A Practical Guide to Qualitative Healthcare

SCOPE AND SEVERITY OF CITATIONS DURING SURVEY

Every healthcare facility is surveyed either by the state or by the federal government within 10 to 12 months following the previous survey. It is the government’s way of ensuring that these facilities are operating in accordance with the regulations governing that facility and that residents are receiving quality care. At the end of the survey, facilities are informed of issues identified and these are referred to as citations or tags. A formal written report will then be issued by the state.

1. Survey citations or tags in nursing homes, as outlined throughout this book, are F tags.

2. The tags have a number assigned to them for identification purposes. E.g. F309, F157 etc.

3. There are also K tags, which are environmental issues, safety issues, and fire codes.

4. Although K tags mostly relate to environmental issues, they can at times also be cited for clinically related issues. E.g. room temperatures and resident comfort and safety issues.

5. When a facility is cited for deficient practice, it is an F tag, as outlined throughout this book. However, what holds equal or more weight is the scope and severity of that F tag.

6. Scope and severity is a system of rating the seriousness of deficiencies. It is a national system used by all state survey agencies when conducting nursing home Medicare and Medicaid certification surveys.

7. For each deficiency identified, the surveyor determines the level of harm to the resident (s) involved (severity) and the scope of the problem within the nursing home.

8. The surveyor then assigns an alphabetical scope and severity value from A through L with A being the least serious and L the most serious.

9. The letters J’ ‘K’ and L’’ for any of the regulations is immediate jeopardy.

10. Immediate jeopardy is a situation in which the facility’s non-compliance with one or more of regulations has place resident (s) at risk for abuse, harm, injury, impairment or death or potential for harm.

11. Immediate jeopardy can be an isolated incident or widespread.

12. When the survey results or Statement of Deficiency (SOD) are received from the state, the facility has ten business days to prepare and send back a plan of correction (POC). In New York State, this can be monitored on the Health Commerce System (HCS).

13. Upon submission of the plan of correction (POC), the facility must receive notice from the state whether the POC was accepted or if changes are required.

14. If the facility disagrees with a particular tag, it can file an Informal Dispute Resolution (IDR), which allows the facility to provide additional information that may result in revision and/or reversal of the statement of deficiency.

15. The State always conduct a post survey revisit after every plan of correction is submitted. This revisit is often done as a follow-up phone call to ensure the facility is in compliance with the stated plan of correction.

16. When a facility receives a level G or an Immediate Jeopardy (IJ) tag, the post survey revisit involves an actual onsite revisit by the State within ninety days to validate correction of deficiencies.

17. NOTE: As part of the preparation for survey of a facility, the survey team looks at a four year history of a facility’s deficiencies from past surveys and complaint surveys. During the survey, they will check to see if there are repeat deficiencies!

18. The following chart is an abbreviated version of how scope is determined.

Shaded boxes in the grid mean deficiency ratings which reflect Substandard Quality of Care. These areas are mainly:

Physical or chemical restraints

Abuse not addressed

Staff mistreatment of residents-verbal, mental, physical or sexual abuse

Employing individuals who have been found guilty of abuse, neglect or mistreatment

Dignity issues

Lack of resident choices

Preventing resident from organizing or participating in a group in or out of facility

Not providing notice before room or roommate change.

Lack of adequate activities and a qualified activities director

Not making sure residents have adaptive equipment and these are properly applied

Misplacement of residents’ clothing and personal items

Failure to notification family of changes to residents’ plan of care

Lack of discharge planning and follow-up

Lack of consultation services

Pain not properly addressed

Not having a qualified social worker who addresses residents needs and individuality

Environment is not safe, clean, comfortable and homelike

Poor housekeeping and laundry practices

Uncomfortable temperatures and sounds

Residents decline and not properly accessed and care planned

Lack of qualified nursing staff

Lack of a Medical Director

Development of pressure ulcers not properly documented

Inadequate care of hospice residents

Inadequate care of dialysis residents

For each letter of deficiency received, the state has different categories of penalty that it can be imposed on facilities.

1. Category 1—Directed Plan of Correction (obtain services of an outside consultant)

—Directed In-service training (comprehensive outline for in-services)

2. Category 2—Denial of payment for new admissions

—Denial of payments for all residents

—Civil Money Penalties of $50.00 to $3,000.00 per day

3. Category 3—Temporary Management

—Immediate Termination

—Civil Money Penalties of $3,050 to $10,000 per day.

ADMISSION OF A RESIDENT

Before admitting an individual to a long term care skilled facility, the facility must thoroughly review the submitted documentation and ensure it can meet the needs of that individual. Hospitals, acute care setting, group homes, adult homes or home settings must complete and submit documentation to the long term care facility for review to determine the needs of the individual prior to consent for admission.

In New York State the required documentations are a PRI (Patient Review Instrument) and a Screen. The combination of both documents is referred to as a Level 1 PASRR (Pre-Admission Screening and Resident Review).

NOTE: A PRI alone is not complaint with the PASRR regulation! Must receive the PRI and the Screen!

These documents are completed by the referring institution by a health care professional who has completed the State’s PRI and Screen certification course and have been issued a PRI and a Screen identification number.

The PRI (Patient Review Instrument) is a medical tool that identifies whether or not a resident is qualified for skilled nursing care. The PRI provides demographic information including the payer source, diagnoses, level of care required with activities of daily living such as eating, transferring from one surface to another, toileting needs, need for therapy, current medications individual is receiving, an outline of the care and services received prior to admission to the long term care setting, need for follow-up consultations and the individual’s preferred living arrangements.

The Screen is a document that determines if there is a substantial medical need to require admission to a long term care setting rather than medical services that can be easily given in the community. If the completed Screen indicates that the individual has Mental Illness, Mental Retardation or Developmental Disabilities, the resident then requires a level 2 PASRR (Pre-Admission Screening and Resident Review).

There are two agencies responsible for level 2 PSARR completion:

1. Individuals with Mental Illness require a level 2 PSARR which is done by a government appointed regulatory agency which in New York State is IPRO (Island Peer Review Organization). These trained Mental Health Professions review and make the determination on whether an individual with Mental Illness can be admitted to a long term care setting.

2. Individuals with Mental Retardation and Developmental Disabilities require a level 2 PSARR which is done by New York State Developmental Disabilities Service Office.

An individual with Mental Illness, Mental Retardation and Developmental Disabilities can only be admitted to a long term care skilled facility if approved by the aforementioned.

NOTE: Failure to comply with this process is a violation of the Federal PSARR regulation and can result in as much as Immediate Jeopardy!

NOTE: Each time a resident requires hospitalization, a new PRI and screen must be submitted to the skilled care facility prior to re-admission.

NOTE: Surveyors generally ask for the level 1 PASRR (PRI and Screen) for all residents been reviewed and a list of residents with level 2 PSARR to ascertain if residents with Mental Illness, Mental Retardation or Developmental Disabilities are appropriately placed in a long term care facility!

NOTE: Upon admission, Social Services MUST review all level 1 and level 2 PSARRS.

NOTE: It is advisable for them to copy the PSARR and keep a copy in their section of the medical records and a list of ALL residents who are level 2 PSARR.

NOTE: Social Services documentation on all residents should clearly reflect ongoing need for continued admission, especially residents with level 2 PSARR.

For all admissions, a thorough review of submitted documentation must be conducted to ensure the facility can meet the individual’s needs to minimize re-hospitalization. E.g. approving a level 1 PASRR for a ventilator resident when the facility does not have a ventilator unit. E.g. approving a resident with a positive level 2 PSARR without the accompanying clearance from the regulatory agency.

Potential tag: F285—PSARR Requirement for Mental Illness and Mental Retardation

ASSESSMENT OF A RESIDENT

When a resident is admitted to a skilled care facility, a thorough head to toe assessment must be done and the resident must be made aware of his or her rights. Assessment and discharge start on admission and are ongoing. An initial full clinical assessment is done but throughout the course of the resident’s stay in the facility, there is ongoing assessment by the interdisciplinary team to ensure that the resident is receiving the highest level of care needed to attain and maintain his or her physical, mental and psychological well being in accordance with the regulations. These areas include but are not limited to:

Residents aware of their rights to quality of life and to receive necessary care in a dignified manner

Minimum Data Set (MDS)

Care Planning

Pain or discomfort management

Wound treatment and prevention

Prevention of medication errors either by the delivery system or storage system

Accident/Incident prevention

Potential for elopement properly assessed and resident safety ensured

Prevention of abuse, neglect and mistreatment and ensured follow-up in suspected cases

Care for by staff with no criminal backgrounds

Adequate staff to ensure residents needs are met

Staff members are trained and competent to take care of their needs

Free from physical restraints

Assessment of why resident is refusing care/treatments

Right to refuse or to implement advance directives

Physician Services including choice of a physician

Medical care supervised by a Medical Director

Aware of the facility’s discharge, transfer and bed hold policy

Resident/family right to notification of any changes to the Resident’s plan of care

Right to be free from misappropriation of personal property

Enjoy meaningful therapeutic recreation

The right to smoke

Dietary needs including weight management

Dining Observation

Sanitary food storage, preparation and distribution

Management of nasogastric or gastrostomy tubes

Receives appropriate consistency foods and liquids

Fluid restrictions monitoring if required

Residents with special needs e.g. dialysis, indwelling catheters, colostomy, ileostomy, oxygen usage, blood glucose monitoring

Treatment and Prevention of Infections

Immunizations

Receive all Necessary Consults

Receive all necessary labs and x-rays

Dental services

Hearing Aid and Eyeglasses

Need for Rehabilitation Services

Maintain at optimal functional level without any decline

Ongoing maintenance of a clean, sanitary home-like environment

Appropriate noise levels

A hazard free environment with preparations in the event of an emergency

Ongoing quality assurance programs to review potential for deficient practices

Ensure their private medical records are secure

Prevention of unnecessary hospitalization

Dignified treatment in the event of death

RESIDENTS RIGHTS

Violation of resident’s rights, abuse, neglect and mistreatment are the underlying component to most cases reported to the Department of Health!

As per the State Operation Manual, residents in a healthcare facility have the right to autonomy and choice about how they wish to live their everyday lives and received care subjected to the rules of the facility and not in violation of any of the regulatory requirements.

As per the Long Term Care Survey Guide, the following is a list of residents’ rights:

1. Residents have the right to