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5 tips for avoiding deficiencies

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Susan LaGrange
Susan LaGrange

Here are five quick tips to operationalize for the top five most frequently cited deficiencies nationwide. Facilities could choose one per day and revisit each week to focus on audits, discussion, education and system updates.

1.  F-323: Accidents and Supervision

Immediately date it and communicate it! Ensure a timely root-cause analysis investigation is completed and documented AND that the information collected is analyzed to update the care plan with relevant resident-centered goals and interventions.

2.  F-441: Infection Control

A good process surveillance system (including audits for hand washing, using PPE, dressing change technique, ADLs, etc.) will allow you to see where your staff needs additional training and mentoring.

3.  F-309: Quality of Care

A good system check is essential for this tag. This includes the creation of an accurate and comprehensive assessment process that leads to an individualized care plan, proper implementation of the care plan and evaluation of the process. Remember the importance of keeping residents at their highest level of functioning to ensure staff are better able to address:

  • Pain management
  • Dementia care[1]
  • Non-pressure-related skin ulcer/wounds
  • Hospice services (including collaboration in the Plan of Care)
  • Dialysis services

4.  F-371: Food Sanitation

This tag is loaded! There are multiple areas to audit and ensure systems are in place. Here are a few areas to start:

Labeling:  ALL food items in coolers, freezers, even unit refrigerators!

Auditing:  Food temps, refrigerator/cooler/freezer temps, dish washer temps and chemicals, hand hygiene in kitchen, process for thawing frozen food, placement of food items in cooler, rotating of stock, dishwashing process, ice water pass, etc.

Ensure your ice machine is on a regular cleaning schedule. Don't forget to have a clean receptacle to store the ice scoop!

Cleaning audits: range Hood, floors, equipment and utensils, ceiling lights, etc.

5.  F-329: Unnecessary Drugs

The process for tracking the use of antipsychotic medications is crucial—but all meds must be reviewed to ensure the resident's drug regimen is free from unnecessary drugs. Areas to review include:

Consistently completing and documenting the monitoring medications (i.e., regular lab work, BP's, pulse, etc.).

Ensuring documentation for psychotropic medications include adequate indications for continued use and targeted behaviors being assessed and addressed.

Monitoring and documenting evidence for effectiveness of medication AND adverse consequences.

Ensuring gradual dose reductions are attempted in accordance with F329.

These hot tips are certainly not all-inclusive—but address some concrete, high-focused areas that can assist with proper quality and compliance!

To see more, CMS's survey and cert letter is here


Susan LaGrange, RN, BSN, NHA, is the national education coordinator at Pathway Health Services.


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