Q&A: I just found out my facility was placed on a focus list! Any advice?

By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - June 12, 2019

Q: I just found out my facility was placed on a focus list! Any advice?

 

A: Consider looking at the facility's past survey history. You can pull CASPER reports with this information, which helps you pinpoint troubled areas. Make a list of these areas and prioritize them based on how many residents are affected by the issue and/or by the potential for harm to the residents. Once you have this past survey deficiency data, begin to look at systems that help keep you in compliance with these areas. For example, if you were cited for pressure ulcers, look at the entire pressure ulcer prevention and tracking system that you currently have (including a comprehensive review of policies). See if you can determine what areas of the system are breaking down. Again, using pressure ulcers as the example, if prevention devices are not being used properly, dig deeper to uncover why they are not used. If you find staff education is an issue, then provide the education. It has been my experience that facility leaders often start with education and hope that it resolves the issue but in reality you must first pinpoint why a system or process is breaking down so the education can be targeted to your specific issues. Involve other staff to help you identify issues; being a SFF means all hands on deck when it comes to correcting issues. Those who work closest to the resident are usually best at providing information and solutions so don't forget to include them. Once you have identified issues and solutions, test the solution on a small group before implementing change to the entire facility. This allows you to tweak the interventions if they do not produce the desired result. Once you roll out changes, don't forget to audit for compliance. Finally, take some time to take care of you and find little ways to celebrate any successes along the way. You can do this!


Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA

Vice President of Curriculum Development, AAPACN

 


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