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The survey process can be overwhelming. Surveyors arrive and begin evaluating whether the facility has met specific quality standards. Often, even the prospect of an impending survey leads to anxiety and fear for facility leaders and staff. Being aware of common citations and proactively putting plans in place to avoid those findings can help lessen the anxiety. Knowing the most-cited deficiencies and being survey ready at all times can help reduce the number of and lower the scope and severity of common citations.
Over the years, the top ten survey deficiencies have remained relatively constant, but the reasons that facilities receive a specific citation do vary across the country. Let’s look at the most-cited deficiencies across the nation since January 2019 and delve further into common reasons for the top two citations.
The underlying requirement in §483.40 of the Code of Federal Regulations (CFR) for F740 (Behavioral Health Services) feeds into multiple facets of the care process—and multiple additional F-tags:
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
In the realm of the revised survey process, an interesting F-tag has joined the list of the most frequently cited deficiencies across the country. The tag is F-842, and in case that regulatory number is not immediately familiar, it has to do with documentation: “Resident Records – Identifiable Information.”
Given our profession’s consistent focus on documentation, does that come as a surprise? It certainly did for this writer! Between January 2018 and April 2019, F-842 has been cited nearly 3,000 times, across all CMS Survey and Certification Regional Offices. In 2019 so far, there have been 250 deficiencies cited under F-842. Long-term care has long been required to maintain residents’ personal privacy and keep medical records confidential. This is not a new requirement of participation, so what is happening? Many of the citations stem from the medical record not being accurate and complete, which is a component of F-842.
Below are brief descriptions of a few of the cited deficiencies.
Every nursing facility must have resident care policies and procedures for respiratory care and services, including tracheostomy care and suctioning, to avoid a citation under §483.25(i) F695 Respiratory/Tracheostomy Care and Suctioning. The care policies must be developed with the medical director, the director of nursing, and when appropriate, a respiratory therapist. The respiratory care policies and procedures must be consistent with professional standards, be comprehensive and person-centered, and address each resident’s goals and preferences. The care policies must be developed prior to admitting any resident with respiratory care needs.
The State Operations Manual (SOM) defines an anticipated discharge as “a discharge that is planned and not due to the resident’s death or an emergency (e.g., hospitalization for an acute condition or emergency evacuation).” For every discharge that meets this definition of anticipated, whether it be to another healthcare facility or to the resident’s home, the discharging facility is required to provide a discharge summary. With its primary purpose being to ensure that care is safely coordinated from one setting to another, the discharge summary must inform the continuing care providers of the course of treatment provided by the discharging facility. This document should be detailed and include an accurate description of the resident’s current status along with current individualized care instructions.
In order to avoid a citation for §483.21(c)(2) F661 (Discharge Summary), the discharging facility must include at least the following in the discharge summary:
Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”
That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”
It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”
Here are seven key steps a DNS can take to get out in front of PDPM:
Nursing homes can have the most beautiful policies and procedures for infection prevention and control in the world, but if staff aren’t following through on them, they are a waste of paper, notes Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and faculty member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA.
“So monitoring and auditing infection prevention processes in the facility is a critical component of quality care,” says Burdsall. “Unfortunately, the focus on infection prevention has not always been well-supported because infection surveillance, monitoring whether proper supplies are available and used correctly, and watching whether staff are performing hand hygiene and correctly using personal protective equipment all take time, which means the effort costs money.”
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