Top 10 COMPLIANCE ISSUES FOR CONSIDERATION

1. Top 10 COMPLIANCE ISSUES FOR CONSIDERATION Lisa Thomas RN-BC State Training Coordinator November 6, 2014

2. OBJECTIVES • 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

3. §483.20(k)(3)(ii) • 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

4. §483.25 Quality of Care • 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

5. §483.25 (a)(3) • 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

6. §483.25 (c) Pressure Sores • F314- Based on the comprehensive assessment of a resident, the facility must ensure that – • 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 • A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

7. §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

8. §483.25 (h) Accidents • F323- The facility must ensure that- • The resident environment remains as free from accident hazards as is possible; and • 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

9. §483.25 (k) Special Needs 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

10. §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

11. §483.25 (m) Medication Errors • 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

12. §483.35 (c) Menus and Nutritional Adequacy • 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

13. §483.35 (i) Sanitary Conditions • 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

14. §483.65 Infection Control • 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

15. §483.65 Infection Control §483.65(a) Infection Control Program: • The facility must establish an infection Control Program under which it- • Investigates, controls, and prevents infections in the facility; • Decides what procedures, such as isolation, should be applied to an individual resident; and • Maintains a record of incidents and corrective actions related to infections

16. §483.65 Infection Control • §483.65(b) Preventing Spread of Infection • When the infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. • 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

17. §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

18. Miscellaneous Deficiencies • 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