The right time to stay out of the limelight
Being proactive with reviewing policies and practices early this year can help your community avoid experiencing one of the top ten most frequently cited deficiencies, and maybe even achieve a deficiency-free survey. The top ten most cited areas in an assisted living are outlined below.
Number 10: A0008
Admission/Health Assessment requires the Agency for Health Care Administration (AHCA) Form 1823 to be completed no more than 60 days before admission or by the 30th day from admission. A physician, physician’s assistant, or Advanced Registered Nurse Practitioner (ARNP) must complete the Form 1823 (1823) at a minimum of every three years, or after a significant change, whichever comes first.
If the 1823 is not completed, it does not necessarily require an additional face-to-face examination. The facility may obtain omitted information either verbally or in writing. The omitted information must be documented in the resident’s record and include the name of the physician, name of the staff taking the information and the date and time.
A good practice to put in place to ensure Admission/Health Assessments are complete is to have a process where two or three different staff members review the form for completion and then sign off on an attached sheet that they have reviewed. This sheet does not become part of the record; rather, it is a tool for the Resident Service Director, administrator and possibly another lead staff member who is skilled or better yet, CORE trained, for completion. Sometimes, more people looking at the form will cause possible omissions to be identified.
Number 9: A0054
Medication Records is regularly cited due to incorrect directions for use on the Medication Observation Record (MOR). The MOR must be updated each time the medication is given, is missed, there is refusal to take medications as prescribed or there is a medication error.
Electronic Medication Observation Records allow the Resident Service Director or administrator to review observation records in real time to provide opportunities for improvement. These programs give sight to the leadership team to see where education should be provided and to help determine how high the medication responsibilities might be on a particular assignment. Sometimes, the acuity of a facility shifts, and staffing should be looked at to meet the individual needs of the residents within the guidelines of the rules.
Number 8: A0025
Resident Supervision in Facilities must offer personal supervision as prescribed by the Health Assessment (Form 1823). Supervision includes:
- Daily observation by designated staff of the activities of the resident;
- Monitoring the quantity and quality of the resident’s diet;
- Awareness of the resident’s general health, safety and physical and emotional well-being;
- General awareness of the resident’s whereabouts; and
Contacting the health care provider, family, guardian/power of attorney and case manager for significant change or the resident is discharged or moves out.
There should be a written record of any significant change, illness that resulted in medical attention, changes in method of medication administration or other changes that result in provision of other services. Many times, the staff will provide the care. It should be noted if a resident is requiring more care so possible interventions can be made to bring the resident back to the previous level or a new Health Assessment obtained to reflect the new normal for that resident.
Number 7: A0019
Continued Residency is the responsibility of the assisted living facility (ALF) administrator. Criteria for continued residency must be the same as admission criteria with certain exceptions being made for residents receiving hospice services. Hospice services must be agreed upon by the resident/family, facility and the hospice caring for the resident’s increased needs. An interdisciplinary plan of care must be developed and good communication must be maintained in order to meet the resident’s care needs. Hospice services are not a blanket to cover all needs of a resident. It is best practice to meet weekly with the hospice organization and the family, even if via a phone, to ensure the resident’s care is accomplished with excellence.
Number 6: A0152
For Physical Plant and Safe Living Environment, it is considered best practice to have weekly rounds completed by the department heads and encourage staff to bring concerns to the attention of the administrator. Educate residents and families on concerns over small rugs, good fitting shoes and other areas.
Number 5: A0093
Food Service and Dietary Standards is getting close to the top in frequency of citations. Consider the following:
- All regular and therapeutic diets must be reviewed annually by licensed or registered dietician;
- Substitutions must be of comparable nutritional value and must be documented before or when the meal is served;
- Menus must be planned at least one week in advance and conspicuously posted or easily available to residents;
- No more than 14 hours between the end of dinner and beginning of breakfast;
- For residents without kitchen access, a snack must be offered at least once a day; and
- Three-day supply of nonperishable food must be on hand to cover the census.
Food and dining is a time for celebrations. Encourage residents to be involved in the menu planning. Notify the physician of resident’s refusal to comply with a therapeutic diet and document.
Number 4: A0081
Staff In-Service Training is not a surprise. Make a list and stay consistent, if possible, on who is providing this training. Items to consider are:
- Initial training should be one hour in-service on infection control, including universal precautions and facility sanitation process before any direct care staff provide (CNAs, nurses and home health aides are exempt);
- All other trainings must be completed within 30 days of hire; and
- Ensure that the staff can demonstrate and are competent the elopement policy and procedures.
Number 3: A0030
For Resident Rights and Facility Procedures, communities should have a grievance procedure for receiving and responding to resident complaints. Practice with the staff so they can implement this process promptly when there is a complaint. Have house rules and procedures in writing that address, at minimum, the facility’s policy regarding resident responsibilities, alcohol and tobacco usage, medication storage, resident elopement, reporting resident abuse, neglect and exploitation, administrative and housekeeping schedules, infection control, sanitation and universal precautions.
Also include requirements for coordinating and delivery of services to residents by third-party providers. Physical restraints (including half and quarter rails) must be reviewed annually by the physician (physician order every 6 months) and have consent unless the resident chooses to have the device and can remove or avoid without assistance. It should not need to be said that a resident has the right to be treated with dignity and respect, individuality and have privacy, but it should be clearly stated. The resident should also have access to adequate and appropriate health care consistent with established standards within the community.
Number 2: AZ814
Background Screening must be completed prior to a person starting as an employee. A person must be rescreened if they have a break for over 90 days. This citation always has a $500 fine imposed with it.
Number 1: A0078
Staffing Standards tops the list. This is a citation that includes failing to have a statement of freedom from tuberculosis (TB) updated annually. If your employee gets a chest x-ray, a health care provider must sign off annually that the employee is free from TB. This does not mean a new chest x-ray must be done. Please remember that a communicable disease statement is only required once and must be documented by a health care provider. Another portion noted in the citation is that staff must be qualified to perform their assigned duties consistent with their level of training, education, preparation and experience, and this includes contract staff.
Many times, being at the top is the goal. In this case, however, making sure your facility is managing the requirements of an assisted living facility is important so you can stay away from the “Top Ten.”