Survey Citations: Sweet 16 Strategies For Success Prt.2 Of 2


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The second Eight most frequently cited regulations during the first quarter of 2021 include the following:

9. F0656 Develop/Implement Comprehensive Care Plan

10. F0886 COVID-19 Testing – Residents and Staff

11. F0609 Reporting of Alleged Violations

12. F0761 Label/Store Drugs and Biologicals

13. F0842 Resident Records – Identifiable Information

14. F0755 Pharmacy Services/Procedures/Pharmacist/Records

15. F0600 Free from Abuse and Neglect

16. F0610 Investigate/Prevent/Correct Alleged Violations

  • F0656  Develop/Implement Comprehensive Care Plan


This regulation pertaining to care plans is often found in the top deficiencies cited, and in past years has even been in the number 1 position. There are so many opportunities for citations because deficiencies could address the facility’s lack of developing a person-centered care plan, as well as a deficit of implementing or carrying out the care plan as stated. This tag is often cross-tagged with F0689 or F0684.


  • F0886COVID-19 Testing – Residents and Staff


This is a new tag that was generated in response to the COVID-19 Public Health Emergency (PHE). This covers the testing of staff and residents, using community positivity rates and facility outbreaks. The directives on when/how often to test, are subject to change.

  • F0609 - Reporting of Alleged Violations


Reporting of Alleged Violations comes in at number 11 and often appears higher up on the list of most often cited deficiencies. Staff must understand what it means to report all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation immediately to the administrator.


  • F0761Labeling/Store Drugs and Biologicals


Labeling/Store Drugs and Biologicals covers an array of possible citations regarding proper and safe storage and limiting access to all but authorized personnel. Deficiencies could be levied for such things as unlocked medication carts, unlocked medication rooms, expired medications on medication carts, and in medication rooms. This tag also addresses medications not being stored under proper temperature controls and medications being left unattended at a resident’s bedside.


  • F0842 - Resident Records - Identifiable Information


Resident Records – Identifiable Information is a regulation that covers a multitude of requirements regarding resident medical records, including but not limited to confidentiality in protecting the resident’s information against unauthorized use (regardless of the storage method), required professional standards of practice for the facility to maintain records on each resident that are complete, accurately documented, readily accessible, and systematically organized.


  • F0755 - Pharmacy Services/Procedures/Pharmacist/Records


Pharmacy Services/Procedures/Pharmacist/Records covers pharmacy services and pharmacy consulting services. The consulting services should promote safe and effective medication use. These regulations cover the acquisition of medications, including emergency drug supplies, receipt of medications, dispensing medications, administering medications, and disposition of medications.


  • F0600 - Free from Abuse and Neglect


This section of the Abuse regulations highlights residents’ right to be free from all types of abuse and neglect. If your practices are questioned or your staff is unable to answer questions, your policies and procedures could be reviewed by surveyors. Policies, procedures, and education should address all types of abuse, including exploitation. This regulation covers staff to resident abuse, resident to resident abuse, and visitor to resident abuse.


  • F0610 - Investigate/Prevent/Correct Alleged Violations


This regulation pertains to the investigation, prevention, and correction of alleged violations. Every facility should thoroughly investigate all alleged violations, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.


Sweet 16

Strategies for Survey Success

Part 2 of 2


Strategy #9 Survey Ready

The surveyors are back, and they are in full swing across the country. They are arriving with upwards of 9-11 surveyors. Special focus facilities are a top priority for CMS. It should go without saying that every facility should have their survey documentation ready for when surveyors walk through the door. This documentation should be already set up in three-ring binders, with all the required information that is part of the Entrance Conference Checklist. There should be no running around looking for or making hard copies of requested items. For data that needs to be updated weekly, assign a person, and implement a system with an expectation for all updates to be completed before the responsible staff members leave work Friday afternoon. Be sure all off-shift supervisory staff are apprised of the Facility Prepared Survey books location.


Strategy #10 Document Refusal of Care


Be sure to document education regarding risk associated with a resident who may choose not to follow a clinician’s recommendations. Remember that a care plan should include when a resident chooses to decline the care or service, the risk that the declination poses, and efforts to educate the resident and representative on those risks. Alternatives to address the identified risk/need should also be documented.  


Strategy #11 Abuse Prevention and Reporting


You must keep up with education on abuse prevention and reporting. Surveyors often ask staff members questions about what types of abuse could occur, what they would do if a resident reported an abuse situation to them, and to whom they would report. Make sure key staff members know what determines “an injury of an unknown source.” An injury would have to be one that was not witnessed or could not be explained by the resident, and the injury is suspicious because of the extent of the injury, the location of the injury(e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Be sure your education provides good examples of all types of abuse, including sexual abuse. With three citations in the top 16, falling under Abuse Prevention regulations, all facilities must continue to be vigilant about their program. Be sure your procedures include all seven requirements, including Screening and Hiring, Training, Prevention, Identification, Investigation, Protection, and Reporting /Response.  


Strategy #12 Plan Pandemic Impact


When it comes to care planning, don’t forget to include how the pandemic and related restrictions may have affected certain individuals. It is very important to recognize any emotional distress that may have been caused by social isolation. This relates to person-centered care as well as trauma-informed care.


Strategy #13 Stay Current with Rules and Regulations


Continue to have a staff member and a designated backup staff member responsible for monitoring any news coming in from the CMS, CDC, and your State and local advisory groups. Be sure your facility is keeping up with changes, both in practice and in policy and procedure statements. Be mindful about updates on previously waived requirements due to the Public Health Emergency (PHE), for example, CMS is ending the waivers for providing written notice before a room/roommate change and for the timing of notification of discharge or transfer (per Bulletin #QSO-21-17-NH, April 8, 2021)


Strategy #14 Staff Communication


Keep your staff abreast of what is going on, as far as changes in testing requirements, and what notifications are being distributed to Residents and Resident representatives. Be sure that Supervisory personnel has copies of memos going to families and residents, so they can answer questions that may come their way.


Strategy #15 Resident Feedback


If you have not been able to hold a Resident Council meeting for several months, due to group activity restrictions, you should make every effort to obtain resident input in some way. If possible, hold smaller group meetings, perhaps based on each separate unit, or you could have your Social Worker and Activity Director go room to room to meet individually with residents to get their input on any concerns or suggestions they may have. Document your efforts to obtain resident input, be sure to include follow-up on their concerns or suggestions, and circulate the “meeting minutes” to those residents who participated.


Strategy #16 Overlapping Tags


HHI encourages you to increase your awareness about how many tags relate to each other. Facilities can be cited more than once on various regulations, including some that are mentioned in the top 16 tags in this 2 part HHI blog.  As an example, the regulations found in F0689, Free of Accident Hazards/Supervision/Devices, F0684 Quality of Care, F0677 ADL Care for Dependent Residents, and F0656 Develop/Implement Care Plan are tags that have overlapping responsibilities.



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Topics: Survey

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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