CHAPTER 22 | Federal Regulations 351
Citations at scope and severity of B to L require a POC. Harm-level citations are a serious concern for noncompliance in resident care. If the facility has a second G-level citation in a subsequent survey or investigation, they will be put into a double-G situ- ation. Facilities with double-G citations face specific and automatic penalties. Anytime a G-level citation is received, it is important for the team to develop a POC, continue to audit that plan, and develop sys- tems that will help ensure compliance with the regu- lation that received the G-level citation. A citation at level 4, immediate jeopardy (IJ), rep-
resents a situation in which the facility’s noncompliance has placed the health and safety of residents at risk of serious injury, serious harm, serious impairment, or death.10
These situations must be accurately identified
by surveyors, thoroughly investigated, and resolved by the nursing facility as quickly as possible. In addition, noncompliance cited at IJ is the most serious deficiency type and carries the most serious sanctions for the facil- ity. An IJ can be issued for a breakdown in nutrition or dining services processes and systems. Consider this example: A dining service department received an IJ related to serving foods and beverages that were not properly inspected. This resulted in an Escherichia coli outbreak, causing serious harm to numerous residents and placing the entire nursing facility population in immediate jeopardy. CMS may impose a denial of payment for new admissions against a SNF when CMS finds that a facil- ity is not in substantial compliance with the require- ments of participation. In this situation, payment will be denied for all those being admitted under Medicare. In the case of Medicaid facilities, the state may deny payment to the facility and CMS may deny payment to the state for all new Medicaid admissions to the facility. CMS or the state must deny payment for all new admis- sions when the facility is not in substantial compliance (as defined in 42 CFR §488.401) 3 months after the last day of the survey identifying the noncompliance or when the state survey agency has cited a facility with substandard quality of care on the last three consec- utive standard surveys. SOM Appendix PP provides all regulations that a facility must be in substantial compliance with at all times when it participates in the Medicare and Medicaid programs.5 its own regulations that must be met.
Each state also has It is important for the RDN, NDTR, and other
dietary personnel to be familiar with all parts of the SOM and review it frequently. Regulations, require- ments of participation, and guidance or interpre- tations may change; training sessions on how the regulations are intended to be implemented and viewed by surveyors are often conducted. Nutrition practitioners must stay abreast of these opportunities and the changes that might involve an aspect of food management or nutrition services.
The Survey
Long-term care facilities volunteer to participate in the federally funded Medicare or Medicaid programs. To receive payment under these programs, SNFs and nursing facilities must comply with the requirements in 42 CFR §483, Subpart B. To certify a SNF or nurs- ing facility, an initial health survey, along with a Life Safety Code survey, must be completed. The facil- ity is then reviewed periodically in a recertification survey, known as the standard health survey. These are unannounced surveys conducted by the state survey agency, which is contracted by the federal gov- ernment. The survey may occur on any day or at any time.9
At least 10% of standard health surveys must begin either on the weekend or in the evening or early morning hours before 8:00 AM or after 6:00 PM. Likewise, the month in which a survey begins should not, if possible, coincide with the month in which the previous standard survey was conducted.9 The standard survey (recertification survey) is a
periodic, resident-centered inspection that gathers information about the quality of services furnished in a facility to determine compliance with the require- ments of participation. Each SNF or nursing facil- ity is subjected to a standard survey no later than 15 months after the last day of the previous standard survey, and the statewide average interval between standard surveys should not exceed 12 months.9 A complaint or facility reported incident survey, also known as an abbreviated standard survey, focuses on a specific issue that has been identified by the survey agency. These surveys gather informa- tion primarily through resident-centered techniques focused on facility compliance with the requirements for participation. They are the result of complaints or facility reported incidents received by the state agency.
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