Top 10 COMPLIANCE ISSUES FOR

CONSIDERATION

Lisa Thomas RN-BCState Training Coordinator

November 6, 2014

Briefly review the 10 most frequently cited

deficiencies for long term care providers from standard and complaint surveys for 2013

Discuss how many times each deficiency was cited on standard surveys

Discuss how many times each deficiency was cited on complaint surveys

OBJECTIVES

F282- Be provided by qualified persons in

accordance with each resident’s written plan of care.

Appeared in the Top Ten Deficiencies list 10 times

Cited 51 times on standard surveys Cited 19 times on complaint surveys

§483.20(k)(3)(ii)

F309 – Each resident must receive and the

facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care

Appeared in the Top Ten Deficiencies list every month of 2013.

Cited 91 times on standard surveys Cited 34 times on complaint surveys

§483.25 Quality of Care

F312 – A resident who is unable to carry out

activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene

Appeared in the Top Ten Deficiencies list 7 times.

Cited 52 times on standard surveys Cited 20 times on complaint surveys

§483.25 (a)(3)

F314- Based on the comprehensive assessment

of a resident, the facility must ensure that –(1) A resident who enters the facility without

pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and

(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

§483.25 (c) Pressure Sores

F314- Appeared in the Top Ten Deficiencies list 11

times Cited 66 times on standard surveys Cited 20 times on complaint surveys

§483.25 (c) Pressure Sores

F323- The facility must ensure that- (1) The resident environment remains as free

from accident hazards as is possible; and(2) Each resident receives adequate supervision

and assistive devices to prevent accidents Appeared in the Top Ten Deficiencies list 12

times Cited 128 times on standard surveys Cited 40 times on complaint surveys

§483.25 (h) Accidents

F328- The facility must ensure that residents receive proper treatment and care for the following special services: Injections Parenteral and Enteral Fluids Colostomy, Ureterostomy, or Ileostomy Care Tracheostomy Care Standard: Tracheal Suctioning Standard: Respiratory Care Foot care Prosthesis

§483.25 (k) Special Needs

F328- Appeared in the Top Ten Deficiencies list 6

times Cited 38 times on standard surveys Cited 13 times on complaint surveys

§483.25 (k) Special Needs

F333- Residents are free of any significant

medication errors Appeared in the Top Ten Deficiencies list 8

times Cited 49 times on standard surveys Cited 14 times on complaint surveys

§483.25 (m) Medication Errors

F363 – Meet the nutritional needs of residents

in accordance with recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences;

Be prepared in advance; and Be followed Appeared in the Top Ten Deficiencies list 9

times Cited 45 times on standard surveys Cited 17 times on complaint surveys

§483.35 (c) Menus and Nutritional Adequacy

F371-The facility must procure food from sources

approved or considered satisfactory and store, prepare, distribute and serve food under sanitary conditions

Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and

Store, prepare, distribute and serve food under sanitary conditions

Appeared in the Top Ten Deficiencies list 12 times Cited 86 times on standard surveys Cited 11 times on complaint surveys

§483.35 (i) Sanitary Conditions

F441- The facility must establish and maintain

an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection

§483.65 Infection Control

§483.65(a) Infection Control Program: The facility must establish an infection Control

Program under which it-(1) Investigates, controls, and prevents

infections in the facility;(2) Decides what procedures, such as isolation,

should be applied to an individual resident; and

(3) Maintains a record of incidents and corrective actions related to infections

§483.65 Infection Control

§483.65(b) Preventing Spread of Infection(1) When the infection Control Program

determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.

(2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease

§483.65 Infection Control

§483.65(c) Linens – Personnel must handle, store, process and transport linens so as to prevent the spread of infection Appeared in the Top Ten Deficiencies list 12

times Cited 101 times on standard surveys Cited 18 times on complaint surveys

§483.65 Infection Control

F157- notification F225- Abuse Prohibition F226- P&P on Abuse F241- Dignity F287- MDS records not electronically transmitted F315- B&B program, restore, UTI’s F322- tube feeding care F329- unnecessary medications F332- medication error rate 5% or greater F364- loss of nutritive value, taste and appearance F502- performed, timely, received promptly

Miscellaneous Deficiencies