted in parenthesis indicates the fire resistive ratings required for fireproofing structural members, and floor/roof assemblies. Automatic sprinkler designations for fully or partially sprinklered buildings are used by the Division to insure that the facility maintains compliance with the requirements of the Life Safety Code.
I (443) Fire Resistive
I (332) Fire Resistive
II (222) Fire Resistive
II (111) Protected Noncombustible
II (000) Unprotected Noncombustible
III (211) Protected Ordinary
III (200) Unprotected Ordinary
IV (2HH) Heavy Timber
V (111) Protected Wood Frame
V (000) Unprotected Wood Frame
FS Fully Sprinklered
PS Partially Sprinklered
DEFICIENCY - This is the result of the Department's review when the facility has failed to meet minimum regulatory requirements.
DEPARTMENT - Department of Health.
FIELD OFFICE - There are five regional offices located throughout the state that are responsible for monitoring health care facilities within the geographical territories assigned to each field office. The five regional offices are Harrisburg, Jackson Center, Norristown, Pittsburgh and Williamsport.
FIRE SAFETY EVALUATION SYSTEM (FSES) - When a health care facility does not comply with the Life Safety Code and for various reasons cannot readily come into compliance, a fire safety evaluation is performed. The Fire Safety Evaluation System (F.S.E.S.) is part of Appendix C of the Life Safety Code. This system provides a methodology to assist in developing equivalencies for health care facilities in order to comply with the Life Safety Code. The equivalency concept of the Code specifically allows the use of systems, methods or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability and safety to those prescribed by the Code. This alternate system of determining compliance requires the approval of the Fire Authority.
INCIDENT INVESTIGATION - An abbreviated standard survey conducted to investigate an unusual incident where resident health or safety may be at risk.
INITIAL COMMENTS - A statement made at the beginning of each deficiency report which tells the reader the construction type of the health care facility, the type of survey and the date(s) of the survey.
LAST INSPECTION - This is the most recent survey conducted by the Department that may be discloseable to the public. This may be a licensure, recertification, complaint, revisit or incident investigation.
LICENSURE SURVEY - A survey completed to verify that the facility is in compliance with state licensure regulations. The surveys are completed prior to the expiration of the current license and are usually unannounced.
LIFE SAFETY CODE SURVEY - A survey completed to verify that the facility at least meets the minimum requirements that provides a reasonable degree of safety through construction, fire protection, egress, and occupancy features necessary to minimize danger from fire, smoke, fumes or panic.
MONITORING VISIT - An unannounced survey to note progress towards the facility's correction of identified deficiencies.
NFPA STANDARDS - The National Fire Protection Association, which is an organization that develops, publishes, and disseminates timely consensus standards covering all areas of fire safety. The NFPA standards have been adopted by numerous state and federal authorities, giving them the force of law.
OBSERVATION -- The facility is required to submit a plan of correction for each observation. The plan must include how the facility will correct the identified concerns and what system will be implemented to prevent reoccurrence. The facility will indicate a target date for the correction of each observation. The department will conduct a revisit to determine if the facility was successful in implementing the plan of correction.
OCCUPANCY SURVEY - An announced survey conducted to insure regulatory compliance in a new or renovated area of the building prior to granting approval for patient utilization of the area.
PHYSICAL ENVIRONMENT - The
physical plant on building(s) that are utilized and equipped for the delivery of
patient care. The physical
environment includes essential life safety features, as well as electrical
service, plumbing, lighting, heating and ventilating systems, furniture, and
other features essential for patient care.
PLAN OF CORRECTION - This is the response the facility must develop to address/answer deficiencies identified during a survey. The facility has ten calendar days to submit to the Department of Health an acceptable plan of correction.
RECERTIFICATION SURVEY - An unannounced Medicare/Medicaid (certification) survey completed between 9 and 15 months following the last certification survey to verify that a facility is in compliance with federal regulations.
REVISIT SURVEY - An unannounced Medicare/Medicaid (certification) survey conducted after the date identified on the plan of correction when the facility determined that deficiencies would be corrected.
SCOPE OF DEFICIENCY (Nursing
Homes Only)
ISOLATED -- Scope of a deficiency is isolated when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.
PATTERN -- Scope of a deficiency is a pattern when more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the health care facility.
WIDESPREAD -- Scope of a deficiency is widespread when the problems causing the deficiency is pervasive in the health care facility and/or represents a systemic failure that affected or has the potential to affect a large portion or all of the facility's residents.
STANDARD SURVEY - A periodic inspection done to gather information concerning whether or not the facility meets the requirements for state licensure and Medicare/Medicaid participation.
UNANNOUNCED SURVEY - Surveys that are initiated without prior notification to the facility before entrance to conduct an inspection. All surveys are unannounced except for occupancy and initial licensure visits.