Decoding the Top 5 ODH cited F-Tags in 2023: What surveyors don’t want you to know.

The Ohio Department of Health surveys of 2023 found many commonalities amongst long term care facilities that are often easily cited. The top 5 citations that were issued have many facets and have components that are highly dependent on human actions, which makes them easy to spot through observations. Let’s delve into these top 5 F tags and explore some ways you can prepare and avoid each of them.

NUMBER 5:

F812 - Food Procurement, Storage, Prep, and Service—Sanitary Conditions.

Food plays a critical role in healthcare, and F812 highlights the importance of effective management of the entire meal prep and dining process. From the start of the survey, until the exit conference, your kitchen staff, and floor staff alike, need to be on their toes. The kitchen is now the first stops the assigned surveyor makes, sometimes even before they get settled in for the entrance conference. 

The kitchen tour can be a quick once-over with the intent to return for a more thorough observation during tray line. But this is why the kitchen needs to be tidy and in order ALL the time. Your dietary manager needs to run a tight ship. Carol, who’s been a dietary manager for 12 years says, “It’s helpful to assign specific duties to the dietary aides so that people can be held accountable for those particular tasks”. It also “helps promote a sense of teamwork and decrease the stress on one person” to get it all done. Low hanging fruit: hanging pots/pans not dried thoroughly; dried food on utensils; dented cans not separated to a “do not use” labeled area, away from usable canned foods; open food items not closed/dated/stored properly or past use date, and a personal favorite… staff food in the resident refrigerators.

Besides the physical plant, there’s a human element at play here, too. Look at any Resident Counsel Meeting minutes and you’ll see that food is a “hot topic” amongst the residents. You can’t possibly please 100% of the residents all of the time. After all, nobody can make it as good as “I” did, right? All it takes is a complaint of cold food to get a surveyor looking further into the situation. They’ll be asking for a guest tray before you know it. And let’s not forget the meal pass observation. One staff member delivering a tray without sanitizing their hands prior to handling, or the one tray that is stuck on top of the cart without items properly covered can start the ball rolling in the wrong direction. And it seems there is no leeway or “substantial compliance” consideration when it comes to food.

DISCUSSION:

What is the most frustrating “food/kitchen”-related example that you’ve been cited for?

Share one tip you’ve learned from experience to avoid future citations for others.

NUMBER 4:

F677 - ADL Care Provided for Dependent Residents

This is not one to be taken lightly. After all, most of the residents under our care are there because they can’t take care of themselves. CMS emphasizes the need for healthcare facilities to provide comprehensive care for dependent residents, addressing their basic needs, such as maintaining good nutrition, grooming, and personal and oral hygiene. Another example of citations that can come simply from surveyor observations.

  We’ve all seen it… the resident with bed head in the common area. Staff is in a rush to get the resident who needs fed to the dining room but doesn’t brush their hair before leaving the room. How about the same resident sitting at the dining table with their tray in front of them but nobody assisting them to eat. That resident will surely have the attention of the survey team. 

  Staff, though well-meaning, are sometimes more task driven than detail oriented. Here’s where we, from a management perspective, can help the staff by ensuring things are structured so that staff have the time to get those important tasks done. A few things we can do to help make a positive difference for staff, and residents, alike:

1.     Be mindful of the number of residents that staff will have to have up and in the dining room for that first meal of the day. – it doesn’t make any sense to leave residents who need assistance with feeding in bed for breakfast. Staff do not have the time to go room-to-room to feed residents individually. Not to mention, food will not maintain its temperature for that long. Structure get-up lists so that work can be distributed between the night and the day shift to make the workload more manageable in the allotted time.

2.     Be sure meal times are realistic to allow things to get done. You can’t expect the shift that starts at 7am to have their residents up and also be able to deliver breakfast trays that arrive on the floor at 730am. Structure meal times to start a little later in the morning, even if your evening meal needs to be a little later. You may also consider an open-dining concept if that works for your facility. Person-centered care, where meals are served when the resident is ready, has proven successful for many facilities, improving quality of life, resident mood and meal intake. 

3.     Have an “all hands on deck” approach to the morning routines. Enlist management staff’s assistance to ensure residents are appropriately groomed and in the dining room before the trays are served. During your survey, ensure management staff round regularly, evaluating the “condition” of residents. “Guardian Angel” programs, where staff are assigned to check on specific residents on a daily basis, are helpful in these instances.

DISCUSSION:

What’s your strategy to help floor staff get morning tasks completed? 

How have you handled those difficult residents who refuse hygiene assistance?

NUMBER 3:

F689 - Creating Environments Free of Accidents and Hazards

The third most cited F-tag, Accidents and Hazards is always a hot topic for surveyors, and lawyers alike. Creating a safe environment within healthcare facilities has to be a top priority. CMS stresses the importance of implementing measures to prevent accidents and hazards, safeguarding the well-being of both residents and staff.

Establish good safety practices for your facility and ensure they are being followed by staff. I know, sadly, that is often easier said than done. The simplest things are not done because staff consider them time-intensive or an efficiency-buster. The comments… “Who needs a gait belt when I can just pull them up by the arms” or “Sally has the hoyer lift on the other hall, so I’ll just pick Mrs. Jones up under the arms and put her in her wheelchair” are cringe-worthy. And not only do you have to monitor that equipment is used, but is it being used correctly? Too often, people forget steps or use items improperly which decreases the safety of the items that are meant to make the task safer. That’s why it’s a must to address concerns immediately when noted with the individuals involved and then, reeducate the masses.

Evaluation of the resident’s risk should be a regular occurrence, starting on admission to the facility. And it should be regularly re-evaluated, at least on a quarterly basis. Even slight changes in a resident’s cognitive or functional level can increase their risk for falls. The intent isn’t to have a “let’s wait and see what happens” approach. Prevention is key! Look for things that potentiate a fall, address those and monitor for effectiveness. And don’t forget to look around… clutter in a room or sometimes even the layout of the furniture can hinder the ability of people to move around in a room.

  Quality of life should also be in the forefront of your mind when implementing a safety plan for the resident. If your assessment tells you that “Harriet” should wear shoes with a firm sole, a wide base and good arch support due to her Parkinson’s, but she loves wearing her cute little slip-on, flat bottomed slippers from the nearest department store, document the education and care plan it! You don’t get cited because a fall with injury happens. You get cited for not intervening when the opportunity to do so exists.

  I know, it feels like the worst thing has happened when someone falls and gets injured in your building. You can’t predict or control everything, no matter how proactive you are. However, how you respond can be a saving grace. Dive deep in your investigation and find the root cause of the incident and address it. Educate everyone who needs to be aware of any new interventions that are put into place, particularly the family or significant other/responsible party.

DISCUSSION: 

Who do you feel offers you the best insight to the resident’s fall risk? And why?

Number 2:

F684 - Ensuring Quality of Care

It’s no surprise this catch-all category made it to #2. F684 focuses on ensuring facilities identify and provide the needed care and services that meet professional standards of practice, and align with the residents’ preferences and goals for care. Though you could put a lot of issues under this tag, it is supposed to be used by surveyors when the issue identified has caused or has the potential to cause a negative outcome to the resident’s physical, mental or psycho-social well-being and there is no other tag that addresses the issue specifically. Concerns that arise with end-of-life care are addressed here, as well.

  Here is where the lack of following ordered tasks can get you cited. Imagine your resident with a significant history of CHF, who is supposed to be weighed daily, isn’t weighed several times during the month, including consecutive days over the past week. He slowly develops symptoms of CHF that go unnoticed by the staff. Soon he is in full blown CHF and is transferred to the hospital due to respiratory distress and is noted to have a ten-pound weight gain and lower extremity edema. Of course, that’s the chart the surveyor reviews. They find that physician’s orders were not followed which may have identified the ensuing CHF, allowing for earlier intervention in the facility and preventing the hospitalization. There’s a D level citation for you, just with one chart reviewed.

  In addition, non-pressure related wounds and wound care can be reviewed under this tag. Key factors need to be clearly defined and documented to show the areas are correctly classified as non-pressure wounds. Assessment of the area and a description of the wound that differentiates it from a pressure ulcer, along with other correlating factors that contribute to the development, such as diagnosis and contributing factors, should be included in the record. Preventative skin measures should be in place, appropriate treatment and monitoring completed, and any non-compliance by the resident should be documented; these could show that the facility has done its due diligence to prevent occurrence, appropriately treat an area that does develop and ultimately prevent a citation.

  Hospice and end of life care often can fall into this tag as well. When your resident is placed on hospice services, there is a whole new care plan that is established, in conjunction with the hospice provider. This outlines what each party is responsible for in the care provided. Ensure you are living up to the facility’s end of the bargain, but also monitor that the hospice is meeting theirs. Ultimately, the facility is still responsible for the care being provided to the resident. Ensure care policies are being followed and that staff is documenting their communication to the hospice regarding pain management, changes in condition, or declines noted. It’s all about collaboration of care between the hospice and the facility. Be sure the resident’s care plan is updated when the significant change assessment is completed to reflect the change in goals to palliation and slowing of declines related to the terminal diagnosis to avoid additional tags related to care planning.

DISCUSSION: In what ways and how often do you collaborate with your Hospice providers

And the Number 1 most cited F tag in 2023… (drumroll please…):

F880 - Infection Prevention and Control

That can’t possibly be a surprise to anyone who has worked in long term care since 2020, with the focus for the past few years being COVID-19. Though it’s always been a hot topic and easy target, CMS surveyors prioritize infection prevention and control, underscoring the crucial role of robust measures in healthcare settings. This F tag emphasizes the need for stringent protocols to prevent and manage infections, ensuring the safety of both patients and healthcare professionals.

  It’s been a challenge the last few years for long term care providers to keep up with the frequent, and sometimes drastic, changes in regulations related to infection control processes.  Now that the public health emergency has ended, do you think we can get back to “normal”? This area of oversite was already hard enough to manage before the pandemic.

  Infection prevention and control spans over multiple departments in the facility, making an observation of a breach in practice more likely to be spotted. It’s always the simplest of things that is observed: dirty linen on the floor, an STNA not sanitizing their hands after leaving a room before touching the next meal tray to deliver, a nurse who lays the accu check machine down in a room and brings it back to the med cart without a barrier, activity staff enter an isolation room to ask the resident a question without donning PPE. No ill intention on anybody’s part, nevertheless, you get no leeway. 

  Regularly scheduled in-servicing is a must with infection control. It may be helpful to gear education towards specific departments and educate each department separately. This will allow staff to focus on areas and scenarios that are directly related to their job duties and potential situations they may encounter. As a result, it will be more meaningful and impactful to them. 

  So… what’s your next step? These may have been the top five citations for 2023, but there are a lot of other tags out there. How are you regularly monitoring compliance in these areas and others? Regular rounding is one key element, as long as you are addressing observations that could be problematic. Educate staff one on one and bring examples to general meetings to discuss with others. Get fresh eyes on what’s going on. Whether it’s internal or outsourced, you’ll be surprised at what you don’t see because you are so used to looking at it. Perspective is everything! Mock surveys are our thing. We’d love to work with you to keep your 2567 short or non-existent. Call us! QA Healthcare Consulting LLC.