Top 10 Survey Citations - March 2021

Regulation | March 03, 2021 | by Janine Finck-Boyle

LeadingAge analyzed the top 10 survey citations as focused infection control surveys continue and many states amp up annual certification surveys.

Over the last few months, state agencies have resumed annual surveys in nursing homes. To complement the anecdotal reports from members about specific findings and deficiencies cited, LeadingAge offers this analysis of data from the QCOR – Quality, Certification and Oversight Reports, on the frequent survey deficiencies cited since January 2021. What we found were some significant changes from earlier analyses, as well as some deficiencies consistent with past reports.

The F-tags listed in this report are the nationwide top ten represented in all 15,000 + nursing homes that had an annual and/or complaint survey. Our review has shown that the Covid -19 pandemic changed the top ten landscape.

As of March 1, 2021, the following F-Tags made up the top 10:

  • F0884 Reporting - National Health Safety Network(NHSN)
  • F0880 Infection Prevention & Control
  • F0886 COVID-19 Testing-Residents & Staff
  • F0689 Free of Accident Hazards/Supervision/Devices
  • F0684 Quality of Care
  • F0580 Notify of Changes (Injury/Decline/Room, etc.)
  • F0883 Influenza and Pneumococcal Immunizations
  • F0885 Reporting-Residents, Representatives & Families
  • F0686 Treatment/Services to Prevent/Heal Pressure Ulcers
  • F0609 Reporting of Alleged Violations

Listed below is a brief review of the F-tag guidance and a “TIP” for each one, based on the survey analysis of the findings.

F0884 – new tag created by CMS for federally required reporting to the NHSN. The citation is received for non-compliance and is cited by federal surveyors off site as NHSN data is reviewed.

  • F0884 Tip – ensure that your data is reported, check your policy and procedure for reporting and always have a back up team member that can enter the data.

F0880 – the catch all for Infection control and focusing on a nursing home having an infection prevention and control program with policies, procedures, systematic monitoring, training and education. This F – tag is usually in the top 3 and most reports have it as #1 but as it moves to #2 for this review.

  • F0880 Tip – 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 PPE? Is your monitoring and practices preventing the spread of infection? Key tools to use by your Infection Preventionist are line listings and tracking infections.

F0886 – new F tag created with the CMS regulation on testing residents and staff using community positivity rates and/or COVID-19 outbreaks.

  • F0886 Tip -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.

F0689 – the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents.

  • F0689 Tip – Use a systems approach to identify hazards, including inadequate supervision, implement resident-centered approaches and engage all staff, residents and families on resident safety training and promote ongoing discussion and input on resident safety in the organization. Monitor data related to care processes that lead to accidents.

F0684 – ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident’s preferences and goals for care and meet professional standards that will meet each resident’s physical, mental and psychological needs.

  • F0684 Tip – Review care plans and documentation to establish they are resident centered. The clinical assessment process should be fluid. Staff should be completing ongoing clinical assessment and identifying changes in condition. Create a performance improvement plan that includes a communication link and documentation monitoring. Don’t forget to ensure resident and/or resident representatives are included in the care plan.

F0580 – facility must inform the resident, consult with the resident’s physician or representative when there is an accident or injury, significant change, after a significant treatment change and the decision to transfer or discharge.

  • F0580 Tip – 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 of the resident representative. Another good opportunity for a performance improvement project!

F0883 – under the infection prevention program section of F-tags, a facility must develop policies and procedures for immunization programs: influenza and pneumococcal. The policies and procedures must contain an education component for residents and resident representatives.

  • F0883 Tip – 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.

F0885 - new F-tag established during Covid; a facility must inform residents, representatives, families and staff by 5pm the next calendar day if there is a positive case in the facility or 3 or more residents or staff with new onset respiratory systems.

  • F0885 Tip – Ensure that you have a policy and procedure for informing residents, representatives, families and staff that includes the 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.

F0686 – this F-tag focuses on the prevention and treatment of pressure ulcers.

  • F0686 Tip – Since this F-tag could link and have cross tagging to MDS, care plans or physician orders, documentation is the key for compliance. Is the pressure ulcer avoidable or was it unavoidable? Did the team communication 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 has reviewed. Use the CMS Critical Element Pathway for pressure ulcers as a tool for mock survey.

F0609 – reporting of alleged violations for abuse, neglect, mistreatment, injuries of unknown origin and misappropriation of resident property. This F-tag has a time frame of reporting for 2 hours and 24 hours depending on the injury or non injury of the resident.

  • F609 Tip – Check staff knowledge of reporting alleged violations to residents. Do they know the process and who the report would be communicated to as well as the time frames? Is there documentation to complete of the alleged incident? Don’t forget to incorporate all shifts and all days -- evenings, nights and weekends.

This drill down offers a snapshot of findings. We want to be able to help nursing homes not only ensure compliance but incorporate quality improvement in their processes. If you have any questions, please contact Janine Finck-Boyle at Jfinck-boyle@leadingage.org.