1. 2015 Survey Trends and Systems Review NYSHFA Audio Conference
Presenters:
Linda M. Elizaitis, President, CMS Compliance Group
James Houle, Life Safety Consultant, CMS Compliance Group
CMS Compliance Group, Inc. T: E. W.
This presentation is property of CMS Compliance Group, Inc. Reuse or distribution without prior written authorization by CMS Compliance Group, Inc. is strictly forbidden.

2. 2015 Top 10 Deficiencies – National vs NYS
2015 National Top 10 Deficiencies
2015 NYS Top 10 Deficiencies
1. F-441 Infection Control, Prevent Spread, Linens
1. F-371 Food Procurement, Store/Prepare/Serve – Sanitary
2. F-371 Food Procurement, Store/Prepare/Serve - Sanitary
2. F-441 Infection Control, Prevent Spread, Linens
3. F-323 Free of Accident Hazards/Supervision/ Devices
4. F-309 Provide Care/Services for Highest Well Being
4. F-225* Investigate/Report Allegations/ Individuals
5. F-431* Drug Records, Label/Store Drugs & Biologicals
5. F-279 Develop Comprehensive Care Plans
6. F-329 Drug Regimen is Free From Unnecessary Drugs
6. F-282 Services by Qualified Persons/ Per Care Plan
7. F-279 Develop Comprehensive Care Plans
7. F-280* Right to Participate in Care Planning – Revise CP
8. F-514* Resident Records – Complete/ Accurate/ Accessible
8. F-241 Dignity and Respect of Individuality
9. F-241 Dignity and Respect of Individuality
9. F-309 Provide Care/Services for Highest Well Being
10. F-282 Services by Qualified Persons/ Per Care Plan
10. F-329 Drug Regimen is Free From Unnecessary Drugs

3. NYS 2014 vs 2015 Top 10 Deficiencies
2014 NYS Top 10 Deficiencies
2015 NYS Top 10 Deficiencies
1. F-441 Infection Control, Prevent Spread, Linens
1. F-371 Food Procurement, Store/Prepare/Serve – Sanitary (↑)
2. F-371 Food Procurement, Store/Prepare/Serve - Sanitary
2. F-441 Infection Control, Prevent Spread, Linens (↓)
3. F-323 Free of Accident Hazards/Supervision/ Devices
3. F-323 Free of Accident Hazards/Supervision/ Devices (↔)
4. F-282 Services by Qualified Persons/Per Care Plan
4. F-225 Investigate/Report Allegations/Individuals (↑)
5. F-279 Develop Comprehensive Care Plans
5. F-279 Develop Comprehensive Care Plans (↔)
6. F-309 Provide Care/Services for Highest Well Being
6. F-282 Services by Qualified Persons/ Per Care Plan (↓)
7. F-253 Housekeeping and Maintenance Services
7. F-280 Right to Participate in Care Planning – Revise CP (↑)
8. F-280 Right to Participate in Care Planning – Revise CP
8. F-241 Dignity and Respect of Individuality (NEW)
9. F-281 Services Provided Meet Professional Standards
9. F-309 Provide Care/Services for Highest Well Being (↓)
10. F-225 Investigate/Report Allegations/Individuals
10. F-329* Drug Regimen is Free From Unnecessary Drugs (NEW)

4. Top 10 Deficiencies – Buffalo
F-371 Food Procurement, Store/Prepare/Serve - Sanitary
F-441 Infection Control, Prevent Spread, Linens
F-280 Right to Participate in Care Planning – Revise CP
F-241 Dignity and Respect of Individuality
F-309 Provide Care/Services for Highest Well Being
F-323 Free of Accident Hazards/Supervision/Devices
F-157* Notify of Changes (Injury/Decline/Room, etc)
F-242* Self Determination – Right to Make Choices
F-279 Develop Comprehensive Care Plans
F-312* ADL Care Provided for Dependent Residents

5. Top 10 Deficiencies - Rochester
F-280 Right to Participate in Care Planning – Revise CP
F-225 Investigate/Report Allegations/Individuals
F-312* ADL Care Provided for Dependent Residents
F-323 Free of Accident Hazards/Supervision/Devices
F-441 Infection Control, Prevent Spread, Linens
F-329 Drug Regimen is Free From Unnecessary Drugs
F-431* Drug Records, Label/Store Drugs & Biologicals
F-241 Dignity and Respect of Individuality
F-282 Services by Qualified Persons/ Per Care Plan
F-371 Food Procurement, Store/Prepare/Serve - Sanitary

6. Top 10 Deficiencies – Capital District
F-371 Food Procurement, Store/Prepare/Serve - Sanitary
F-441 Infection Control, Prevent Spread, Linens
F-241 Dignity and Respect of Individuality
F-309 Provide Care/Services for Highest Well Being
F-225 Investigate/Report Allegations/Individuals
F-514* Resident Records – Complete/Accurate/ Accessible
F-282 Services by Qualified Persons/Per Care Plan
F-323 Free of Accident Hazards/Supervision/Devices
F-279 Develop Comprehensive Care Plans
(Tie) F-253* Housekeeping and Maintenance Services and F-314* Treatment/Svcs to Prevent/Heal Pressure Ulcers

7. Top 10 Deficiencies – Central NY
F-225 Investigate/Report Allegations/Individuals
F-371 Food Procurement, Store/Prepare/ Serve - Sanitary
F-309 Provide Care/Services for Highest Well Being
F-441 Infection Control, Prevent Spread, Linens
F-314* Treatment/Svcs to Prevent/Heal Pressure Ulcers
F-323 Free of Accident Hazards/Supervision/Devices
F-279 Develop Comprehensive Care Plans
F-241 Dignity and Respect of Individuality
F-253* Housekeeping and Maintenance Services
F-325* Maintain Nutritional Status Unless Unavoidable

8. Top 10 Deficiencies – Hudson Valley
F-279 Develop Comprehensive Care Plans
F-282 Services by Qualified Persons/Per Care Plan
F-371 Food Procurement, Store/Prepare/Serve - Sanitary
F-280 – Right to Participated in Care Planning – Revise CP
F-315* No Catheter, Prevent UTI, Restore Bladder
F-329 Drug Regimen is Free From Unnecessary Drugs
F-431* Drug Records, Label/Store Drugs & Biologicals
(3-way tie at #8/#9/#10) F-309 Provide Care/Services for Highest Well Being
F-441 Infection Control, Prevent Spread, Linens
F-456* Essential Equipment, Safe Operating Condition

9. Top 10 Deficiencies - NYC
F-371 Food Procurement, Store/Prepare/Serve - Sanitary
F-282 Services by Qualified Persons/Per Care Plan
F-431* Drug Records, Label/Store Drugs & Biologicals
F-441 Infection Control, Prevent Spread, Linens
F-253* Housekeeping and Maintenance Services
F-279 Develop Comprehensive Care Plans
F-280 Right to Participate in Care Planning – Revise CP
F-281* Services Provided Meet Professional Standards
F-329 Drug Regimen is Free From Unnecessary Drugs
F-323 Free of Accident Hazards/Supervision/Devices

10. Top 10 Deficiencies – Long Island
F-282 – Services by Qualified Persons/Per Care Plan
F-280 Right to Participate in Care Planning – Revise CP
F-329 Drug Regimen is Free From Unnecessary Drugs
F-253* Housekeeping and Maintenance Services
F-441 Infection Control, Prevent Spread, Linens
F-514* Resident Records – Complete/Accurate/ Accessible
F-323 Free of Accident Hazards/Supervision/Devices
F-241 Dignity and Respect of Individuality
F-371 Food Procurement, Store/Prepare/Serve - Sanitary
F-431* Drug Records, Label/Store Drugs & Biologicals

11. Upstate Area Offices Top Cited Deficiencies
Buffalo
F-371
F-441
F-280
F-241
F-309
F-323
F-157*
F-242*
F-279
F-312*
Rochester
F-225
F-329
F-431*
F-282
Capital
F-514*
F-253* / F-314*
Central
F-314*
F-253*
F-325

12. Downstate Area Offices Top Cited Deficiencies
Hudson Valley
F-279
F-282
F-371
F-280
F-315*
F-329
F-431*
F-309
F-441
(Tie) F-456* / F-309 / F-441
NYC
F-253
F-281*
F-323
Long Island
F-253*
F-514*
F-241

13. #1 F-371 Food Procurement, Store/Prepare / Serve- Sanitary
Citations
CNA observed taking bread out of wrapper with bare hands and buttering, then touching trays, resident’s hair and then assisted another resident with unwrapping sandwich and touching bread, breaking it up and putting into soup (S/S: D)
Fish cooked for previous day’s meal observed in walk-in but no cooling/ reheating logs to show food was properly cooled (S/S: E)
Undated spoiled milk in activities room, food not maintained at hot holding temps, disposable ware/napkins stored on floor (S/S: F)
F-371
The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

14. Systems to Review: Food Procurement, Store/Prepare/ Serve- Sanitary
Kitchen Cleaning
Cooling
Remote Kitchens
Refrigerator Temperatures
Holding food temperatures

15. #2 F-441 Infection Control, Prevent Spread, Linens
Facility cat observed walking on dining table while residents waited for meals and the table was not disinfected prior to meal service (S/S: D)
Shower trolleys on multiple units were soiled, potentially affected all residents who used this equipment (S/S: E)
No handwashing supplies were available for staff to use before leaving soiled utility room (S/S: F)
F-441
The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

16. Systems to Review: Infection Control, Prevent Spread, Linens
Handwashing during medication and/or treatment administration
Contact precautions
Flu vaccinations

17. #3 F-323 Free of Accident Hazards/ Supervision/Devices
Resident exited the facility through resident room window and reentered through front of building without staff knowledge (S/S: D)
Residents received the wrong liquid consistency, resulting in aspiration (S/S: E)
On 2 occasions resident was observed with back buckled seat belt across her chest (S/S: G)
F-323
The facility must ensure that –
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

18. Systems to Review: F-323 Free of Accident Hazards/ Supervision/Devices
Risk Management and Accident Prevention Programs
Falls Prevention
Elopement Protocols
Safe Smoking Program
Side rail PMP and gaps

19. #4 F-225 Investigate/Report Allegations/ Individuals
F The facility must—
§483.13(c)(1)(ii) Not employ individuals who have been-- (A) Found guilty of abusing, neglecting, or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities
§483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
§483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
§483.13(c)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Facility failed to report and investigate incident where resident wearing oxygen attempted to light a cigarette, burning himself on the face (S/S: D)
Failure to report resident-to- resident physical and verbal abuse that resulted in roommate asking for a room change (S/S: D)
Inconsistencies found in staff reports regarding resident falling and thorough investigation not completed to determine reason for inconsistencies (S/S: E)

20. Systems to Review: F-225 Investigate/ Report Allegations/Individuals
Resident Observation & Reporting
Bruises/Scratches
Background checks
Investigations
Staff Statements

21. #5 F-279 Develop Comprehensive Care Plans
No care plan to address multiple falls and injuries of a resident with self-injurious behavior (S/S: D)
Self-inflating resuscitation bag with tracheotomy attachments and mask not made available to resident on ventilator ( S/S: D)
No CCPs developed for palliative care and restraint use and use of psychoactive medications for multiple residents (S/S: E)
F-282
§483.20(d) (A facility must..) use the results of the assessment to develop, review and revise the resident’s comprehensive plan of care.
§483.20(k) Comprehensive Care Plans (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25; and (ii) Any services that would otherwise be required under § but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

22. Systems to Review: F-279 Develop Comprehensive Care Plans
Individualized plan of care
Measurable goals
EMR
Timely implementation
Revision/Review after changes in condition
All care areas & major diagnosis

23. #6 F-282 Services by Qualified Persons/ Per Care Plan
Resident who required assistance with ADLs left by sink unattended and found on floor later by another resident (S/S: D)
Resident found without shoes or heel protectors for physical therapy even though family had brought sneakers for him to use (S/S: D)
Services not provided in accordance with written plan of care for resident observed with greasy hair, unshaven and dry skin (S/S: D)
F-282
Be provided by qualified persons in accordance with each resident’s written plan of care.

24. Systems to Review: F-282 Services by Qualified Persons/Per Care Plan
Assistive devices not observed to be in use
Consults not completed per physician order
Lab/Diagnostic tests

25. #7 F-280 Right to Participate in Care Planning – Revise CP
No revision to CCP for resident who was independent with setup help for ADLs and then required extensive assist from staff member (S/S: D)
CCP not revised for resident with UTI who was on a daily diuretic and experienced a decline in continence and oral intake at meals (S/S: D)
Resident’s spouse was not invited to care planning meetings despite being at facility nearly every day to visit (S/S: D)
F-280
The resident has the right to -- unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.

26. Systems to Review: F-280 Right to Participate in Care Planning – Revise CP
Family/Resident interviews
Invitation/review of care plan
Decline in ADLs
Significant Change

27. #8 F-241 Dignity and Respect of Individuality
Resident refused to wear clothing protector and said he had his own but CNA forced him and fed him without speaking to him or explaining to him what she was doing (S/S: D)
LPN said loudly that residents needed a staff member to sit with them during meals because they are “feeders.” Residents were served last because they required assistance (S/S: D)
Staff did not knock on residents’ doors and announce themselves or ask permission to enter resident rooms (S/S: E)
F-241
The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.

28. Systems to Review: F-241 Dignity and Respect of Individuality
Staff education and monitoring
Exposure
Privacy
Dining

29. #9 F-309 Provide Care/Services for Highest Well Being
RN assessment not completed for more than a week after resident complained of not feeling well and having trouble breathing (S/S: D)
Incorrect treatment to buttocks completed by CNA, and correct treatment was signed as being administered by LPN (S/S: E)
Stool sample not tested for blood as ordered, resulting in intestinal bleed and no follow up consults were provided (S/S: G)
F-309
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

30. Systems to Review: Provide Care/Services for Highest Well Being
Hemodialysis
Anticoagulants
Advance Directives
Pain
Care of the resident with dementia

31. #10 F-329 Drug Regimen is Free From Unnecessary Drugs
1. General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above.
2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
Antianxiety meds administered without nonpharmacological interventions attempted first, and no monitoring documented (S/S: D)
Medication administered without adequate medical indication because physician forgot to put it in record (S/S: D)
Psych consult did not provide notes on suicidal ideation or behaviors but recommended a dosage increase that was signed off on by physician even though no documented behaviors existed in medical record (S/S: D)

32. Systems to Review: F-329 Drug Regimen is Free From Unnecessary Drugs
Rationale for use
Nonpharmacological interventions
Documentation
Consultant Pharmacist recommendations

33. Things to Think About Immediate Jeopardy Citation Areas:
Advance Directives
Anticoagulants
Physician Notification of Changes
Side Rails
Nursing Staffing Data

34. NYS 2015 – Top 10 K-tags 2015 Top 10 K-tags
1. K-56 Automatic Sprinkler System – Throughout
2. K-147 Electrical Wiring & Equipment
3. K-62 Automatic Sprinkler System – Maintained
4. K-29 Hazardous Areas – Construction, Protection, Separation
5. K-38 Exit Access – Accessible at All Times
6. K-25 Smoke Barriers – Fire Resistance Rating
7. K-18 Corridor Doors
8. K-69 Commercial Cooking Equipment
9. K-50 Fire Drills
10. K-20 Vertical Openings – Fire Resistance Rating

35. NYS Top 10 K-tags – 2014 & 2015 2015 Top 10 K-Tags 2014 Top 10 K-Tags
1. K-56 Automatic Sprinkler System – Throughout
2. K-62 Automatic Sprinkler System – Maintained
3. K-29 Hazardous Areas -Construction, Protection, Separation
4. K-25 Smoke Barriers – Fire Resistance Rating
5. K-38 Exit Access – Accessible at all times
6. K-18 Corridor Doors
7. K-147 Electrical Wiring & Equipment
8. K-50 Fire Drills
9. K-76 Medical Gas Storage & Admin Areas
10. K-20 Vertical Openings – Fire Resistance Rating
2015 Top 10 K-Tags
1. K-56 Automatic Sprinkler System – Throughout
2. K-147 Electrical Wiring & Equipment
3. K-62 Automatic Sprinkler System – Maintained
4. K-29 Hazardous Areas – Construction, Protection, Separation
5. K-38 Exit Access – Accessible at All Times
6. K-25 Smoke Barriers – Fire Resistance Rating
7. K-18 Corridor Doors
8. K-69* Commercial Cooking Equipment
9. K-50 Fire Drills
10. K-20 Vertical Openings – Fire Resistance Rating

36. #1 K-56 & #3 K-62 Sprinklers Throughout/ Maintained
Sprinkler pipes in ceiling with wires attached to/supported by sprinkler pipe
Paint on sprinklers
Sprinkler hangers
Full fabric shower curtains obstructing sprinkler flow in showers
Duct work >4’
Elevator machine rooms

37. #2 K-147 Electrical Wiring and Equipment
Electrical panels lacking directory
Electrical boxes lacking covers
Extension cords, cube taps and power strips

38. #4 K-29 Hazardous Areas – Construction, Protection, Separation
Room storage >502
Self-closing doors
Storage within 3’ of panels

39. #5 K-38 Exit Access – Accessible at All Times
Storage in corridor
Door locking, delayed egress
Dual lamps

40. #6 K-25 Smoke Barriers – Fire Resistance Rating
Penetrations not sealed with approved fire stop

41. #7 K-18 Corridor Doors Corridor Doors Stairwells
Obstructions to closing of doors on corridor
Doors positive
Stairwells
Self-closing doors
Door latching
Doors propped open

42. #8 K-69 Commercial Cooking Equipment
“K” extinguisher with no signage
Ansul system monthly inspection
Hood cleaning documentation

43. #9 K-50 Fire Drills Fire Drills were: Fire Procedures
Not quarterly and not on each shift
Not under varied conditions and times
Fire Procedures
Fire extinguishers mounted more than 5’ from finished floor
Kitchen staff unfamiliar with:
Code phrase
Ansul system
“K” extinguisher

44. #10 K-20 Vertical Openings – Fire Resistance Rating
Floor-Floor
Floor-Roof

45. Other Areas to Pay Attention To
Emergency Generators
Documentation
Required load bank
Combustibles
Hand Sanitizers
Alcohol-based sanitizers mounted adjacent to or over ignition source (light switches, electrical receptacles)
Storage of more than 10 gallons of alcohol-based hand sanitizer in one smoke compartment
Miscellaneous
Portable Heaters
Manometers not provided on filter banks
Smoking regulations
Oxygen storage

46. 2012 Life Safety Code Anticipated Changes from 2000 LSC to 2012 LSC

47. Thank You!
Thank you to NYSHFA for having CMS Compliance Group present on 2015 Survey Trends & Systems to Review!
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