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MDH Shares Survey Data and Other Information During Statewide Call

The Minnesota Department of Health (MDH) held a statewide regulatory call for care centers on July 16 and provided updates on commonly-cited deficiencies and other topics. MDH recorded Monday’s call and will post the recording on its webpage within the next week, and it will remain archived there for 90 days. Here are notes from the call: 

Joint Surveyor-Provider Training

Save the dates: Working together with LeadingAge Minnesota and other stakeholders, MDH will develop another round of joint provider-surveyor trainings this fall. Programs will be offered Oct. 30, Oct. 31, Nov. 1, Nov. 8 and Nov. 9 and locations to be determined. 

Most-Cited Deficiencies

Mary Absolon, Licensing and Certification Program Manager, reviewed survey data for the period Oct. 1, 2017 to the present. Here are the top 10 citations for re-certification surveys (based on 279 surveys completed):

  • F0880 Infection Prevention & Control 88
  • F0689 Free of Accident Hazards/Supervision/Devices 52
  • F0684 Quality of Care 49
  • F0686 Treatment/Svcs to Prevent/Heal Pressure Ulcer 45
  • F0677 ADL Care Provided for Dependent Residents 41
  • F0609 Reporting of Alleged Violations 38
  • F0656 Develop/Implement Comprehensive Care Plan 37
  • F0641 Accuracy of Assessments 36
  • F0758 Free from Unnec Psychotropic Meds/PRN Use 33
  • F0761 Label/Store Drugs and Biologicals 32

G-level citations are most commonly issued in relation to the following issues:

  • F0686 Treatment/Svcs to Prevent/Heal Pressure Ulcer 14 45.2% (the prior tag, F0314 accounted for an additional two G-level citations)
  • F0689 Free of Accident Hazards/Supervision/Devices 13 41.9% (the prior tag, F0323 accounted for one additional G-level citation)
  • F0688 Increase/Prevent Decrease in ROM/Mobility 4 12.9%
  • F0309 Provide Care/Services For Highest Well Being 3 9.7%
  • F0684 Quality of Care 3 9.7%
  • F0676 Activities Daily Living (ADLs)/Mntn Abilities 1 3.2%
  • F0726 Competent Nursing Staff 1 3.2%
  • F0373 Feeding Asst - Training/Supervision/Resident 1 3.2% 

Infection Control & Prevention

Kathy Como-Sabetti, RN, and Tammy Hale, RN, of the MDH Infectious Disease Epidemiology, Prevention and Control (IDEPC) division, provided an update on Group A Streptococcus (GAS) outbreak in long-term care facilities and wound care infection prevention recommendations

Notably, Minnesota has seen an increase in invasive Group A strep statewide, with the number of cases in 2017 being more than double the number in 2016. Also, the number cases occurring in long-term care has increased, both in absolute terms and as a percentage of the overall number of cases statewide.

We recommend that providers listen back to these informative presentations once MDH posts the recording of the statewide call.  We will include a note in Advantage as soon as the recording is up. 

Federal Complaint Investigation Process in SNF/NF

MDH will begin implementing an alternative process for investigating complaints at SNFs/NFs. The alternative process will involve the responsibility of the Licensing & Certification (L&C) program survey staff to conduct investigations that involve alleged violations of federal nursing facility requirements. 

L&C staff currently investigate federal complaints with surveys. This will include stand-alone federal complaints in the future. If the allegation also involves suspected maltreatment (neglect, abuse, and exploitation), the L&C federal abbreviated standard survey results will be forwarded on to the Office of Health Facility Complaints (OHFC) to determine if maltreatment under the Minnesota Vulnerable Adults Act (VAA) should be substantiated, unsubstantiated, or determined to be inconclusive. 

Federal deficiencies (and any state nursing facility licensing orders) would be issued by the L&C staff, in compliance with CMS timeframes, with any maltreatment findings issued subsequently by OHFC. OHFC will continue to issue maltreatment reports that include “a statement of any action taken by the lead investigative agency” which often includes deficiency and violation information.  

The project is presently at a pilot stage, and MDH will provide additional information in the weeks ahead.  

Focused Comparative Surveys

This summer CMS will be conducting comparative focus surveys throughout the country on three specific issues: Dementia Care (F744), Abuse/Neglect (F600-F610), Admission/Transfer/Discharge (F621- F626). These comparative surveys began May 1 and will end Sept. 1.  

During these events, a federal surveyor will follow the standard investigative protocols and pathways.  The sample will include 60 percent of the State’s survey sample of residents that triggered the concern area. Following completion of the investigation, the survey will conduct an exit with the administrator and other staff the facility wishes to include. CMS will not issue a 2567 unless there is a deficiency at an IJ level of harm or substandard quality of care.  In other cases, it will provide information that a facility can use to make corrections.  

CMS has completed three of these surveys in the Twin Cities metro area already, and it will conduct additional surveys throughout the state over the next six weeks. Please note, these issue-specific federal focus surveys are different from the federal look-behind surveys that CMS conducts on a small number of facilities every year. Those full comparative surveys will continue as they have in the past.

A new round of focus surveys will begin Oct. 1, 2018, with the topics to be identified by each CMS Regional Office.  

Legionella Testing

As we reported last week, CMS has updated its Quality, Safety & Oversight memorandum concerning Legionella. Ever since CMS established the requirement last year for facilities to have water management programs addressing Legionella, there has been uncertainty about whether facilities must test their water for the presence of the pathogen itself.  

This memorandum states clearly that “CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. … LTC surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use.” 

For additional guidance about when a facility might choose to conduct testing, see this Centers for Disease Control and Prevention Frequently Asked Questions page. 

Provider Resources

Both MDH (click here) and CMS (click here) have posted survey-related and other regulatory resources to their websites.  The CMS site, in particular, offers a wide range of resources, including a Frequently-Asked-Questions document, survey forms including critical element pathways, and others.

As we reported last week, CMS has prepared a Frequently Asked Questions document concerning bed rails, which addresses questions arising under F604, F700 and F909.  CMS intends to post the document on its website within the next month; meanwhile, members may access the document by clicking here.

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