LeadingAge has analyzed the deficiencies cited from the Quality, Certification, and Oversight Reports (QCOR) since January 2021. The F-tags listed are the nationwide top ten represented in over 15,000 nursing homes that had a Centers for Medicare & Medicaid Services (CMS) annual and/or complaint survey.
As of March 1, 2021, the following are the 10 most cited F-tags, with recommendations on how to avoid each citation based on analysis of the findings:
- F884 Reporting (NEW): National Health Safety Network (NHSN): Ensure that data is reported to NHSN and always have a backup team member that can enter the data.
- F880 Infection Prevention and Control: Review your in-services and training for staff. Can they demonstrate infection control procedures and state to a surveyor how your organization is following practices for hand hygiene and donning and doffing of PPE? Are your monitoring activities and practices preventing the spread of infection?
- F886 COVID-19 Testing-Residents and Staff: Double check who is monitoring the community positivity rates and ensure there is a backup team member. Have you verified lab turnaround times and documented if they are over 48 hours? Using audit tools with monitoring criteria will help keep your organization in compliance.
- F689 Free of Accident Hazards/Supervision/Devices: Use a systems approach to identify hazards, including inadequate supervision. Implement resident-centered approaches; engage all staff, residents, and families in resident safety training; and promote ongoing discussion and input about resident safety in the organization. Monitor data related to care processes that lead to accidents.
- F684 Quality of Care: Review care plans and documentation to determine they are resident-centered. The clinical assessment process should be fluid. Staff should be completing ongoing clinical assessment and identifying changes in resident condition. Create a performance improvement plan that includes a communication link and documentation monitoring. Do not forget to ensure resident and/or resident representatives are included in developing and implementing the care plan.
- F580 Notify of Changes (Injury/Decline/Room, etc.): During COVID-19, residents have to be transferred or discharged due to positive cases. Make sure your organization is documenting and alerting the resident and resident representative about the WHY of the decision. This includes room changes or roommate change or status. Ensure that the resident record has the most up-to-date mail address, email, and phone number for the resident representative. This could be a good opportunity for a performance improvement project!
- F883 Influenza and Pneumococcal Immunizations: Documentation is key to compliance for this F-tag. Your organization must offer the vaccines to all residents and educate them on the vaccines and the side effects. However, the resident or resident representative has the opportunity to refuse. Refusal must be documented in the resident record.
- F885 (NEW) Reporting to Residents, Representatives, and Families: Ensure that you have a policy and procedure for informing residents, representatives, families, and staff about COVID-19 that includes a reporting time frame. How will this communication be completed? Who will communicate, and who is the backup? Document the information along with the specifics of the process. Are you using different modes of communication – electronic, paper, in person meetings, phone calls? Whatever is the mechanism, make sure staff can relay the process back to surveyors.
- F686 Treatment/Services to Prevent/Heal Pressure Ulcers: Since this F-tag could link and have cross tagging to the MDS, care plans, or physician orders, documentation is the key for compliance. Is a pressure ulcer avoidable or was it unavoidable? Did the team communicate about skin integrity as well as risk factors to avoid pressure ulcers? Is the staging of the wound accurate? Ensure there is a thorough in-service on wound staging and that the nursing team understands the information. Use the CMS Critical Element Pathway for pressure ulcers as a tool for conducting your own mock survey. Pressure Ulcer Critical Element Pathway (cmscompliancegroup.com)
- F609 Reporting of Alleged Violations: Check staff knowledge of reporting alleged violations against residents. Do they know the process and who the report would be communicated to, as well as the time frames? Is there documentation for complete investigation of the alleged incident? Do not forget to incorporate all shifts and all days ― evenings, nights and weekends.
A few of the top ten citations are newly created since the beginning of the COVID-19 pandemic. It is apparent that the surveyors are citing the newly created regulations in addition to other F-tags.
Compliance Perspective
Issue
It is essential that all leaders of nursing homes are aware of the newly created F-tags, in addition to being knowledgeable about all other regulations in the State Operations Manual. All nursing facilities must be in compliance with Medicare and Medicaid requirements for rules of participation. Not being knowledgeable of CMS requirements can result in citations at the level of substandard quality of care and result in sanctions. You can access the State Operations Manual, Appendix PP, here.
Discussion Points
- Review your policies and procedures for annual Medicare/Medicaid surveys and ensure your staff are prepared.
- Train all staff to prepare them for annual survey and ensure that appropriate staff are aware of newly created regulations. Document that this training occurred and file in each employee’s education file.
- Review previous statements of deficiencies and plans of correction. Audit to ensure that corrections remain in place. Periodically audit to ensure that staff are knowledgeable about CMS requirements and their role in maintaining compliance.
