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:

1. F880 - Infection prevention and control

2. F689 - Free of accidents, hazards/supervision/devices

3. F812 - Food procurement/storage

4. F656 - Develop/implement comprehensive care plan

5. F684 - Quality of life

6. F761 - Label/storage of drugs and biologicals

7. F657 - Care plan timing and revision

8. F758 - Free from unnecessary psychotropic med/prn use

9. F677 - ADL care for dependent residents

10. F550 - Resident rights

(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.

CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in October 2019.

October 2019 Revisions

In October 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected the health inspection and quality measure domains. This section provides details on these changes.

Ratings changes for facilities that receive the abuse icon: To make it easier for consumers to identify facilities with instances of non-compliance related to abuse, starting in October 2019, CMS added an icon to highlight facilities that meet either of the following criteria: 

1. Harm-level abuse citation in the most recent survey cycle: Facilities cited for abuse where residents were found to be harmed (Scope/Severity of G or higher) on the most recent standard survey or on a complaint survey within the past 12 months. 
2. Repeat abuse citations: Facilities cited for abuse where residents were found to be potentially harmed (Scope/Severity of D or higher) on the most recent standard survey or on a complaint survey within the past 12 months and on the previous (i.e., second most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13 to 24 months ago). 

Nursing homes that receive the abuse icon have their health inspection rating capped at a maximum of two stars. Due to the methodology used to calculate the overall rating, the best overall quality rating a facility that receives the abuse icon can have is four stars. 

Removal of quality measures related to pain: CMS removed two quality measures (QMs) from the Nursing Home Compare website and the Five-Star Quality Rating System in October 2019. These measures are: 

• Percentage of short-stay residents who report moderate to severe pain. 
• Percentage of long-stay residents who report moderate to severe pain. 

As a result of dropping these two measures, the cut-points for the long-stay, short-stay, and overall QM ratings changed. These changes were made to maintain, as close as possible, the same distribution of short-stay and long-stay QM ratings as were posted on Nursing Home Compare in July 2019. 

CMS has established a Dementia Care Resources page to provide information that was previously housed at the National Nursing Home Quality Improvement Campaign. Additional resources are available through the QIO program.

At the conclusion of the session, the participant will be able to accomplish the following:

• Describe the burden of multidrug-resistant organisms (MDROs).
• Describe challenges to preventing MDRO transmission in nursing homes.
• Define Standard Precautions, Enhanced Barrier Precautions, and Contact Precautions.
• Identify which residents and activities meet criteria for Enhanced Barrier Precautions.
• Discuss best practices for implementing Enhanced Barrier Precautions.

The U.S. Department of Health and Human Services published a new Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics - PDF. Individual patients, as well as the health of the public, benefit when opioids are prescribed only when the benefit of using opioids outweighs the risks.  But once a patient is on opioids for a prolonged duration, any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient. The HHS Guide provides advice to clinicians who are contemplating or initiating a change in opioid dosage.

“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. In certain situations, a reduced opioid dosage may be indicated, in joint consultation with the care team and the patient. HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.

Compiled from published guidelines and practices endorsed in the peer-reviewed literature, the Guide covers important issues to consider when changing a patient’s chronic pain therapy. It lists issues to consider prior to making a change, which include shared decision-making with the patient; issues to consider when initiating the change; and issues to consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and provide behavioral health support. 

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.