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Writing a plan of correction that will be accepted by the state survey agency is the first half of the battle to deal with any citations that the survey team hands out on the statement of deficiencies (form CMS-2567) in situations that don’t involve immediate jeopardy (IJ), says Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a partner in the Benesch Healthcare+ Practice Group at Benesch, Friedlander, Coplan & Aronoff in Columbus, OH. Note: Learn more about how to write a plan of correction that reduces negative impacts from survey in the AADNS Navigator article, “Writing a Plan of Correction: Keys to Success.”
The second half of the battle is successful, ongoing implementation of the plan of correction—and the stakes can be high. “While the plan of correction serves as the facility’s allegation of compliance in non-immediate jeopardy cases, substantial compliance cannot be certified and any remedies imposed cannot be lifted until facility compliance has been verified,” states the Centers for Medicare & Medicaid Services (CMS) in section 7317.1, Verifying Facility Compliance, of Chapter 7, “Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities,” of the State Operations Manual (SOM).
Note: Section 7317.2, Revisits, in chapter 7 of the SOM includes a chart that explains how surveyors certify compliance, the role of onsite revisits, and required remedies, up to and including the provider’s termination from the Medicare and Medicaid programs. In addition, section 7600, Continuation of Payments During Correction, addresses payment scenarios where states pursue alternative remedies to termination, and facilities do or don’t take corrective action according to the approved plan of correction and do or don’t achieve substantial compliance. Further, the August 17 Quality, Safety, & Oversight (QSO) memo QSO-20-35-ALL reviews changes to the revisit policy during the COVID-19 public health emergency.
Once again, the holiday season is upon us. However, due to the pandemic, the way people celebrate will be different this year. Holiday traditions that normally call for large gatherings of people—such as family dinners, religious ceremonies, and company holiday parties—will be planned keeping in mind the Centers for Disease Control and Prevention’s (CDC) recommendations for reducing disease transmission. Social distancing is critical because anytime people gather, especially those who do not live together, the risk of spreading the COVID-19 infection increases for everyone. The higher the level of community transmission in the area where the gathering is held, the higher the risk of spreading COVID-19 at the gathering. The frail elderly living in skilled nursing facilities (SNFs) are particularly susceptible to the spread of COVID-19, and it has been found that as the spread of the virus increases in the community, the risk for an outbreak in an SNF increases dramatically (AHCA, 2020).
Facility leaders, in addition to making personal holiday decisions, also need to be proactive and start making plans for how their facility will approach the holidays. This plan should not only include procedures for residents and staff but also address physical plant issues that may occur.
Getting the Facility Prepared
A surveyor approaches the DNS and shares that the team is investigating an acquired pressure injury and preliminary findings suggest the facility has not met the requirements for F684, Quality Care. Unless the director of nursing services (DNS) can produce evidence that contradicts their current assessment of the acquired pressure injury, the survey team will cite a deficiency, at a harm level. The DNS, confident everything was done to prevent the pressure injury, is shocked the survey team is considering issuing a citation and becomes anxious.
Leaders who have been in the long-term care field for a while have likely experienced a similar situation. The circumstances of a survey naturally produce some tension and anxiety, especially when the scope and severity of the deficiency a survey team is considering is significant; however, there are several tactics the DNS and other leaders can use to respond. By remaining calm and presenting compelling evidence of compliance, the DNS may be able to achieve a better outcome for the facility.
Know and understand the regulation
It is imperative to know and understand the regulation in question so that any discussions with the survey team are informed. The State Operations Manual (SOM), Appendix PP is the best resource for that knowledge and understanding. It states what the regulation is, but also provides instructions, checklists, and tools the surveyors utilize to investigate compliance. There are also interpretive guidelines through which the Centers for Medicare & Medicaid Services (CMS) clarifies the regulations with explanations, definitions, and examples of noncompliance.
In 1995, an artist named William Utermohlen was diagnosed with Alzheimer’s disease. He chronicled his experience living with dementia in self-portraits to express what was happening to him. As the disease progressed, his portraits became more abstract, and his final drawings were of distorted facial images with missing eyes. These images communicate the depth of confusion, fear, and loss of self and personhood Mr. Utermohlen experienced. According to the Centers for Disease Control and Prevention (CDC), almost 50 percent of the population living in nursing homes has some form of dementia. This statistic is not expected to decline, as the large baby boomer population is coming into the time of life when the risk for dementia increases significantly. Skilled nursing facilities (SNFs) and other post-acute care settings confront many challenges when caring for people with this complex disease, but the core tenet of care, which all settings should uphold, is to honor the person and their abilities while minimizing the person’s deficits.
It is essential to acknowledge there is a fundamental difference in viewing a resident as a person who also has dementia versus seeing a person as a “dementia resident.” The latter suggests the caregiver views the person as a disease first and foremost. While there are often medical complexities and clinical risks that accompany dementia, the person and not the disease is who is being cared for.
According to the Centers for Disease Control and Prevention (CDC), the elderly are the population most vulnerable to the effects of COVID-19, and the risk of illness severity increases with age. Other conditions—including diabetes mellitus, chronic kidney disease, neurological conditions such as dementia, cancer, cardiovascular disease, and obesity—also increase the risk for a severe case of COVID-19. Because those living in skilled nursing facilities (SNFs) generally are those with advanced age, comorbidities, or both, SNFs are on the forefront of battling this virus. Adding to the complexity of this fight, a recent paper by Perrotta et al., “COVID-19 and the Elderly: Insights into Pathogenesis and Clinical Decision-Making” reports that elderly patients with COVID-19 may present with atypical symptoms. This article explores how the nurse leader can help nurses gain the competencies necessary to care for residents who exhibit symptoms of potential COVID-19.
F726 Nursing Services
F-tag F726, Nursing Services, requires the following:
§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.
§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. (emphasis added)
Frailty made news in the U.S. healthcare community during the first phase of the COVID-19 pandemic when the United Kingdom-based National Institute for Health and Care Excellence’s (NICE) COVID-19 Rapid Guideline: Critical Care in Adults recommended that clinicians use frailty as a factor in determining whether patients would benefit from the most aggressive treatment (i.e., admission to the intensive care unit and ventilator use), says Margaret Sayers, MSc, NP, co-founder and vice president of product and research at the geriatric care solutions technology company Patient Pattern in Buffalo, NY.
“Frailty is becoming more well-known in the United States, but it has been used around the world for about 30 years,” explains Sayers. “In fact, since 2017 everyone over 65 in the United Kingdom has a frailty score calculated each time they have a healthcare encounter in any setting.”
Healthcare providers in the United Kingdom and other countries, including Canada, pay attention to frailty because it is a measurement of risk in people with multiple chronic illnesses, says Sayers. “Frailty is a measurement of risk that is agnostic to age and diagnosis. If a person is frail because their chronic conditions have impacted them cognitively or functionally, then they are frail whether they are 50 or 90.”
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