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Part III Standards for Compliance

determine the severity of the citation. See Figure 21.1 for the scope and severity grid for rating nursing home deficiencies.

The scope of a citation is based on the number of residents who have been affected or could have been affected by the facility not meeting the requirements for a specific regulation. Depending on the number of residents involved, the pattern could be isolated (usually three or less and severity of A, D, G, or J; more than three and severity of B, E, H, or K) or wide- spread (affecting a whole unit, facility, or everyone who had the potential to be affected by this noncompli- ance; severity would be C, F, I or L). The severity of the citation is based on the following:

Level 1: No actual harm with potential for minimal harm (A, B, C)

Level 2: No actual harm with potential for more than minimal harm that is not immediate jeopardy (D, E, F)

Level 3: Actual harm that is not immediate jeopardy (G, H, I)

Level 4: Immediate jeopardy to resident health or safety (J, K, L)

Harm level citations are a serious concern for survey- ors who find this noncompliance in the care of a resi- dent. A facility may go into “Denial of Payment” if they cannot get back into compliance in a timely manner. If the facility has another G-level citation in a following survey or investigation, they will be put into a “Double G” situation. A citation at Level 4, Immediate Jeopardy (IJ), means the survey team cannot leave the facility until a safety plan is put into place; this ensures that all residents are safe from what- ever caused the IJ situation. This process is described in SOM Appendix Q (4).

Appendix PP provides all the regulations that a facility must be in substantial compliance with at all times when it participates in the Medicare and Medicaid programs (3). Each state has its own regula- tions that must be met as well to meet state requirements. SOM Appendix P is the Survey Protocols for Long

Term Care Facilities (5). In this appendix, the survey process for the traditional survey and the Quality Indicator Survey (QIS) is described. The QIS survey process is covered more completely in the QIS training manual (6). This appendix also includes the protocols for Hydration, Dining/Food Service, and Nurse Services/Sufficient Staff that are used in the Traditional Survey. These protocols are built into the QIS processes.

All parts of the SOM are important for the RDN, NDTR, and other dietary personnel to be familiar with and to review frequently. Regulations and interpreta- tions change periodically; there are often training ses- sions conducted on how the regulations are intended to be implemented and viewed by the surveyors. Appendixes P and PP are the guidance that every facil- ity, staff member, and surveyor uses to ensure residents are receiving the care and services necessary for their well-being.

RESIDENT ASSESSMENT

INSTRUMENT The Resident Assessment Instrument (RAI) is used by the interdisciplinary team (IDT) to look at the resident in a holistic manner, placing equal importance on quality of life and quality of care. Information gathered during this process, specific to the resident’s strengths and needs, is used to develop an individualized plan of care. The instrument then enables the nursing facility to track the achievement of goals or the need to revise the

Figure 21.1 Scope and Severity Grid for Rating Nursing Home Deficiencies Isolated

Immediate jeopardy to resident health or safety Actual harm that is not immediate jeopardy

No actual harm with potential for more than minimal harm that is not immediate jeopardy

No actual harm with potential for minimum harm aA-level citations not reported by CMS.

Pattern

Widespread

JK L GH I

DE F Aa BC

Source: Department of Health & Human Services. Nursing Home Data Compendium 2013 Edition. Data from: Certification and Survey Provider Enhanced Reporting (CASPER). www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/nhs.html. Accessed October 14, 2015.