C.A.R.E.
Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Per the January 31, 2018 CASPER Data for last standard health surveys of active Skilled Nursing Facilities (excluding complaint, federal monitoring, and special focus surveys), the most frequently cited Severity Level is the D Level at 55.65% with E Levels coming in in second at 28.92%.
Severity Levels
|
Severity Levels |
Number |
% of Deficiencies |
|
B |
1,671 |
1.82% |
|
C |
2,250 |
2.46% |
|
D |
50,967 |
55.65% |
|
E |
26,487 |
28.92% |
|
F |
7,413 |
8.09% |
|
G |
1,719 |
1.88% |
|
H |
182 |
0.20% |
|
I |
1 |
0.00% |
|
J |
416 |
0.45% |
|
K |
361 |
0.39% |
|
L |
110 |
0.12% |
|
Total Deficiencies |
91,577 |
100% |
The purpose of a nursing home survey is to detect deficits (actual and potential) related to the services provided to the patients and residents within the facility. The inspection entails a review of the entire span of clinical and operational components with the common goal of safeguarding quality care. The survey process entails on-site observations, interviews with staff, family and patients as well as data analysis and medical record reviews.
The seriousness of the deficiency (F-Tag) is determined by the Scope and Severity of the issue. The below grid depicts the range of deficiencies and the interpretation of substantial compliance, substandard care to immediate jeopardy.
Severity (Level 1, 2, 3 and 4)
The term Severity refers to the how serious the issue is or what the potential for harm.
|
Level |
Letter |
How Serious and Potential for Harm |
|
Level 1 |
A, B, C |
Not Serious Not Actual Harm No potential for harm |
|
Level 2 |
D, E, F |
These tags are cited when there is noncompliance that is not actual harm but results in minimal discomfort to the resident or has the potential to cause harm. These are very common citations in nursing home surveys. |
|
Level 3 |
G, H, I |
They represent actual harm has occurred to a resident. Please note, a bruise, skin tear, or upsetting a resident can be considered actual harm. |
|
Level 4 |
J, K, L |
These are the lowest level tags a facility can receive on survey. This is Immediate Jeopardy terrain, and shortened to ‘IJ’. It is important to distinguish that an ‘IJ’ is an abbreviation for Immediate Jeopardy. “IJ” does not correspond to the I or J on the Scope and Severity Grid. It characterizes the organization of the row of letters J, K, and L, only. Therefore,
No actual harm must occur to receive an IJ tag. |
Immediate Jeopardy citations are often accompanied by a fine. This is known as Civil Monetary Penalty (CMP). The dollar amount ranges from $3,050 per day up to $10,000 per day. No to mention, a CMP’s may be retroactive to the date of the incident.
Scope (Isolated, Pattern, Widespread)
The term Scope refers to the number of residents who are impacted by the deficiency.
Isolated typically means the deficiency included a very small number of residents or a limited number of staff are involved or that the situation occurred only occasionally.
Pattern. This column is chosen when more than a few residents are affected, more than a limited number of staff are involved, or there are repeat occurrences. The rule of thumb for this column is 75%. If a deficient practice affects more than 3 residents but less than 75% of the nursing home population, it generally will be considered a “Pattern.”
Widespread. A problem affects many residents or if there is systemic failure in a facility.
Assessment Factors Use to Determine the Seriousness of Deficiencies Matrix
Harmony Healthcare International (HHI) is here to help. We understand how much work is involved for you and your staff to run an efficient, compliant, and fiscally sound facility.
Harmony Healthcare International (HHI) can:
- Identify areas of risk and opportunity
- Education on rules and regulations
- Implement Systems (QAPI)
- Monitor progress and performance
Harmony Healthcare International (HHI) performs monthly compliance audits. If you need help with this area, please contact us by clicking here. Looking to train your staff? Join us in person at one of our our upcoming Competency/Certification Courses. Click here to see the dates and locations.
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