Survey Tips for F689 and Past Noncompliance | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Survey-Tips-for-F689-and-Past-Noncompliance.aspx | Survey Tips for F689 and Past Noncompliance | | | | | 3/13/2024 4:00:00 AM | | <p></p><div>AHCA’/NCALs Quality and Regulatory Department is offering a bi-weekly blog series with important survey tips. Through these blog series, we will share important tips based on the latest trends in surveys throughout the nation. The posts will also include general survey preparation and survey management tips to implement in your facility. If there’s a specific topic that would be helpful to address, please email <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org</a>. </div><div> </div><div>Year after year, F689 (Free of Accident Hazards/Supervision/Devices) continues to be one of the top cited F-tags and frequently cited at a Jeopardy-level scope and severity. In 2024, there has already been almost 400 F689 citations nationally. The graph below displays the number of national citations for F689. </div><div><div style="text-align:center;"><br><img src="/News-and-Communications/Blog/PublishingImages/Pages/Survey-Tips-for-F689-and-Past-Noncompliance/Survey%20Tip%20Image.PNG" alt="Survey Tip Image.PNG" style="margin:5px;" /><br></div></div><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><blockquote style="margin:0px 0px 0px 40px;border:none;padding:0px;"><div>Source- qcor 3.7.2024</div></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote></blockquote><div><br></div><div><span style="font-size:11pt;">AHCA/NCAL has developed a list of the components of the regulatory requirement for reporting violations and tips on how to ensure compliance based on a review of the common reasons facilities received citations for F689- Supervision/Hazards/Accidents. </span></div><div><span style="font-size:11pt;"><br></span></div><div><span style="font-size:11pt;"><strong>Tips to avoid accidents and keep residents safe: </strong></span></div><div><span style="font-size:11pt;"><br></span></div><div><ul><li><span style="font-size:11pt;">Develop a culture of safety and commitment to implementing systems that address resident risk and environmental hazards. </span></li><li><span style="font-size:11pt;">Ensure you have a process in place to <a href="https://066b40b5535506586917-68298049b65edbd7ec9f493f0b1c8eb3.ssl.cf2.rackcdn.com/ahca_3ad244d9a8c9db86a24dee853f06b557.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">communicate</a> any interventions specific to residents. For example, ensure frontline staff are aware of interventions established for fall prevention so each established intervention is followed. </span></li><li><span style="font-size:11pt;">If an elopement risk assessment shows a resident is at risk for wandering, there should be interventions established to ensure the resident is always appropriately supervised. </span></li><li><span style="font-size:11pt;">Check wander guard bracelets and door-mounted devices frequently (daily) to ensure the bracelet is in place and working properly, and all exit doors are locking properly. </span></li><li><span style="font-size:11pt;">Audit all residents who require any devices attached to their bed for mobility purposes to ensure the least restrictive method is used, and the resident is not restrained by the device. </span></li><li><span style="font-size:11pt;">Complete walking rounds to check for environmental hazards throughout the facility. This responsibility can be shared amongst management staff to ensure multiple individuals are checking for hazards inside and outside the facility. </span></li><li><span style="font-size:11pt;">Develop facility policies and procedures for allowing residents to sit outside of the facility. These procedures should include supervision by staff, sunscreen application, and protective eyewear/hats, as appropriate. </span></li><li><span style="font-size:11pt;">Complete competency assessments routinely on mechanical lift transfers. </span></li><li><span style="font-size:11pt;">Educate, and re-educate facility staff on how to access the residents’ individual care plans. Ensure staff are aware that they must check the care plans daily, at the beginning of each shift, to ensure all new/updated interventions are followed. </span></li><li><span style="font-size:11pt;">Complete a post fall evaluation, as soon as possible after a fall. Develop/update interventions, as appropriate to prevent future falls. </span></li></ul></div><div> </div><div><strong style="font-size:11pt;">Tips to achieve Past Noncompliance if an adverse event occurs:</strong><span style="font-size:11pt;"> </span><br></div><div><br></div><div><span style="font-size:11pt;">The first step is to ensure the resident is safe and has been assessed as appropriate by nursing staff. Once the resident has been assessed and is in a safe position, providers are encouraged to follow these steps: </span></div><div><br></div><div><ul><li><span style="font-size:11pt;">When an adverse event occurs, including an elopement, pull together all appropriate staff to have an Ad Hoc Quality Assurance (QA) meeting. </span></li><li><span style="font-size:11pt;">At this meeting, discuss what occurred, what you believe to be the root cause (may be an initial conclusion until you can complete a thorough investigation). </span></li><li><span style="font-size:11pt;">Make sure all staff sign in at the meeting. </span></li><li><span style="font-size:11pt;">Start a folder or binder for all documentation to support what you have completed. </span></li><li><span style="font-size:11pt;">Complete any reports to the SSA, as appropriate. </span></li><li><span style="font-size:11pt;">Begin to fill in your internal Plan of Correction. </span></li><li><span style="font-size:11pt;">Do an initial audit- for elopement, this will normally be a count of all residents in the building to ensure everyone is present in the facility. </span></li><li><span style="font-size:11pt;">Establish what the ongoing monitor will be, based on the Root Cause Analysis (RCA). </span></li><li><span style="font-size:11pt;">Identify who will complete the ongoing monitor. </span></li><li><span style="font-size:11pt;">Complete staff training with all appropriate staff and contract staff. </span></li><li><span style="font-size:11pt;">Update any care plans, as appropriate, and ensure interventions are appropriate and communicated to all staff. </span></li><li><span style="font-size:11pt;">Review interventions routinely to ensure they are still appropriate. </span></li><li><span style="font-size:11pt;">Maintain your folder or binder in a safe place so it is accessible when surveyors enter the facility. </span></li></ul></div><div><br></div><div><span style="font-size:11pt;">For more tips on preventing accidents, keeping your residents safe, and achieving past noncompliance, review this <a href="https://educate.ahcancal.org/products/accidents-how-to-stay-ahead-of-f689-and-keep-your-residents-safe" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">webinar </a>on <a href="https://educate.ahcancal.org/products/accidents-how-to-stay-ahead-of-f689-and-keep-your-residents-safe" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">ahcancaled</a>. Additional information is available regarding <a href="/News-and-Communications/Blog/Pages/Reminders-for-Residents-with-Electronic-Cigarettes.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">e-cigarettes</a> in nursing homes and <a href="/Survey-Regulatory-Legal/MemberOnlyDocs/Elopement%20Toolkit.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Elopement specific training</a>. Please send any questions to <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org</a>.</span></div><p></p> | AHCA’/NCALs Quality and Regulatory Department is offering a bi-weekly blog series with important survey tips. | |
Reminders for Residents with Electronic Cigarettes | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Reminders-for-Residents-with-Electronic-Cigarettes.aspx | Reminders for Residents with Electronic Cigarettes | | | | | 2/23/2024 5:00:00 AM | | <div>Electronic cigarettes are being used more frequently by residents in skilled nursing facilities. Below are some reminders on regulations and safety concerns related to e-cigarettes in facilities. <a href="https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Appendix PP</a> states, e-cigarettes do not pose the same dangers of ignition as regular cigarettes. However, they are not without risk. Some risks associated with e-cigarettes include: </div><div><br></div><div><ul><li>Potential health risks to the smoker </li><li>Second-hand aerosol exposure </li><li>Nicotine overdose </li><li>Explosion or fire caused by the battery <br></li></ul></div><div><br>Facilities are responsible for overseeing the use and storage of these devices to maintain an accident-free environment. Some tips to keep your residents safe include: </div><div> </div><div><ul><li>Assess residents for safety prior to allowing them to use the device </li><li>Consider keeping devices at the nurses’ station, like securing residents’ cigarettes </li><li>Keep loose batteries in a case to prevent contact with metal objects </li><li>Never charge a vape device with a phone or tablet charger, only use the appropriate charging equipment </li><li>Only charge devices during the daytime hours<a href="https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-or-fire-explosions" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083"></a><br></li><li>Replace the batteries if they get damaged or wet </li></ul></div><div><br></div><div>For more information on e-cigarette safety, visit the <a href="https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-or-fire-explosions" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Food and Drug Administration website</a>. Please send questions to <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org</a>. <br></div> | Here are some reminders on regulations and safety concerns related to e-cigarettes in skilled nursing facilities. | |
Clarification Regarding the NHSN 2023 Annual Survey Requirements | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Clarification-Regarding-the-NHSN-2023-Annual-Survey-Requirements.aspx | Clarification Regarding the NHSN 2023 Annual Survey Requirements | | | | | 1/16/2024 5:00:00 AM | | <div>Nursing facilities may have received a recent email from the National Health and Safety Network (NHSN) stating they are required to complete the 2023 <a href="https://www.cdc.gov/nhsn/psc/locations.html" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">annual facility survey</a> by March 1, 2024, or they may see an interruption in their service in NHSN. </div><div><br></div><div>The Centers for Disease Control and Prevention (CDC) clarified that the 2023 annual facility survey is only required for providers who are reporting into the HAI modules (UTI/MDRO/CDI/PPM). Therefore, providers who submit data outside of these modules (i.e., COVID-10, annual Health Care Provider Influenza Vaccination data) are NOT required to complete the survey. </div><div><br></div><div>For additional questions or concerns, please contact the <a href="mailto:nhsn@cdc.gov?subject=2023%20Annual%20Facility%20Survey" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">NHSN Help Desk</a> or the AHCA <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory team</a>.<br></div><p></p> | Nursing facilities may have received a recent email from the National Health and Safety Network stating they are required to complete the 2023 annual facility survey by March 1, 2024, or they may see an interruption in their service in NHSN.
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HCS Assisted Living Study Underway | https://www.ahcancal.org/News-and-Communications/Blog/Pages/HCS-Assisted-Living-Study-Underway.aspx | HCS Assisted Living Study Underway | | | | | 10/31/2023 4:00:00 AM | | <p>Hospital & Healthcare Compensation Service (HCS) is conducting its annual <a href="https://hhcsinc.com/survey-questionnaires.html" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">Assisted Living Salary & Benefits Study</a> and requests your participation. Assisted Living providers are asked to complete the study’s questionnaire by November 20. The study is published by HCS and supported by NCAL. <br></p><p><span style="font-size:11pt;">There is no cost to participate. Participants may purchase the results at the reduced price of $185, versus the $375 nonparticipant rate. Questionnaires may be downloaded at: </span><a href="http://www.hhcsinc.com/" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank" style="font-size:11pt;">www.hhcsinc.com</a><span style="font-size:11pt;">. </span><br></p><p><a href="https://www.hhcsinc.com/hcs-reports.html" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" target="_blank">Last year’s Report </a>contained data from over 1,100 ALFs/RCFs/PCFs nationwide. The results cover management salaries, nonmanagement wages, and fringe benefits. Data will be reported by region, state, CBSA, revenue size, profit type, and bed-size. Information on eighteen fringe benefits, shift differentials, turnover rates, sign-on bonuses, and other facility/staffing metrics will also be included. The results will be published in January 2024.<br></p><p><span style="font-size:11pt;">For any questions or deadline extension requests, please contact Rich Cioffe at </span><a href="mailto:rcioffe@hhcsinc.com" data-feathr-click-track="true" data-feathr-link-aids="["60b7cbf17788425491b2d083"]" style="font-size:11pt;">rcioffe@hhcsinc.com</a><span style="font-size:11pt;">, (201) 405-0075, ext. 10.</span></p><div><br></div> | Hospital & Healthcare Compensation Service is conducting its annual Assisted Living Salary & Benefits Study and requests your participation. | |