lisa thomas rn-bc state training coordinator november 6, 2014
TRANSCRIPT
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Top 10 COMPLIANCE ISSUES FOR
CONSIDERATION
Lisa Thomas RN-BCState Training Coordinator
November 6, 2014
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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
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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)
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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§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
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§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
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§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
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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