State Calculations

debRN0417 · May 10, 2011

Not to muddy the water, but...did the surveyor show there was actual harm done to a resident? I had a complaint survey last year...long story short, a resident had a low blood sugar on an out trip but suffered no harm. Surveyor said she'd give me a G tag unless the doc. could say that despite all of our efforts, the woman's blood sugars were brittle. I was all set to argue no harm but she backed off once the doc told her all the ins and outs. How can you get a G tag if there is no harm?

That's what I am wondering. How did the surveyor prove there was harm? Did any residents have to be hospitalized or something? You are right CCM- you cannot get a "G" unless there is proven harm.

If you were recited then there will be another revisit. Your complaint survey restarted the cycle.

The first "G" is usually a CMP.

The second re-cite (first revisit) can mean no reimbursement- not always though. It may be another CMP. The second revisit, if you do not clear will certainly stop medicare reimbursement. A thrid revisit that does not clear results in termination from the program.

Hopefully you will clear and it will be okay, however I am confused at what was the initial harm that started this whole thing.

txdon · May 11, 2011

I miss spoke, we received an E tag for 309. The G tag was in the category of special needs. This was the revisit for that we got recited on 3 out of the 7 original tags. We are waiting for the 527. It is due by Thursday of this week. What happens if it's late? Any thoughts on clearing on the 309 tag since we provided facilitywide flowsheets?

debRN0417 · May 12, 2011

The 2567 is the statement of deficiencies that the state provides the facility that lists the deficiencies and the findings of the survey team. It will let you know exactly what was cited and what you have to address. You have 10 days to respond to the 2567 from the date that you receive the written report which is usually within 10 working days from the date of exit (end of the survey).

If you were recited on 3 of the original 7 deficiencies, then you will have to submit your plan of correction on the 2567 for each of those three deficiencies. When you do your plan of correction, you must be sure that you have credible evidence that you have corrected the deficiency which could be the flowheets that you are talking about....HOWEVER- you have to have a plan of action to ensure that the deficient practice will not reoccurr. That means inservicing, auditing, or whatever it is that your facility will need to do to make sure that if/when the survey team comes back that they do not find a repeat deficiency again. (I hope I am not telling you stuff that you already know or is redundant for you but I just want to make sure that I am giving you information that is helpful and I am not sure how much info you need regarding the whole survey process).

So if you cleared your "G" tag then you MAY not get another survey. It is up to the state agency whether or not they will come back. They CAN but MAY not. In my state we usually do not do a revisit if the facility has cleared the harm tag and just got recited with a "D" in other areas. The supervisor at the state agency may do what they call a "desk review" and look at your plan of corrrection and may request your credible evidence to prove that you have responded to the citation and done what you need to do in order to correct the deficiency as well as have a plan in place to prevent it from happening again and for continued monitoring of the issues.

I hope this is helpful information. Let me know if there is other information I can help you with or if I didn't anwer exactly what you needed to know. I'll do my best to help you.

Hopefully your 2567 will be on time, however if it is late for some reason then the clock starts ticking for you on Thursday for your 10 CALENDAR days (not working days) so just make sure that you are ready to respond to the report as soon as it arrives and get the POC back to the state agency within the 10 day time frame (which I believe would start for you on Thursday if I understand you corrrectly). Try to set your allegation of compliance date (AOC) date as soon AS POSSIBLE. If AT ALL POSSIBLE do not set the date at the 45 days because should you get another complaint or an issue within that time frame then you will definitely get a revisit and it could keep the door open as far as your cycle and cause greater problems in terms of trying to clear. BUT make sure that whatever date you set (whether is is before the 45 days or on the 45th day) that you will have everything done and that you are sure that if there would be a revisit after the date you set that you have all your credible evidence, that you are monitoring and have all the auditing evidence, monitoring evidence, inservicing evidence, or whatever

it i that you said you were going to do to correct the problem and prevent recurrence and that there are no further issues.

debRN0417 · May 12, 2011

Jut to clarify something about the AOC date: for example: If you set your AOC date at June 30th- that is the date you are saying that you have everything corrected and that there are no further issues with the deficient practice, that it no longer exists. During the time from now until June 30th- your cycle is still open. That means you are saying you will not be in compliance until June 30th. If you get a complaint or something before your AOC date (Jun 30th) then you are still in an open cycle and you will get a revisit becuse you are till out of compliance. After June 30th, you are considered back in compliance. Any complaint or anything that comes in after that date is a new cycle and they cannot go back to the original deficiencies that you got.

That is why it is important to try and not wait the 45 days if at all posible so that you can close your cycle as soon as possible and be considered back in compliance.

I hope this make sense.

txdon · May 12, 2011

Thanks for clarifying the POC process. We did get our 2567 back and were recited on two tags, one recite G, 1 new G tag with 4 D tags. The problem is once we're cited in a specific area, everything in that area is under scrutiny. The surveyor isn't looking just at what was cited but other things within that category. These citations occurred prior to my employment there. This is all new to me. Corporate has flocked to our facility. This is very serious. At any rate, I do have another question - I have done countless inservices on handwashing, disposal of soiled linens, and not wearing gloves in the hall. However, CNA and nurses are still being seen wearing gloves in the hall and not complying. Their excuse is, "I know, I was in a hurry and forgot." Any suggestions on what I need to do? It's so frustrating because I spent a lot of time educating but they chose not to apply what they know their supposed to do. I need suggestions.

debRN0417 · May 12, 2011

Progressive discipline. Start out with the verbal warning. Document the date and time of the verbal warning. Then written warning. Then disciplinary action. Make sure you have documented that you have formally inserviced all staff on the proper procedure and that you have a sign in sheet that every staff member has signed in and was inserviced. Place a copy of the inservice documentation in each employees file with the documentation that they attended the inservice and are aware of the correct procedure. Make sure each employee understands the ramifications of their not following proper procedure. Spell it out with exactly what the expectations are and what will occur if the proper procedure is not followed. Enlist the aid of others (managers, supervisors, charge personnel) to help you monitor staff behaviors. You are only one person and cannot be expected to be everywhere at all times. They need to understand that not only is it a violation of the proper procedure, but it also places a risk on the well being of the residents (and staff) not to mention their continued employment. Handwashing and use of gloves is basic nursing and something that should be second nature. They should not have to think about how to do the right thing It should be natural. At this point with the revisits and re-citations that your facility has had, your facility is loosing a great deal of money which also hurts the residents and will end up also affecting staff in terms of future raises and benefits that the facility will not be able to provide employees.

Infection Control is a BIG deal. It risks the staff health as well. I wish there was a magic spell that you could use to make everybody always do the right thing, but we all know there is not. Unfortunately it may take an actual write up with the risk of termination to make some people get a grip and think about what they are doing.

Cover yourself. Make sure you have documented everything you have done to correct the problem and if the employees do not do the right thing and they have been educated, then that is their choice and they have a clear knowledge and understanding of what is at stake. As long as you have done (and documented) everything, you should not be held responsible for others "memory lapses". BUT make sure administration and corporate know the challenge you are facing and enlist their help in monitoring.

CathRN · Jan 21, 2012

If you are looking for the "tags", go to www.cms.gov and download appendix PP, which is the tags themselves, appendix P,which is the survey process and appendix Q, which is the Immediate Jeopardy appendix. Nothing the surveyors do are secret, it out there on the web to be found.

Also, in Texas, you will need to go to the DADS website and download the "Texas Food Establishment Regulations" because the DONS and nurses are responsible for nutrition for the residents as well.

I hope this helps