CHAPTER 22 | Federal Regulations 355 Box 22.4 Case Study


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


Creating a plan of correction


The facility should complete a root cause analysis to identify the causal factors underlying variations in performance. Initial questions could include the following: • Is nursing notifying dietary about the adaptive equipment?


• Is occupational therapy notifying nursing and dietary staff of the functional concerns and needs of the resident?


• Is dietary updating the diet cards aſter being notified of diet and texture changes and additions or deletions of adaptive devices?


• Is the dietary aide able to read the diet 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 resident’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 specific adaptive equipment needed for eating or feeding has been written on the resident’s diet card.


Part 3: How to prevent recurrence


Occupational therapy and nursing staff will be given in-service training on the proper procedure for ordering or notifying the dietary department about residents needing adaptive equipment.


Part 4: Monitoring


The foodservice manager will be responsible for updating the diet card notations and for ensuring that a system is in place for keeping track of adaptive equipment. The registered dietitian nutritionist will review these monthly during meal rounds, and the staff development nurse will perform weekly care plan and implementation audits. Audits will be placed in the plan of correction (POC) binder. Audits and results will be reported to the quality assessment and assurance committee at quarterly meetings.


documentation and professional standards used. If the facility disagrees with the results of the informal dispute resolution, they may request a hearing before an administrative law judge of the US Department of Health and Human Services Departmental Appeals Board. The informal dispute resolution process is described in §7212.2 in Chapter 7 of the SOM.8


Civil Money Penalties


A CMP is a monetary penalty that CMS or the state may impose against nursing homes. It may be for either the number of days or for each instance that a nursing home is not in substantial compliance with one or more requirements for long-term care facili- ties, regardless of whether the deficiencies constitute IJ. Additionally, the per-day or per-instance CMP may be imposed for past noncompliance.


CMS may impose daily CMPs, particularly where IJ is cited. In the past, these findings usually resulted in a per-instance (one-time) CMP. In addition, CMS is required to impose CMPs in the range of $3,050 to $10,000 per day when IJ is present. The federal regulations allow the CMS to commence a daily CMP on the first date that the CMS determines that IJ has occurred (not necessarily corresponding to the survey date). The CMP continues until substantial compli- ance has been achieved (as verified by an on-site revisit survey conducted after issuance of the State- ment of Deficiencies). CMS rules also provide that the high-limit CMPs ($3,050–$10,000 per day) must continue until there is satisfactory evidence that the IJ has been removed (abated). Once the IJ has been abated, CMS will continue to impose a daily CMP but at a lower level (historically at $100–$400 per day) until substantial compliance is achieved. CMS has released a Civil Money Penalty Analytic Tool to assist in promoting the consistent (and increased) applica- tion of CMPs.15


Regulations and


Interpretive Guidelines A licensed facility is expected to comply with Medi- care and Medicaid program requirements and state law on a continual basis. To do so, they must regularly


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