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A few months ago, we provided members with a list of the top ten federal deficiencies since January of 2019. Since then, articles have delved deeper into the top four citations. This month, we will examine the number five and six top citations, explore common reasons that facilities struggle to meet these regulations, and discuss why surveyors cite them.
As a reminder, the top ten deficiencies are:
F880 - Infection prevention and control
F689 - Free of accidents, hazards/supervision/devices
F812 - Food procurement/storage
F656 - Develop/implement comprehensive care plan
F684 - Quality of care
F761 - Label/storage of drugs and biologicals
F657 - Care plan timing and revision
F758 - Free from unnecessary psychotropic med/prn use
F677 - ADL care for dependent residents
F550 - Resident rights
(The citations above in red have the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)
Meet Ms. Smith and Mrs. Johnson
During the DNS’s daily rounds, he overhears two CNAs conversing about how two residents frequently argue. The DNS inquires and learns Ms. Smith and Mrs. Johnson, both residents living in the memory care neighborhood, had an argument over a purse the previous evening. Ms. Smith grabbed the purse out of Mrs. Johnson’s hand, hit her twice with the purse, and walked away. Later the same day, a CNA sees Ms. Smith holding Mrs. Johnson’s arm and warning her to stay away from her purse or she will hit her with it again. Mrs. Johnson shakes her head and asks Ms. Smith to help her find her dog. The CNA re-directs Ms. Smith’s attention and assists her to her room so she can watch her favorite TV show. Two days later, Mrs. Johnson’s husband reports a bruise on his wife’s arm and is demanding to know what happened to her. There is no documentation in the medical record or incident report on file for any of the resident to resident altercations observed by the CNAs, nor the bruise. The following day, a state surveyor enters the facility to investigate a hotline complaint of abuse and requests the medical records for Ms. Smith and Mrs. Johnson.
Ms. Smith and Mrs. Johnson probably remind readers of other residents currently or previously in their care. The scenario described is also likely familiar. However, the perception of and regulatory requirements related to resident to resident altercations have evolved, as has the expectation for each case to be investigated for potential abuse. F600 states “The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.”
Last month, we provided members with a list of the top ten federal deficiencies since January of 2019. As a reminder, the top ten deficiencies are:
(The citations above in red reflect the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)
This month, we will take a deeper dive into the number three and four top citations and explore common reasons that facilities are struggling to meet these regulations.
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.
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