CMS has directed the State Survey Agencies to resume more normal survey activities and the on-site survey process is back in full gear. HHI obtained the data directly from CMS’ Quality, Certification, and Oversight Reports for the period of January 1, 2021, to April 9, 2021. The data comes from surveys conducted across the country.
In this two-part blog, HHI will share the Top 16, most frequently cited survey tags during this timeframe. In addition, HHI offers some strategies and tips for survey preparedness.
The Top Eight Citations for the period of January 1, 2021, to April 9, 2021:
- F0880 Infection Control and Prevention
- F0884 Reporting – National Health and Safety Network
- F0689 Free of Accident Hazards/Supervision/Devices
- F0684 Quality of Care
- F0686 Treatment/services to Prevent/Heal Pressure Ulcers
- F0812 Food Procurement, Store/Prepare/Serve Sanitary
- F0580 Notify of Changes (Injury/Decline/Room, etc.)
- F0677 ADL Care Provided for Dependent residents
- F0880 - Infection Control and Prevention Citations come in as the number 1 regulation being cited during this period. If you have been a follower of survey results over the years, you will note some familiar citations. Except for new survey tags that were added due to the response to the COVID-19 pandemic, the regulations being cited have not changed much. If you are not a follower, you would think that Infection control became a big issue just this past year. This of course is not true. Infection Control is always in the top 5, possibly the top 3!
- F0884 - NHSN Reporting is one of those new requirements that have been added because of the COVID-19 pandemic. Lack of reporting or untimely reporting to the NHSN is being cited remotely, by the federal government. State agencies are not involved with giving this deficiency. A facility that has been negligent or late in reporting will receive their deficiency, without having a surveyor step into the building. This is what puts this tag near the top of the list.
- F0689 - Free of Accident Hazards/Supervision/Devices. This regulation is often cited in conjunction with other tags. There is a lot of opportunity for tagging this regulation, and facilities can be caught off-guard with the supervision aspect of this regulation. Adequate supervision will change from resident to resident and from time to time for the same resident. Be aware this tag covers a lot of material, and includes such things as resident-to-resident altercations, resident smoking concerns, not following the care plan, staffing levels that provide appropriate care and supervision, medication cart not locked, and physical plant hazards, just to name a few.
- F0684 - Quality of Care. This regulation pertains to the fundamental principle of providing quality of care in all treatment and care being provided to facility residents. This starts with the Resident assessment. All care must meet professional standards of practice and must reflect person-centered care and resident choices. If surveyors note a resident’s decline they would try to determine if the decline was avoidable or unavoidable.
- F0686 - Treatment/Services to Prevent/Heal Pressure Ulcers. Under normal times, limited mobility can contribute to the possibility of developing pressure ulcers. With a lessening of activity and even minimizing out-of-room opportunities during COVID-19 restrictions, there could be an increased risk for pressure ulcers. This is another area where surveyors would look to determine if a pressure ulcer is avoidable or unavoidable.
- F0812 - Food Procurement, Store/Prevent/Serve Sanitary. This tag comes and goes from the top ten citations nationwide. There is no surprise that it is here at number 6. The focus on sanitation goes back to infection prevention.
- F0580 - Notify of Changes (Injuries/Decline/Room). This goes back to basics. The physician and resident’s representative must be promptly notified and consulted when there is an accident or injury, after a significant change, and the decision to transfer or discharge. The resident and representative must be informed of a room or a roommate change.
- F0677 - ADL Care Provided for Dependent Residents. This regulation will be cited if surveyors determine that dependent residents are not receiving the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. If there is a decline in resident’s ability to perform ADLs, surveyors will look to determine if those declines were unavoidable. Diagnosis alone will not be a justification.
Part 1 "Sweet 16" Strategies for Survey Success
Strategy #1. Follow the Plan of Correction Beyond the Stated Timeframe
It’s all about infection control and prevention. If you have been cited for any infection control practices over the past 14 months, you should continue to follow your plan of correction, even if your plan said you would work your plan for less time. Surveyors coming into your facility will be reviewing these recent survey results before their arrival. Due to the pandemic, facilities have been allowed to narrow the focus of QAPI activity, but infection prevention must be part of that plan. Ongoing education and monitoring of staff should be a continuous focus throughout this year.
Strategy #2. Systems for Reporting to NHSN
You must have a backup plan for all reporting responsibilities. Some facilities have told us that one person is responsible for all reporting requirements. This takes a load off everyone else, but not necessarily a good operational plan. Designate a backup person or persons who have access to the reporting systems and are capable of completing the NHSN and other state and federal submissions.
Strategy #3. Prepare for Guests
Make sure your facility is ready for company. Let’s face it, there has not been a lot of traffic coming in and out of our facilities over the last 14 months. First impressions say a lot. Take a good look at each of your nursing units. Are they clean, really clean? Are the corridors clear? Has the clutter been put away? Have the Resident closets been neatened up? Are wheelchairs clean and in good repair? Is there any O2 tubing on the floor? Are there any missing light bulbs? Are your resident bulletin boards up to date? Is your survey material still available?
Strategy #4. Move, Move, Move!
Get your residents up and moving as much as possible. If COVID-19 restrictions still have your facility limiting group functions, be sure you are including doorway activities that focus on Resident movement. This is a sound idea to incorporate into your “normal” activities programming for those that don’t like to venture far from their rooms.
Strategy #5. Data Analysis in Preparation of Survey
When surveyors are picking their sample, much of their decision-making comes from information that you already have, and that you have provided to them. You must look at your data and determine which are your most vulnerable and dependent patients. Take a good look at each of their care plans to make sure they are uniquely identifiable and have person-centered approaches. Then go to the next step and observe the staff that is providing the care. Are they following the plan? Is there enough supervision for that resident? Does the need for supervision change in the evening after a long day?
Strategy #6. Food Preparation and More
There are many opportunities for citations in the kitchen and dining services, from storage to preparation, but a high-risk focus area should be the transfer of harmful substances or disease-causing microorganisms to food, by hands, food contact surfaces, sponges, clothes, towels, or utensils which are not washed after touching raw food, and then touching ready to eat foods. Monitor your food service workers and ensure they are following your policies as far as food handling procedures.
Strategy #7. Resident Participation in Activities of Daily Living
If you think there could be a concern with residents who have had a decline inability to perform ADLs, you should be making referrals to your Rehab team for possible Part B services. Also, consider using the Activities of Daily Living Critical Element (CE) Pathway to assess whether your facility has practices in place to identify, evaluate and intervene to, maintain, improve, or prevent an avoidable decline in ADLs.
Strategy #8. Communicate Consistently and Frequently with Residents, Staff, and Families
Be proactive with notifications to residents and representatives. Go beyond the minimal requirement of notifications. If changes are being planned to operations, for example, a change in visitation schedule or location, give the families advanced notice that you are working on implementing updated practices, based on revised regulations and let them know when they can expect to hear about the changes that will be forthcoming.
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