”There are far, far better things ahead than any we leave behind.” – C.S. Lewis.
The ending of 2021 marks the beginning of 2022. Endings. Beginnings. Suffering and loss. Hope and inspiration. Experiencing and trying to embrace the paradoxes of life have defined these extraordinary last two years. A never-ending thank you to the healthcare teams and other essential workers who have and continue to sacrifice so much for our communities.
This year also marks the 11th year of The Adelman Advantage and my partnership with Chip Kessler and Extended Care Products. My gratitude to Chip for being the most patient and supportive publisher, editor and friend. Thanks to all of you who read and share the newsletter and provide valuable feedback. I love our community. We look forward to 2022 and beyond and delivering quality information and educational resources in the senior living space. Stay tuned for some new features.
We conclude the year by looking ahead with a proactive approach to the changes that await COVID-19 survey activities. Per the CMS November 12, 2021, Memorandum QSO-22-02-ALL, CMS announced steps for State Survey Agencies (SAs) to address the backlog of complaint and recertification surveys. These steps include:
Revising the criteria for conducting COVID-19 Focused Infection Control (FIC) Surveys;
Guidance for resuming recertification surveys; and
Temporary guidance and minor flexibilities related to complaint investigations.
CMS is also increasing oversight in nursing homes through a more focused review of quality-of-life and quality-of-care concerns.
CMS is taking the following steps and SAs will focus their efforts on identifying concerns for all aspects of quality of care, quality of life, and ensuring health and safety:
Focused Infection Control surveys: CMS is rescinding the requirement per QSO 20-31-All to conduct FIC surveys within 3-5 days of an outbreak of COVID-19. SAs may still conduct these surveys when concerns related to managing COVID-19, or infection control practices, arise.
Resuming standard recertification surveys: SAs will continue to conduct recertification surveys but do not need to conduct additional recertification surveys to make up for any surveys that could not be completed during the COVID-19 PHE. In other words, SAs will resume the normal survey schedule moving forward, as described in more detail below.
Nursing Home complaints/facility-reported incidents: CMS is providing SAs with flexibility to focus on allegations that are more serious.
Timeframe for clearing backlogs: CMS will collaborate with each state to determine appropriate timeframes for clearing the survey backlog;
Temporary guidance and flexibilities: As described below, CMS is providing temporary guidance and minor flexibilities for SAs to work through the current backlog of complaints and recertification surveys that is a direct result of the suspension of certain onsite survey activities in an effort to control the spread of COVID-19.
SAs will be prioritizing recertification surveys according to the potential risk to residents, such as facilities with a history of noncompliance, or allegations of noncompliance, with any of the following:
Abuse or neglect;
Infection control;
Violations of transfer or discharge requirements;
Insufficient staffing or competency;
Special Focus Facilities (SFFs) and SFF candidates; and/or
Other quality-of-care issues (e.g., falls, pressure ulcers, etc.).
In addition, CMS is temporarily allowing certain mandatory survey protocol tasks to be discretionary or triggered based on concerns identified during offsite preparation activities such as complaints to be investigated during the survey, or those raised by the ombudsman, and previous patterns of citations. These tasks can also be triggered based on concerns identified during the onsite survey through observations, interviews, and record reviews or if complaint(s) are to be investigated during the recertification survey. The mandatory survey tasks eligible for temporary discretion are the following:
Resident Council Meeting
Dining Observation Task
Medication Storage
Increasing Oversight in Nursing Homes
CMS has expressed concern about how residents’ health and safety has been impacted, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues. Surveyors are instructed to be aware that these may be potential areas for further investigation during the survey, such as the following:
Surveying for Nurse Competency
CMS has alerted SAs to pay additional attention to compliance with the requirements for nursing services at § 483.35, which states, “The facility must have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).”
Specifically, surveyors should review the guidance in Appendix PP of the SOM for tag F-726, which guides surveyors to assess compliance with the requirement for nursing staff to have the appropriate competencies. As noted in the SOM, a key component of competency is the ability to identify and address a resident’s change in condition. This expectation applies to licensed and registered nurses as well as nurse aides. These competencies are critical in order to identify potential issues early, so interventions can be applied to prevent a condition from worsening or becoming acute. Without these competencies, residents may experience a decline in health status, function, or need to be transferred to a hospital.
Inappropriate Use of Antipsychotic Medications
Inappropriate use of antipsychotic medications continues to be an area of concern related to quality of care. Nursing homes are required to ensure that each resident’s drug regimen is free from unnecessary drugs (§ 483.45(d)). SAs should continue to focus their efforts on identifying the inappropriate use of antipsychotic medications and emphasize non-pharmacologic approaches and person-centered care practices.
Identifying Other Areas of Concern
In addition to the items above, surveyors are being guided to assess other care areas where residents’ health and safety may be at increased risk, such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers. SAs should use the appropriate critical element pathways to thoroughly investigate these areas to ensure any noncompliance is identified and subsequently corrected.
With this backdrop in mind, the following are the Top 10 survey deficiencies for nursing homes and proactive notes for consideration. [1]
F884 Reporting (NEW): National Health Safety Network (NHSN): PROACTIVE = Ensure that data is reported to NHSN and always have a backup team member that can enter the data.
F880 Infection Prevention and Control: PROACTIVE = 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 monitoring activities and practices preventing the spread of infection?
F886 COVID-19 Testing-Residents and Staff: PROACTIVE = Double-check who is monitoring the community positivity rates and ensure there is a backup team member. Using audit tools with monitoring criteria will help keep your organization in compliance.
F689 Free of Accident Hazards/Supervision/Devices: PROACTIVE = 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: PROACTIVE = 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.): PROACTIVE = Make sure your organization is documenting and alerting the resident and resident representative about the WHY of the decision regarding 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.
F883 Influenza and Pneumococcal Immunizations: PROACTIVE = 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: PROACTIVE = Ensure that you have a policy and procedure for informing residents, representatives, families, and staff about conditions at the facility 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: PROACTIVE = 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.
F609 Reporting of Alleged Violations: PROACTIVE = 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 a complete investigation of the alleged incident? Do not forget to incorporate all shifts and all days ― evenings, nights and weekends.
New Year’s Resolutions for 2022 and Survey Readiness
As the new year arrives and your facility considers compliance and quality improvement, make these resolutions and stick to them!
Review your policies and procedures for annual Medicare/Medicaid surveys and ensure your staff is prepared.
Train all staff to prepare them for an annual survey and ensure that appropriate staff is 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 is knowledgeable about CMS requirements and their role in maintaining compliance.
As we begin the 12th year of the Adelman Advantage, in January, we will report on the United States Supreme Court’s expected decisions on nationwide vaccine-or-testing COVID-19 mandate for large businesses and a separate vaccine requirement for healthcare workers. Oral arguments are set for January 7, 2022.
Stay tuned for resources on pandemic-related litigation, risk mitigation strategies in a changing senior living landscape, regulatory compliance support, and plenty of other interesting developments.
On behalf of Adelman Law Firm and myself, personally, may you have a healthy and happy 2022!
[1] Med-Net Concepts, LLC
