316


Part III Standards for Compliance


or they may be completed entirely during Stage 2. The triggered tasks all start after the transition to Stage 2 because they are triggered due to information gathered during Stage 1. Those tasks are Abuse Prohibition, Admission/Discharge/Transfer, Environment, Sufficient Nurse Staffing, and Personal Funds. Stage 2 analysis starts after the information is all gathered for Stage 2 residents and mandatory and trig- gered tasks are completed. Each surveyor makes com- pliance decisions on his or her own computer for each of the residents and tasks. This information is then transferred to the team lead’s computer, where it is col- lated with each F-tag, associated resident, and the sup- porting documentation.


Decision of Findings for Traditional


and Quality Inidicator Survey The team reviews each potential citation and provides this information to the survey agency supervisor responsible for the survey of that facility. This is a pre- liminary decision on the citation and for the scope and severity. This preliminary information is passed on to the facility administration and then to interested resi- dents, families, and staff. The final decision is made once the data have been reviewed at the district level with the state agency.


After the Survey


For both the traditional survey and the QIS, the process is the same for the writing of the deficiency statements. The state agency has 10 working days to issue the Statement of Deficiency to the facility, and the facility has 10 calendar days to respond and provide their Plan of Correction (POC).


If a facility is issued a Statement of Deficiency or CMS-2567, the facility must submit a POC, which must contain the following:


●


how the facility is going to fix the problem for the residents cited in the CMS-2567;


●


how the facility is going to fix the problem for those residents presently in the facility who have the same problem or are at risk for developing the problem;


●


how the facility is going to ensure that the problem does not happen for new residents or for those residents who presently do not have the problem (Generally this is done with a staff in-service.);


●


who is responsible for monitoring that it does not happen again; and


●


how the corrective action(s) will be monitored to ensure that the deficient practice will not recur


●


(ie, what quality assurance program will be put in place).


Once the POC is received by the state agency, it is reviewed by a surveyor for completeness and the alleged back-in-compliance (BIC) date is noted. When the facility has reached their BIC date, the state agency needs to determine if the facility has met all the criteria they outlined in their POC for compliance. In Chapter 7, Section 7304.4 details what the plan of correction must include (12):


●


how corrective action will be accomplished for those residents affected by the deficient practice;


●


how the facility will identify other residents having the potential to be affected by the same deficient practice;


what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;


●


how the facility plans to monitor its performance to make sure that solutions are sustained; and


● dates when corrective action will be completed. EXAMPLE


Residents 1, 2, and 3 were not given assistive devices to help them in eating their meals, in accordance with their plan of care.


Plan of Correction


The facility needs to determine where the problem is by asking the following questions:


●


Is nursing not notifying dietary about the adaptive equipment?


●


Is occupational therapy (OT) not notifying nursing/dietary?


●


Is dietary being notified but not marking the cards?


● Is the dietary aide able to read the cards?


Part 1: For Specific Residents Resident 1 refuses to use the spoon with the built-up handle. The care plan has been revised to reflect the res- ident’s wishes. Resident 2’s diet card now indicates that this individual needs a special cup for all liquids. Resident 3 has been discharged from the facility.


Part 2: For All Residents Who Use Adaptive Equipment


All residents who use adaptive equipment for feeding have been assessed for their use or acceptance. The


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