Assignments

What You Will Learn •  Long-term care is heavily regulated because the government is a major payer and the recipients of services are among the most vulnerable. •  The Nursing Home Reform Act continues to play a major role in regulatory oversight by enforcing substantial compliance with the Requirements of Participation through the survey and enforcement process. •  Interpretive Guidelines clarify and explain each standard in detail. Although the guidelines provide directions to personnel conducting surveys, they also assist nursing home personnel in understanding what practices they must implement to comply with each standard. •  The traditional survey is being phased out and replaced with the computer-based Quality Indicator Survey. •  The seriousness of each deficiency is indicated by its severity and scope. Remedies, such as civil monetary penalties, are based on the seriousness of the deficiencies. •  An acceptable plan of correction must address five elements for each deficiency cited. •  Compliance with the Requirements of Participation incorporates compliance with the Life Safety Code®. Administrators must become thoroughly familiar with the Requirements of Participation and the main requirements of the Life Safety Code®. •  Nursing homes are required to comply with the accessibility standards for the disabled under the Americans with Disabilities Act. •  Under the Occupational Safety and Health Act of 1970, OSHA is responsible for ensuring the safety and health of nursing home employees. Nursing homes are legally required to comply with OSHA standards and recordkeeping rules. Introduction The health care sector has been the object of numerous regulations, for two main reasons: (1) The government is a major payer for individuals receiving health care services under Medicare, Medicaid, and other public programs. By committing a significant amount of tax dollars to the delivery of health care, the government retains a vested interest in how the money is spent by private organizations that deliver health care. (2) Health care in general, and long-term care in particular, provide services to the frailest and most vulnerable individuals in society. Many of them are physically and/or mentally incapacitated and have no one else to act on their behalf. The regulatory system is deemed obligated to protect vulnerable populations against negligence and abuse, to ensure that they receive needed services for which they are eligible, and to ensure that the services provided meet at least certain defined minimum standards of quality. Administrative agencies have the power to enforce the rules and regulations that they formulate. The most important federal agency regulating nursing facilities certified as skilled nursing facilities (SNF) or nursing facilities (NF) is the Centers for Medicare and Medicaid Services (CMS), an administrative agency under the U.S. Department of Health and Human Services (DHHS). The U.S. Department of Justice enforces compliance with the accessibility standards for the disabled. Workplace safety rules are enforced by the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor. Nursing Home Oversight Regulatory oversight for clinical care delivered in certified nursing homes is authorized under the Nursing Home Reform Act (OBRA-87). States can use their enforcement powers to take action against facilities that do not comply with federal and state standards. Regulatory oversight, however, has its weaknesses. Monitoring for compliance is based on periodic inspections and complaint investigations. Inspections of a nursing home may take place as much as 15 months apart. This sporadic system of monitoring does not guarantee that compliance with standards is continuous. Complaint investigations can be conducted any time, but they take place only when a complaint is filed against the nursing home by a patient, family member, friend, or employee. Nursing home oversight begins with state licensing regulations. Second, the Nursing Home Reform Act prescribes regulations, referred to as Requirements of Participation, that govern federal certification. Although the CMS is responsible for overseeing compliance, the actual task of monitoring for compliance is delegated to each state. The agency responsible in each state (generally the health department or department of human services, under contract from the CMS) to carry out monitoring and compliance with the state licensure standards and the federal Requirements of Participation is referred to as the State Survey Agency. Monitoring is carried out through an annual inspection, called a survey, of the facility. Requirements of Participation The Requirements of Participation (also referred to as conditions of participation) are standards that are widely regarded as minimum standards of quality for nursing facilities. There are 185 regulatory standards, which are classified under 15 major categories. A summary of the 15 broad requirements appears in Exhibit 5–1, which is meant for illustrative purposes only. The actual regulations can be found in the Code of Federal Regulations (CFR), Title 42, Part 483. Exhibit 5–1  Requirements of Participation for SNF, NF, and Dual Certification (Illustrative Only)   1.   Resident rights. These include the right to see a physician of one’s choice, to be fully informed of one’s medical condition and treatments, to refuse treatment, to formulate advance directives, to authorize the facility to manage personal funds and require accounting for the funds, to have personal privacy and confidentiality, and to voice grievances without fear of retaliation. In addition, residents cannot be prevented, coerced, or discriminated against in the course of exercising their rights as citizens of the facility or citizens of the United States.   2.   Admission, transfer, and discharge rights. These rights provide residents certain safeguards against transfer or discharge from a facility and allow one to return to the same facility after brief periods of hospitalization or therapeutic leave. It also requires equal access and delivery of services regardless of the source of payment.   3.   Resident behavior and facility practices. It limits the facility’s use of physical and chemical restraints and prohibits mistreatment, neglect, or abuse of residents.   4.   Quality of life. The facility must promote each resident’s individuality, dignity, and respect. Exercise of choice and self-determination must be allowed. Residents have the right to interact with the community. Residents can organize resident and family groups for mutual support and planned activities, or to air grievances. The facility must make reasonable accommodation for individual preferences, such as meals and roommates. The facility must provide an ongoing program of recreational activities and medically related social services. The standard also requires a clean, safe, comfortable, and homelike environment that will promote maintenance or enhancement of the quality of life of each resident.   5.   Resident assessment. Within 14 days of admission and at least annually thereafter the facility must undertake a comprehensive assessment of each patient’s functional capacity and medical needs. The assessment must be reviewed at least quarterly. Based on the need assessment, the facility must develop a comprehensive plan of care for each resident and provide the services necessary to provide that care.   6.   Quality of care. 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. The facility must provide appropriate treatments to maintain or improve a resident’s functioning and range of motion, unless it is unavoidable. The facility must ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Other patient care requirements include adopting measures to prevent pressure sores, providing appropriate treatment for pressure sores, ensuring adequate nutrition and hydration, providing special treatments as necessary, limiting use of antipsychotic drugs, and confining medication error rates to less than 5%. Indwelling urinary catheters should not be used unless necessary. Treatment and services must be provided to prevent urinary tract infections and to restore bladder function to the extent possible. The environment must be free from accident hazards and each resident should receive adequate supervision to prevent accidents. Facility must ensure that residents maintain acceptable parameters of nutritional status.   7.   Nursing services. The facility must have sufficient nursing staff, including licensed nurses, to provide necessary care on a 24-hour basis.   8.   Dietary services. The facility must provide a nourishing, palatable, and well-balanced diet that meets the daily nutritional and special dietary needs of each resident. Sanitary conditions must be maintained in the storage, preparation, and serving of food.   9.   Physician services. A physician must approve each admission, and each resident must remain under the care of a physician. Unless otherwise prohibited, the physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist. 10.   Specialized rehabilitative services. The facility must provide specialized rehabilitative therapies by qualified personnel under written orders of a physician. 11.   Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental services. 12.   Pharmacy services. The facility must provide pharmaceutical services with consultation from a licensed pharmacist. If state law permits it, unlicensed personnel may administer drugs, but only under the general supervision of a licensed nurse. The standard also requires monthly review of drug regimen for each resident and appropriate labeling and storage of drugs. 13.   Infection control. The facility must have an infection control program and maintain records of incidents and corrective actions. 14.   Physical environment. The facility must comply with the Life Safety Code® of the National Fire Protection Association. The facility should provide for emergency electrical power in case of power failure. The building must have adequate space and equipment for dining, health services, and recreation. Resident rooms must meet certain requirements as to size and furnishings. 15.   Administration. The facility must operate in compliance with all applicable federal, state, and local regulations and must be licensed by the state. The governing body has legal responsibility for the management and operation of the facility. The governing body must appoint a licensed nursing home administrator to manage the facility. Nurse aides working at the facility must receive required training, a competency evaluation, periodic performance review, and needed inservice education. The facility must also designate a physician to serve as medical director. The facility must provide or obtain needed laboratory, radiology, and other diagnostic services. The facility must maintain clinical records on each resident, have detailed written plans and procedures to meet all potential emergencies and disasters, have a written transfer agreement with a hospital that participates in the Medicare and Medicaid programs, and maintain a quality assessment and assurance committee. Interpretive Guidelines The CMS has formulated interpretive guidelines to clarify and explain each standard in detail. Interpretive guidelines also spell out the procedures the surveyors would use to verify compliance. Although the guidelines provide directions to personnel conducting surveys, they also assist nursing home personnel in understanding what practices they must implement to comply with each standard. The standards are identified by F-tags. Interpretive guidelines are furnished for each F-tag. For example, the requirement, Quality of Life (Item 4 in Exhibit 5–1), has 19 standards from F240 to F258. As an example, Exhibit 5–2 provides a portion of the interpretive guidelines for F241–Dignity. Exhibit 5–2  Partial Interpretive Guidelines for F241–Dignity F241 §483.15(a)–Dignity The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality. Interpretive Guidelines: §483.15(a) “Dignity” means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth. Some examples include (but are not limited to): •  Grooming residents as they wish to be groomed (e.g., hair combed and styled, beards shaved/trimmed, nails clean and clipped) •  Encouraging and assisting residents to dress in their own clothes appropriate to the time of day and individual preferences rather than hospital-type gowns •  Assisting residents to attend activities of their own choosing •  Labeling each resident’s clothing in a way that respects his or her dignity (e.g., placing labeling on the inside of shoes and clothing) •  Promoting resident independence and dignity in dining such as avoidance of: •  Day-to-day use of plastic cutlery and paper/plastic dishware •  Bibs (also known as clothing protectors) instead of napkins (except by resident choice) •  Staff standing over residents while assisting them to eat •  Staff interacting/conversing only with each other rather than with residents while assisting residents •  Respecting residents’ private space and property (e.g., not changing radio or television station without resident’s permission, knocking on doors and requesting permission to enter, closing doors as requested by the resident, not moving or inspecting resident’s personal possessions without permission) •  Respecting residents by speaking respectfully, addressing the resident with a name of the resident’s choice, avoiding use of labels for residents such as “feeders,” not excluding residents from conversations or discussing residents in community settings in which others can overhear private information •  Focusing on residents as individuals when they talk to them and addressing residents as individuals when providing care and services •  Maintaining an environment in which there are no signs posted in residents’ rooms or in staff work areas able to be seen by other residents and/or visitors that include confidential clinical or personal information (such as information about incontinence, cognitive status). It is allowable to post signs with this type of information in more private locations such as the inside of a closet or in staff locations that are not viewable by the public. An exception can be made in an individual case if a resident or responsible family member insists on the posting of care information at the bedside (e.g., do not take blood pressure in right arm). This does not prohibit the display of resident names on their doors nor does it prohibit display of resident memorabilia and/or biographical information in or outside their rooms with their consent or the consent of the responsible party if the resident is unable to give consent. (This restriction does not include the Centers for Disease Control and Prevention isolation precaution transmission-based signage for reasons of public health protection, as long as the sign does not reveal the type of infection) •  Grooming residents as they wish to be groomed (e.g., removal of facial hair for women, maintaining the resident’s personal preferences regarding hair length/style, facial hair for men, and clothing style) NOTE: For issues of failure to keep dependent residents’ faces, hands, fingernails, hair, and clothing clean, refer to Activities of Daily Living (ADLs), Tag F312. Procedures: §483.15(a) For a sampled resident, use resident and family interviews as well as information from the Resident Assessment Instrument (RAI) to consider the resident’s former lifestyle and personal choices made while in the facility to obtain a picture of the resident’s individual needs and preferences. Throughout the survey, observe: Do staff show respect for residents? When staff interact with a resident, do staff pay attention to the resident as an individual? Do staff respond in a timely manner to the resident’s requests for assistance? Do they explain to the resident what care they are doing or where they are taking the resident? Do staff groom residents as they wish to be groomed? Reproduced from CMS. 2011. State Operations Manual. Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed January 2014. Survey and Enforcement Enforcement of the standards is based on substantial compliance rather than “zero tolerance” because perfect compliance sets expectations that are unrealistic in most instances. Enforcement of zero tolerance could disqualify most nursing facilities from providing services to Medicare and Medicaid patients. The law defines substantial compliance as “a level of compliance with requirements of participation such that any identified deficiencies pose no greater risk to patient health and safety than the potential for causing minimal harm.” In simple language, it means that violation of a certification standard should not endanger the health and safety of a patient. The law also emphasizes the need for continued rather than cyclical compliance with the standards. To achieve this, the facility must implement policies and procedures for continuous monitoring to sustain compliance. In each state, the designated State Survey Agency is responsible for inspecting nursing facilities and making recommendations to the CMS to determine the provider’s eligibility to participate in the Medicare and Medicaid programs. Two types of surveys are currently in use. Nursing homes in approximately half of the states are inspected under the traditional survey. A new survey process, called the Quality Indicator Survey (QIS), is gradually being phased in to replace the traditional survey over the next few years. Types of Survey The State Operations Manual provides for four types of surveys: standard, abbreviated standard, extended, and postsurvey revisit. This section gives an overview of the traditional survey. The QIS is discussed subsequently. Standard Survey A standard survey is the most common type of survey. This periodic, unannounced survey is conducted for the purpose of certification renewal, generally no later than 15 months after a previous survey. The lapse of time between two surveys depends on the facility’s history of compliance. Timing of the survey is not confined to weekdays and normal business hours; surveys may also be conducted in the evening (after 6 p.m.), early in the morning (before 8 a.m.), or on weekends. Composition of the survey team and length of the survey depend on the size and layout of the facility to be surveyed and the complexity of issues to be investigated. Besides nurses, the team may include social workers, dietitians, pharmacists, activity professionals, or rehabilitation specialists when feasible. Other professionals, such as sanitarians, engineers, physicians, or physician assistants, may be called upon as consultants. According to federal law, surveyors must be trained and they are required to declare any possible conflicts of interest. A conflict of interest may disqualify a surveyor from inspecting a particular nursing facility. Abbreviated Standard Survey An abbreviated standard survey is a standard survey of shorter duration and of a limited scope. This survey focuses on particular tasks that relate, for instance, to complaints received or to a change of ownership, administrator, or director of nursing. During the survey, however, a determination can be made to investigate any area of concern. Extended Survey An extended survey, in which the scope and duration of a standard survey is expanded, may become necessary when indications are present that quality of care may be substandard. An extended survey requires a more detailed investigation of problems and a closer review of the facility’s policies and procedures. A partial extended survey may follow an abbreviated survey on the grounds of substandard quality of care. Postsurvey Revisit The state survey agency, at its discretion, may do a survey revisit. It involves a follow up survey to confirm that the facility is in compliance and has the ability to remain in compliance. The follow-up survey reevaluates the specific care and services that were cited as noncompliant during the original standard, abbreviated, or extended survey. The nature of noncompliance dictates the scope of the revisit. Quality Indicator Survey In many respects the QIS is similar to the traditional survey, but there are two main differences (General Accountability Office, 2012): (1) the QIS is computer based, whereas the traditional method is paper based; and (2) the QIS draws an expanded sample of residents to enable a more thorough review of care delivery whereas the traditional survey is based on the surveyors’ judgment in the sampling of residents. The QIS is a two-stage process. The computerized process guides surveyors through a structured investigation intended to allow surveyors to systematically and objectively review all regulatory areas and subsequently focus on selected areas for further review: •  Stage I: A preliminary investigation of all regulatory areas to identify potential issues for in-depth review in stage II. •  Stage II: In-depth review of issues triggered in Stage I. Identification of deficient areas and the seriousness of deficiencies. The QIS was designed to produce a standardized resident-centered, outcome-oriented quality review. Although the survey process has been revised under the QIS, the federal regulations and interpretive guidelines remain unchanged (CMS, 2007). The electronic system is also expected to improve the consistency of the surveys. Survey Process and Protocols Regulations governing survey and enforcement procedures are published in the Code of Federal Regulations, Title 42, Part 488. The State Operations Manual contains a detailed description of the survey protocols and procedures (CMS, 2009). This section provides a brief overview of the survey process. A standard survey consists of seven successive tasks; in principle, the QIS also incorporates these steps: •  Offsite preparation •  Entrance conference •  Initial tour •  Resident sample selection •  Information gathering •  Determination of compliance •  Exit conference Task 1: Offsite Preparation Offsite preparation before the actual visit to the facility includes potential areas of concern at the targeted facility based on the facility’s compliance history. During the actual visit, surveyors will initially focus on determining whether the previously identified concerns indeed exist. Offsite preparation is based primarily on reports generated by the state’s database. Each facility is required by law to use a patient assessment instrument called the minimum data set (MDS), and to electronically transmit the MDS information to the state in which the facility is licensed. The MDS information is used by the state to compile three main facility-specific reports that are available to the surveyors:   1.  Facility Characteristics Report, which provides demographic information about the patient population in the facility. It includes information on gender, age, payment source, diagnostic characteristics, type of assessment, stability of conditions, and discharge potential.   2.  Facility Quality Measure/Indicator (QM/QI) Report, which ranks the facility on quality indicators that apply to both chronic care (long-stay) and postacute care (short-stay) patients in the facility. The percentile ranking of the facility indicates how it compares with other facilities in the state.   3.  Resident Level QM/QI Report, which provides resident-specific information. The report indicates whether a given resident has a particular condition, such as pressure ulcers or behavioral problems, or whether a given resident is at a high or low risk of developing a condition. Other sources of information include (1) areas of noncompliance on the previous survey, (2) any patterns of noncompliance based on the past four surveys (OSCAR Report 3, where states are required to maintain comprehensive information about past and current surveys and complaint investigations in CMS’s OSCAR database), (3) findings from complaints that were investigated and complaints that have not been investigated, and (4) any areas of concern reported by the State Ombudsman Office. Information about any other potential areas of concern, such as events reported in the news media, may also be included. Task 2: Entrance Conference The survey team coordinator has an on-site meeting with the administrator (or other person in charge of the facility in the administrator’s absence) to provide introductions and explain the purpose of the visit. The surveyors depend on the administrator for various types of information that would help facilitate the survey. For example, surveyors will need copies of the actual work schedules for licensed and registered nursing staff; a copy of the written information that is provided to patients regarding their rights; copies of admission contracts for all patients; whether the facility has any special care units, such as dementia care units; and where the surveyors could find key personnel when needed. The administrator is given copies of the QM/QI and other reports used in the off-site preparation. Signs are posted in the facility to notify the residents, employees, and the general public that a survey is in progress and that the surveyors are available to meet with any concerned individual. Task 3: Initial Tour In an average-size nursing home of approximately100 beds, the tour may take about 2 hours. Members of the survey team may go around independently, with or without members of the facility’s staff accompanying them. However, the suggested protocol is to have a facility staff person accompany the surveyors to answer questions and provide introductions to residents or family. The surveyors talk to residents, employees, and visitors in the facility; visit some patient rooms and key departments, such as the kitchen; and make general observations. The purpose is to make a general assessment in conjunction with the information compiled during off-site preparation. Information is gathered about concerns identified in Task 1 and any new concerns observed during the tour are added. During the tour, the main areas of focus are quality of care, quality of life, the emotional and behavioral conduct of patients and the reactions and interventions by staff, and any environmental and safety issues. Task 4: Resident Sample Selection Information gathered during off-site preparation and the tour is used to develop a resident sample for detailed investigation of patient care. A “case mix stratified” sampling method is used. It is designed to include patients who require heavy care as well as those who require light care and patients who have sufficient memory and comprehension to be interviewed as well as those who cannot be interviewed. To the extent possible, the sample includes patients who may be particularly vulnerable, such as those who have indwelling catheters, are tube fed, are mentally impaired, or have speech or hearing disorders. Patients who have sustained a weight loss, those at risk of dehydration, those with pressure ulcers, or those with other associated risk factors are also included in the sample. Task 5: Information Gathering Most of the surveyors’ time in the facility is spent on the investigative phase of the survey process. Some main areas of investigation include patient care, medication errors, food preparation and dining services, residents’ quality of life, facility environment and safety, procedures for protecting residents against abuse and neglect, and an evaluation of the facility’s quality improvement program. The process includes direct observations; interviews with the facility’s residents, staff, and visitors; and a review of records. Close observations are made of meal preparation; dining services; medication pass; care being given; staff interactions with patients; infection control practices; and the condition of the environment such as cleanliness, sanitation, presence of any pests, safety hazards, functioning of equipment, and the proper and safe storage of drugs and biologics, and housekeeping chemicals and equipment. Record review particularly includes a review of patient assessments, plans of care, and outcomes of clinical interventions. The main purpose of record review is to obtain information necessary to validate or clarify information obtained through observation and interviews. Formal structured interviews are conducted for quality of life assessment. Even though Task 5 is investigative in nature, the State Operations Manual recommends an open and ongoing dialogue with facility staff members. This gives the facility the opportunity to provide additional information if there are questions about compliance. Task 6: Determination of Compliance The surveyors determine the facility’s compliance with each of the standards; a deficiency is cited when a standard is not met. The survey team must evaluate the evidence documented during the survey to determine whether a deficiency exists. Any negative patient outcomes resulting from a failure to meet a requirement must also be documented. Deficiencies are characterized as resident centered or facility centered. Resident-centered requirements must be met for each resident, and a violation affecting any single resident is cited as a deficiency. Facility-centered violations refer to the operational systems such as staffing, food preparation, and infection control. Deficiencies are also evaluated in terms of their severity and scope. Severity is determined by the extent of actual or potential harm and negative health outcomes as a result of not meeting a standard. Scope describes the number of patients that are potentially or actually affected as a result of not meeting a standard. Severity is rated according to four levels and scope is categorized in three types. Severity Levels Level 1. A deficiency that has the potential for causing no more than a minor negative impact on the resident(s). Level 2. Noncompliance that results in no more than minimal physical, mental, and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident’s ability to maintain or reach his or her highest practicable physical, mental and/or psychosocial well-being. Level 3. Noncompliance that results in a negative outcome that has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and/or psychosocial well-being. Level 4. There is immediate jeopardy that warrants an immediate corrective action. Immediate jeopardy means that the noncompliance with a standard has caused or is likely to cause serious injury, harm, impairment, or death to a resident receiving care in the facility. Scope Levels   1.  Isolated. Scope is isolated when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.   2.  Pattern. Scope is a pattern when more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.   3.  Widespread. Scope is widespread when the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that has affected or has the potential to affect a large number or all of the facility’s residents. Widespread scope refers to the entire facility population, not a subset of residents or one unit of a facility. In addition, widespread scope may be identified if a systemic failure in the facility (e.g., failure to maintain food at safe temperatures) is likely to affect a large number of residents and is, therefore, pervasive in the facility. Severity/Scope Grid On the basis of both its severity and scope, each deficiency is assigned to one of 12 categories using a grid (Figure 5–1). The categories determine how serious a deficiency is. A category A deficiency is the least serious and is isolated in scope, whereas a category L deficiency is the most serious and has been evaluated to be a widespread problem that presents immediate jeopardy. The 12 categories have been summarized into four levels that reflect the seriousness of each deficiency: Level 1. A deficiency categorized as A, B, or C has the potential for causing no more than a minor negative impact on the resident(s). If only Level 1 deficiencies are present, the facility is deemed to be in substantial compliance. Level 2. A deficiency categorized as D, E, or F has led to minimal physical, mental, and/or psychosocial discomfort and/or has the potential to compromise residents’ ability to maintain or reach their highest practicable physical, mental, or psychosocial well-being. Level 3. A deficiency categorized as G, H, or I has resulted in a negative outcome, but it does not present an immediate jeopardy. Level 4. A deficiency categorized as J, K, or L presents an immediate jeopardy. Unless immediate corrective action is taken, the facility’s noncompliance is likely to cause serious injury, harm, impairment, or death to a resident or residents. Substandard quality of care is indicated for categories J, K, L, H, I, and F when one or more of the following Requirements of Participation are involved: resident behavior and facility practices, quality of life, and quality of care (see Exhibit 5–1). Figure 5–1  Severity/Scope Grid for Rating Nursing Home Deficiencies Courtesy of Centers for Medicare and Medicaid Services. Task 7: Exit Conference In the exit conference, the surveyors meet face to face with facility officials to present their findings. The administrator may request a copy of the patient sample, provide additional information that may have been overlooked, or ask for further clarifications. Information provided during the exit conference enables the nursing home staff to start remedial action and address the most critical areas of deficiency. Plan of Correction A few days after the exit conference, the facility receives a Statement of Deficiency (Form CMS-2567; see Exhibit 5–3). The Statement of Deficiencies is public record. This federal document is then used by the facility to record its plan of correction (POC), which constitutes the facility’s written plan for corrective action to achieve sustained compliance with the cited standards. The POC must be submitted to the state within 10 days of receiving form CMS-2567. For a POC to be acceptable, it must address five elements for each deficiency cited:   1.  Details on how the facility will correct the deficiency as it relates to the patients found to have been affected by the deficient practice.   2.  How the facility will act to protect residents in similar situations.   3.  The measures the facility will take or the systems it will alter to ensure that the problem does not recur.   4.  How the facility plans to monitor its performance to make sure that solutions are sustained. A plan should be developed, implemented, evaluated for its effectiveness, and integrated into the facility’s quality improvement program. Exhibit 5–3  The Statement of Deficiencies and Plan of Correction (CMS-2567) Courtesy of Centers for Medicare and Medicaid Services.   5.  Dates when corrective action will be completed. The POC serves as the facility’s allegation of compliance. The facility is notified whether or not the POC has been accepted. However, acceptance of the POC by the State Survey Agency does not mean that the facility is in substantial compliance until it is determined through a post-survey revisit that the deficiencies no longer exist. Federal regulations require each state to establish an informal dispute resolution process to allow facilities to contest deficiencies within 10 days of receiving CMS-2567. The 10-day period allowed for an informal dispute resolution cannot be used to delay filing the POC and to take corrective action. Enforcement and Remedies The remedies imposed by the state and federal authorities take into account the seriousness of deficiencies. The law also provides that sanctions should be imposed in a timely manner so as to minimize the time between identification of violations and the final imposition of sanctions. For example, in situations that pose immediate jeopardy (levels J, K, and L in Figure 5–1), the regulations require that either a facility is terminated from the Medicare and Medicaid programs within 23 days or temporary management is imposed to remove the immediate jeopardy within 23 days. In addition, daily civil monetary penalties may be imposed (CMS, 2013). The nursing home has the right to appeal any enforcement action. National Scorecard Table 5–1 furnishes national data on selected deficiency citations in certified facilities. Citations vary considerably across states, but it is not clear whether these variations are actual reflections of substandard performance compared to national averages or whether these reflect inconsistencies in the application of the survey process and the use of interpretive guidelines in different states. If the latter is true, it is hoped that the new QIS will make a difference in overcoming the inconsistencies. Nursing Home Compare and Five-Star Ratings Results of certification surveys and other quality measures pertaining to individual facilities are public information. The CMS provides Web-accessible information on all Medicare and Medicaid certified facilities in the nation through a program called Nursing Home Compare (see For Further Learning). The information allows consumers to compare different nursing homes when selecting a facility. The information includes five-star quality ratings that incorporate performance on survey inspections, quality measures, and hours of care provided per resident by nursing staff. Inspection results and any complaints against the facility give detailed as well as summary information about deficiencies found during the three most recent inspections and complaint investigations. Quality measures include percent of residents with pressure ulcers, urinary incontinence, etc. Information is also provided on any penalties against the nursing home. Staffing information includes the number of RNs, LPNs/LVNs, physical therapists, and nursing assistants. Despite its value, the five-star rating system remains controversial. One recent criticism is that the Nursing Home Compare five-star ratings do not reflect quality of life (Kim et al., 2013). Table 5–1  National Scorecard on Selected Deficiency Citations, 2009 National average Range across states Average number of deficiencies per facility   10.0 4.3–22.0   Facilities with no deficiencies   6.6%      0–22.0% Facilities cited for actual harm or immediate jeopardy (Level G or higher in Figure 5–1) 24.7%   8.2–49.4% Facilities cited for substandard quality of care (Levels F, H, I, J, K, L in Figure 5–1)   7.3%      0–28.0% Deficiencies pertaining to selected Requirements of Participation: Resident behavior and facility practices (% of facilities with citations): Physical restraints 10.8%      0–31.6% Quality of life (% of facilities with citations): Dignity 20.4%   1.3–58.0% Housekeeping 21.2%      0–89.5% Quality of care (% of facilities with citations): Help with ADLs 15.0%      0–58.0% Prevention of pressure ulcers 21.2%      0–48.1% Bladder incontinence care 20.4%      0–44.7% Environment to be free from accident hazards 45.4% 20.7–78.4% Nutritional status of residents 10.7%      0–34.0% Dietary services (% of facilities with citations): Food sanitation 39.7% 7.3–94.7% Data from Harrington, C. et al. 2010. Nursing facilities, staffing, residents and facility deficiencies, 2004 through 2009. Available at: http://www.theconsumervoice.org/sites/default/files/advocate/action-center/OSCAR-2010.pdf. Accessed February 2014. Life Safety Code Modern health care facilities are designed and built to exacting building codes that are primarily concerned with people’s life and safety. The CMS has not developed its own fire safety standards. Instead, the CMS has adopted standards developed by the National Fire Protection Association (NFPA) and has incorporated them by reference into the Requirements of Participation. The NFPA is an international private nonprofit organization and the world’s leading advocate of fire prevention and public safety. Its primary mission is to reduce the worldwide burden of fire and other hazards. Among the many codes and standards developed by the NFPA, the one that applies to nursing facilities is NFPA 101®: Life Safety Code® (LSC). The LSC establishes minimum requirements for new and existing buildings to protect their occupants from fire, smoke, and toxic fumes. It covers construction, protection, and operational features. The LSC is not applicable where CMS finds that a state has in effect a fire and safety code imposed by state law that adequately protects patients in health care facilities. The LSC applies to all facilities referred in the code as “health care occupancy,” which is defined as any inpatient facility that provides medical services or delivers care simultaneously to four or more patients where such patients are incapable of self-preservation because of age, physical or mental disability, or because of security measures not under the occupants’ control (NFPA, 2009). The LSC is a complex document that also incorporates by reference a number of other NFPA codes. Hence, expert consultation is almost always necessary especially when an organization is planning to undertake new construction, expansion of existing facilities, and major renovations. Exhibit 5–4 provides an overview of the code. One lingering issue with the enforcement of LSC is waivers granted to older facilities. The law provides for waivers that may be granted to exempt older facilities from having to comply with current LSC standards in areas where full compliance would present unreasonable hardship. Older nursing homes, for example, have been granted waivers from having automatic fire sprinklers because of the cost of retrofitting these facilities with sprinkler systems. In 2003, however, 31 residents died in nursing home fires in Hartford, Connecticut, and Nashville, Tennessee. Another fire in Maryville, Tennessee claimed the lives of three residents in January 2004. These facilities did not have sprinkler systems. On the other hand, there has never been a multiple-death fire in a fully sprinklered nursing home (General Accountability Office, 2004). In response to fire tragedies, the CMS mandated all nursing homes in the country to have automatic sprinkler systems as of August 2013. The survey and enforcement process described in the previous section includes verification of compliance with the LSC. Deficiencies are cited on form CMS-2567, the same form used for other types of deficiencies. Most states use fire safety specialists within the State Survey Agency to conduct fire safety inspections. Several states, however, contract with their state fire marshal’s offices to conduct the inspections. Hence, the LSC portion of a standard survey may or may not be conducted concurrently with the quality of care review, particularly in states that contract with the state’s fire marshal. A facility has three options to address LSC deficiencies (Figure 5–2): (1) submit a plan of correction, as discussed earlier; (2) petition for a waiver—if a waiver is granted, it may be temporary or permanent; (3) undergo a Fire Safety Evaluation System (FSES) assessment. FSES was developed by the Department of Commerce’s National Institute of Standards and Technology to provide a means for providers who participate in the Medicare and Medicaid programs to meet the fire safety objectives of the standards without necessarily being in full compliance with every standard. FSES uses a grading system to compare the overall level of fire safety in a specific facility to a hypothetical facility that exactly matches each requirement of the fire safety standards. Once a facility has been certified using FSES, it can continue to be certified on that basis in subsequent years provided there are no significant changes that might alter the FSES score (General Accountability Office, 2004). Exhibit 5–4  NFPA 101, Life Safety Code* Note: Main requirements as found in the 2009 edition of the LSC are summarized here for illustrative purposes following 10 general principles of fire protection. Sections of the LSC, and any other NFPA codes, are given in parentheses.   1.   Fire-resistive construction. There are two major groups based on the construction materials: noncombustible construction (Types I and II) and combustible construction (Types III, IV, and V). Type I buildings are noncombustible, made of concrete and steel, and provide the highest degree of fire resistance. Type II buildings are also of noncombustible construction; however, the level of fire resistance is usually less than that required for Type I structures. All new construction is required to be fully sprinklered (18.1.6.1). Corridor walls are required to be continuous from the floor to the floor or roof deck above. These walls must rise through suspended ceilings and any other types of spaces (19.3.6.2.1) and must have a minimum of ½-hour fire resistance rating (19.3.6.2.2). With the exception of doors protecting vertical openings, exits, or hazardous areas, doors protecting corridor openings must be 1¾ in. thick of solid-bonded core wood construction and must be able to resist the passage of fire for at least 20 minutes (19.3.6.3.1). Clearance between the bottom of the door and floor covering is to be no more than 1 in. (19.3.6.3.4). The doors must be capable of fully closing on their own when a force of 5 lbf (pound-force: a unit of force) is applied at the latch edge of the door (19.3.6.3.5). These requirements do not apply to doors for toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials. Fireplaces are not permitted in patient rooms. They can be located in areas that are separated from patient sleeping rooms by construction that has at least a 1-hour fire-resistance rating and must have an approved enclosure that can withstand a temperature of 650° F (19.5.2.3).   2.   Subdivision of spaces. Areas of refuge Large spaces must be compartmentalized to provide fire and smoke compartments inside a building. Every storey with more than 30 patients must have at least two smoke compartments. In addition, the size of a smoke compartment must not exceed 22,500 sq. ft. and the travel distance to the smoke compartment must not be greater than 200 ft. Required smoke barriers must have a minimum of ½-hour fire-resistance rating (19.3.7). In newer buildings, smoke barriers must have a 1-hour fire-resistance rating. An area of refuge is a zone of safety within a building that is protected from the effects of fire and smoke, and provides direct access to an exit. It permits a delay in egress so that people can safely wait in the area of refuge until professional help arrives. Fire barriers Fire barriers are used to provide enclosure, subdivision, or protection by using building materials that have fire-resistance ratings. The ratings must be determined by a nationally recognized testing agency in accordance with NFPA standards (8.3.3.2). All fire-rated products, such as doors and windows, must bear an approved label, which must be maintained in a legible condition (8.3.3.2.3). Fire doors are required to be self-closing or automatic-closing.   3.   Protection of vertical openings. Vertical openings are open shafts through the floors of a building, such as stairways, elevator shafts, and laundry chutes, or they may be openings through a roof. Doors in stair enclosures must be self-closing and must normally be kept in the closed position (19.3.1.7).   4.   Provision of adequate means of egress. Means of egress refers to a continuous and unobstructed way of travel that enables a person to exit a building. At least two separate exits must be accessible from every part of every story of a building (19.2.4.2). As a general rule, door openings in means of egress must be at least 32 in. in clear width (7.2.1.2.3.2). They must be 41½ in. in new construction for means of egress from patient rooms (18.2.3.6). Dead-end corridors must not exceed 30 ft (18.2.5.2), and common path of travel to a means of egress shall not exceed 100 ft (18.2.5.3) in new construction. If locks are used, they must provide egress without having to use a key, a tool, special knowledge, or effort for opening the door (7.2.1.5). For stairs that are a component of the means of egress, the new code requires a width of 36 in., provided the total number of occupants (occupant load) served by the stairs is less than 50. Risers should be between 4 and 7 in. and tread depth should be 11 in. (7.2.2.2.1.2). Dimensions for existing stairs: width to be 36 in.; risers to be 8 in. or less; tread depth to be at least 9 in. Stairs and ramps must have handrails on both sides (7.2.2.4.1.1) and must continue for the full length of each flight of stairs (7.2.2.4.2).   5.   Provision of exit marking, exit illumination, and emergency power. Exists must be clearly visible. If not, the route to every exit must be clearly marked. On signs reading EXIT, the letters must be at least 6 in. high and ¾ in. wide. Exits should also be illuminated. In addition, each exit door must have tactile signage that must comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities (7.10.1.3). Emergency power supply The facility must either have a Type 60, Class 2, Level 2 emergency power supply system or an approved emergency generator that has a fuel supply to operate for 2 hours. The room where the generator is located must be separated from the rest of the building by fire barriers having a minimum 1-hour fire-resistance rating (7.2.3.12). The equipment must be tested twice a year by approved personnel and a log of the results must be maintained (7.2.3.13). The emergency generator must kick on within 10 seconds of a power failure (7.9.1.3) and it must illuminate all means of egress. Emergency illumination must be provided for a minimum of 1½ hours (7.9.2.1).   6.   Limits on the use of interior finish materials. Interior wall and ceiling finishes are classified into three categories according to their capacity to spread fire and produce smoke (10.2.3.4): Class A: Flame spread index, 0–25; smoke developed index, 0–450 Class B: Flame spread index, 26–75; smoke developed index, 0–450 Class C: Flame spread index, 76–200; smoke developed index, 0–450 Chapter 10 of the NFPA 101, Life Safety Code® (2009 edition) provides details on when certain materials such as textile, vinyl, plastic, and paper may or may not be used. Interior floor finishes are classified into two categories that indicate the flammability of the materials. These materials are classified according to their critical radiant flux rating that is determined by a test called the flooring radiant panel test: Class I: critical radiant flux rating of at least 0.45 W/cm2 (watts per square centimeter). Class II: critical radiant flux rating of between 0.22 W/cm2 and 0.44 W/cm2. Draperies, curtains, and other similar loosely hanging furnishings and decorations must be made of flame-resistant materials and shall have a permanently affixed label bearing the identification of size and material type as required by NFPA 701 (10.3.1). Upholstered furniture and mattresses must be resistant to a cigarette ignition (smoldering). Generally, a Class I rating on the materials, in accordance with NFPA 260, is permitted.   7.   Fire alerting facilities. The building must be adequately protected with fire alarms and smoke alarms. Even when a facility has automatic fire detection systems to initiate the fire alarm system, no less than one manual fire alarm box must be provided (9.6.2.6).   8.   Control of smoke movement. Dividing a building into compartments helps limit the spread of fire and restrict the movement of smoke. Walls and partitions serve as smoke barriers when all openings between floors and ceilings through which smoke can travel are appropriately sealed with smoke-resistant materials to create smoke compartmentation.   9.   Protection of hazardous areas. Some of the main hazardous areas in health care facilities are boiler rooms; fuel-fired heater rooms; central laundries; repair shops; paint shops; soiled linen rooms; trash collection rooms; and laboratories employing flammable, combustible, or hazardous materials (19.3.2.1.5). Hazardous areas must be protected with either an automatic extinguishing system or a fire barrier having a 1-hour fire resistance rating (19.3.2.1). Protection or separation is not required in areas where domestic cooking equipment is used for food warming or limited cooking (19.3.2.5.2). Commercial cooking equipment that produces grease-laden vapors must be protected by fire-extinguishing equipment (10.1.1, NFPA 96). An automatic fire-extinguishing system should be installed as primary protection and portable fire extinguishers should be provided as secondary backup (10.2.1, NFPA 96). 10.   Operational features. Fire safety plan and fire drills The administration must develop a plan for the protection of all persons in the event of fire. The plan must include evacuation to areas of refuge within the building and evacuation from the building when necessary. Written copies of the plan must be made available to all supervisory personnel. Periodic instruction and review of duties must be provided to all employees. Fire drills must be conducted at least quarterly on all shifts. The drills must include the transmission of a fire alarm signal and simulation of emergency fire conditions, except that coded announcements instead of audible alarms are permissible when drills are conducted between 9:00 p.m. and 6:00 a.m. Employees must also receive instruction in life safety procedures and devices (19.7.1). Smoking “No smoking” signs must be posted and smoking prohibited in enclosed spaces where flammable liquids, combustible gases, or oxygen are used or stored. Patients classified as “not responsible” must not be allowed to smoke except when the patient is under direct supervision by a staff member. Noncombustible ashtrays and metal containers with self-closing covers into which ashtrays can be emptied must be available in all areas where smoking is permitted (19.7.4). Material in this section is referenced from NFPA 101®, Life Safety Code®, Copyright © 2009, National Fire Protection Association, Quincy, MA. This reprinted material is not the complete and official position of the NFPA on the referenced subject, which is represented only by the standard in its entirety. *NFPA 101® and Life Safety Code® are registered trademarks of the National Fire Protection Association, Quincy, MA. Figure 5–2  How Nursing Homes May Address Fire Safety Deficiencies Reproduced from General Accountability Office. 2004. Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight. Washington, DC: General Accountability Office. General Accessibility Standards Accessibility for disabled people is required under the Americans with Disabilities Act (ADA) of 1990. The legislation is a general civil rights law designed to protect the rights of handicapped people in all aspects of their lives, including employment, recreation, and their use of buildings and facilities. The ADA also covers access to transportation and communication. Nursing home buildings and facilities must be accessible by individuals with disabilities. Under the law, a disability can be a physical or mental impairment that substantially limits one or more major life activities. Title III of the ADA prohibits discrimination on the basis of disability in “places of public accommodation” (i.e., businesses that serve the public) and “commercial facilities” (i.e., other businesses). Although the law does not specifically mention nursing facilities, health care establishments fall within the category of public accommodation. The law requires that certain adaptations, whenever necessary, be made to provide access by the disabled to such public accommodations. For example, there should be no architectural barriers that might prevent access to the building from sidewalks and parking areas. Adequate parking spaces must be reserved for the handicapped. Access ramps must be installed. At least one accessible entrance to the building must be protected from the weather by canopy or roof overhang. Such entrances are also required to incorporate a passenger loading zone. Inside the building, barriers to accessibility should also be removed. Examples of things a facility can do to make its services accessible include positioning telephones, water coolers, and vending machines so that they are easy to use by people in wheelchairs; installing elevator control buttons with raised markings; using flashing fire alarm lights; installing raised toilet seats and grab bars in the bathrooms, and allowing enough room to maneuver a wheelchair; and avoiding high-pile carpeting that makes steering a wheelchair difficult. All building features and equipment must be maintained in operable working condition except for temporary interruptions in services or access due to maintenance or repairs. At least 50% of the patient rooms and toilets in long-term care facilities must be designed and constructed to be accessible. In addition, all public use and common use areas must be accessible and usable by the disabled. In facilities or units of a facility where treatments and rehabilitation of conditions that affect mobility are rendered, all patient rooms and toilets must be accessible. The ADA also requires facilities to provide auxiliary aids for effective communication. Such aids include interpreters, note takers, telecommunication and sound amplifying devices suited for the deaf, audio recordings, videotext displays, and large-print books and publications. However, the facility is not required to provide personal devices and services such as eyeglasses and hearing aids. Any segregation of patients within the facility should be based on clinical factors, not on a person’s disability, because segregation based solely on disability is discriminatory. Another law, the Fair Housing Amendments Act of 1988, prohibits disability-based discrimination in public and private living quarters. OSHA and Workplace Safety The Occupational Safety and Health Administration (OSHA) was created under the Occupational Safety and Health Act of 1970. OSHA’s primary mission is to ensure the safety and health of America’s employees by setting and enforcing standards and encouraging continual improvement in workplace safety and health. Nursing assistants have a high rate of nonfatal occupational injuries. In 2012, the incident rate for nursing assistants was 426 per 10,000 workers, second only to the occupational category of laborers and freight, stock, and material movers (Bureau of Labor Statistics, 2013). According to one research survey, 60% of certified nursing assistants in nursing homes reported work-related injuries. Of all types of injuries, back injuries, other strains and pulled muscles, and open wounds, cuts, and scratches resulted in most job restrictions (Khatutsky et al., 2012). Nursing homes are legally required to comply with OSHA standards. However, OSHA also provides education and consultation, particularly to small and medium-size employers such as nursing homes. For example, OSHA has developed guidelines to help reduce certain types of injuries. OSHA’s educational and consultation services are available free of charge and are independent of the agency’s regulatory role. OSHA Standards and Enforcement Under the Occupational Safety and Health Act of 1970, states can establish OSHA-approved workplace safety and health standards that are comparable to federal standards. OSHA approves and monitors state plans and provides up to 50% of an approved plan’s operating budget. A state must conduct inspections to enforce its standards. Approximately half the states operate OSHA-approved state plans. In general, OSHA standards require employers to maintain conditions that protect employees on the job; comply with general industry standards and standards applicable to their establishments; and ensure that employees use personal protective equipment when required. The general industry standards (29 CFR 1910), which are exhaustive, and the most frequently cited violations in nursing homes can be accessed at the OSHA website (see For Further Learning). Nursing Home eTool is another web-based tool developed by OSHA that provides standards and recommendations to assist employers and employees identify and control hazards. Topics covered under Nursing Home eTool include bloodborne pathogens, ergonomics, dietary, laundry, maintenance, the nurse’s station, pharmacy, tuberculosis, housekeeping, whirlpool/shower, and workplace violence (see For Further Learning). Nursing homes can be cited and fined if they do not comply with OSHA standards. When standards are violated, OSHA assesses penalties and seeks abatement of any hazards. In extreme cases, the matter may be referred to the Department of Justice for criminal investigation. The agency focuses its inspections on the most hazardous workplaces. Federal OSHA unprogrammed inspections are conducted in response to alleged hazardous conditions and include imminent dangers, fatalities/catastrophes, complaints, and referrals. Programmed inspections are selected according to national scheduling plans for safety and health. When employers are found to be in violation of OSHA standards, they are issued citations. Many of these violations result in monetary penalties. OSHA Recordkeeping Requirements OSHA rules require employers to maintain records on all recordable work-related injuries and illnesses. The records must be kept on file for 5 years following the year to which they pertain. Completing these records does not mean that the employer or worker was at fault or that an OSHA standard was violated. An injury or illness is considered work related if an event or exposure in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition. An injury or illness is recordable if it involves any of the following: •  Death •  Loss of consciousness •  Days away from work •  Restricted work activity or job transfer •  Medical treatment beyond first aid •  A significant injury or illness diagnosed by a physician or other licensed health care professional •  Cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum •  Any needlestick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material •  Any case requiring an employee to be medically removed under the requirements of an OSHA health standard (e.g., in case of chemical poisoning) •  Tuberculosis infection as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional after exposure to a known case of active tuberculosis Three different reports must be filled out and maintained by the nursing facility:   1.  Injury and Illness Incident Report (Form 301). This is the first report to fill out. It must be completed within 7 calendar days after a recordable work-related injury or illness occurs.   2.  Log of Work-Related Injuries and Illnesses (Form 300). It is used to classify work-related injuries and illnesses and to note the extent and severity of each case. Each log entry must also include specific details about what happened and how it happened. The log requires each case to be classified into one of six categories: injury, skin disorders, respiratory conditions, poisoning, hearing loss, and all other illnesses. The log requires the employee’s name and job title. However, certain types of injuries or illnesses are regarded as privacy concern cases. For such cases, “privacy case” must be entered in the space normally used for the employee’s name and job title. The nursing home must maintain a separate confidential list of the case numbers and employee names for the privacy concern cases. Privacy concern cases include the following: •  An injury or illness to an intimate body part or to the reproductive system •  An injury or illness resulting from a sexual assault •  A mental illness •  A case of HIV infection, hepatitis, or tuberculosis •  A needlestick injury or cut from a sharp object that is contaminated with blood or other potentially infectious material •  Other illnesses, if the employee independently and voluntarily requests that his or her name not be entered on the log   3.  Summary of Work-Related Injuries and Illnesses (Form 300A). This form is completed at the end of the calendar year. It shows the totals for the year in each category of injury and illness. No later than February 1 of the following year, the Summary (not the Log) must be posted in a visible location where the employees can see it and become aware of the injuries and illnesses occurring in their workplace. The Summary must remain posted until April 30. Terminology for Review deficiency disability immediate jeopardy Nursing Home Compare plan of correction Requirements of Participation scope (of deficiency) severity (of deficiency) State Survey Agency substantial compliance survey For Further Thought   1.  What attitudes do you think nursing home administrators ought to have toward regulations that are often regarded as onerous?   2.  As a nursing facility administrator, what would you do to ensure that your organization is in compliance with the various regulatory standards? Case Conflict of Interest or Not? Bestcare Nursing and Rehabilitation Center is a 290-bed dually-certified 4-story facility located in a large city (the average size of a nursing home in the United States is 108 beds, according to data from Health, United States 2012, published by the National Center for Health Statistics). The facility operates at 92% occupancy, and only 15% of the residents have a private source of payment. In the past, the facility has had quality of care issues in the areas of diets and nutrition; practices in food preparation that may lead to contamination that could cause sickness; proper storage and dispensing of medications; and inadequate number, variety, and quality of recreational programs. Mona Sinclair was the RN leading the survey team for Bestcare’s annual survey. Mona used to be an RN employed by Bestcare, but she left voluntarily 3 years ago for family reasons. Jonathan Husky, the dietitian on the survey team was a consultant on contract for Bestcare, but last year he did not renew his consultancy contract. An LPN on the survey team was discharged from Bestcare approximately 2½ years ago for excessive absenteeism. Another member of the survey team had her mother as a resident in Bestcare, but she moved to a different facility 6 months ago. Questions 1.  What should be the composition of the survey team? 2.  Do the four individuals identified in the case have a conflict of interest? Explain. (To answer this question, you must review Section 7202 of the State Operations Manual, Chapter 7—Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf.) FOR FURTHER LEARNING Accessibility standards under the Americans with Disabilities Act of 1990 http://www.ada.gov/reg3a.html#Anchor-59404 Nursing Home Compare—Type in the state and name of the facility http://www.medicare.gov/nursinghomecompare/search.html OSHA Website https://www.osha.gov OSHA—Forms for recording work-related injuries and illnesses http://www.osha.gov/recordkeeping/new-osha300form1-1-04.pdf OSHA—Nursing Home eTool http://www.osha.gov/SLTC/etools/nursinghome/index.html Requirements of Participation for long-term care facilities http://www.ecfr.gov/cgi-bin/text-idx?SID=cffa4cc8ee1c2457bf262909627ad604&node=42:5.0.1.1.2&rgn=div5 State Operations Manual. Appendix PP: Guidance to Surveyors for Long-Term Care Facilities https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf REFERENCES Bureau of Labor Statistics. (2013). News release: Nonfatal occupational injuries and illnesses requiring days away from work, 2012. Retrieved February 2014 from http://www.bls.gov/news.release/pdf/osh2.pdf. Centers for Medicare and Medicaid Services. (2007). Evaluation of the quality indicator survey (QIS). Retrieved January 2014 from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/QISExecSummary.pdf. Centers for Medicare and Medicaid Services. (2009). State operations manual, Appendix P: Survey protocol for long term care facilities—Part I. Retrieved January 2014 from http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_p_ltcf.pdf. Centers for Medicare and Medicaid Services. (2013). Memo dated March 22, 2013 from Thomas E. Hamilton, director, Survey and Certification Group, to State Survey Agency directors. Retrieved February 2014 from http://www.leadingage.org/uploadedFiles/Content/Members/Nursing_Homes/Survey_and_Certification/2013_CMS_CMP_Analytic_Tool.pdf. General Accountability Office. (2004). Nursing home fire safety: Recent fires highlight weaknesses in federal standards and oversight. Washington, DC: General Accountability Office. General Accountability Office. (2012). Nursing home quality: CMS should improve efforts to monitor implementation of the Quality Indicator Survey. Retrieved February 2014 from http://www.gao.gov/assets/590/588155.pdf. Khatutsky, G. et al. (2012). Work-related injuries among certified nursing assistants working in US nursing homes. RTI Press publication no. RR-0017-1204. Research Triangle Park, NC: RTI Press. Kim, S. J. et al. (2013). The association between quality of care and quality of life in long-stay nursing home residents with preserved cognition. Journal of the American Medical Directors Association, 12/2013; DOI:10.1016/j.jamda.2013.10.012. Abstract retrieved February 2014 from http://www.researchgate.net/publication/259393529_The_Association_Between_Quality_of_Care_and_Quality_of_Life_in_Long-Stay_Nursing_Home_Residents_With_Preserved_Cognition. National Fire Protection Association. (2009). NFPA 101, Life safety code® (2009 ed.). Quincy, MA: Author.       ______________________ Life Safety Code® and NFPA 101® are registered trademarks of the National Fire Protection Association, Quincy, MA.