FTag citations have changed dramatically during COVID-19. Learn about the 10 most frequently cited and how to stay in compliance.
Over the last few months, state agencies have resumed nursing home annual surveys with their pre-COVID 19 frequency. One of the ways that state agencies and the Centers for Medicare and Medicaid Services (CMS) identify deficiencies is through the use of FTags; areas of compliance that are assessed through a nursing home survey.
Results from a LeadingAge Quality, Certification, and Oversight Report (QCOR) finds that the Covid pandemic changed the top ten most commonly cited F-tags. Prior to the pandemic, F812 (Food Procurement), F758 (Free from Unnecessary Psychotrophic Meds/PRN Use), and F880 (Infection Prevention and Control) were the top three 3 most cited deficiencies. Interestingly, F812 and F758 are not even in the top 10 of the most cited F-tags as of October 2021. As shown in the list of the top 10 most commonly cited FTags, there is an increasing awareness and monitoring of pandemic-related issues: Covid testing, infection control, reporting, and immunizations.
- F884 Reporting - National Health Safety Network (NHSN)
- F880 Infection Prevention & Control
- F886 COVID-19 Testing-Residents & Staff
- F689 Free of Accident Hazards/Supervision/Devices
- F684 Quality of Care
- F580 Notify of Changes (Injury/Decline/Room, etc.)
- F883 Influenza and Pneumococcal Immunizations
- F885 Reporting-Residents, Representatives & Families
- F686 Treatment/Services to Prevent/Heal Pressure Ulcers
- F609 Reporting of Alleged Violations
Given these changes to the FTags that are more commonly cited, here is how your nursing home can prepare:
This is a new tag created by CMS for federally required reporting to the National Health Safety Network (NHSN). The citation is received for non-compliance and is cited by federal surveyors off-site as NHSN data is reviewed.
Tip on how to stay in compliance: Ensure that your data is reported! Check your policies and procedure for reporting and always have a backup team member that can enter the data, which is especially important in today’s volatile staffing climate.
This is the catch-all tag for infection control and focuses on ensuring that nursing homes have an infection prevention and control program with policies, procedures, systematic monitoring, training, and education for all staff.
Tip on how to stay in compliance: Review your in-services and training for staff. Ensure that all staff can demonstrate infection control procedures and verbalize and demonstrate to a surveyor on practices for items like hand hygiene and donning/doffing PPE. Review all monitoring and practices to prevent infection and ensure that a facility’s infection preventionist are using line listings and tracking infections.
This is a new FTag created with the CMS regulation on testing residents and staff using community positivity rates and/or COVID-19 outbreaks.
Tip on how to stay in compliance: Double check who is monitoring the community positivity rates and ensure there is a backup team member. Ensure that lab turnaround times are verified and documented if they are over 48 hours. Using audit tools with monitoring criteria will also help keep your organization in compliance.
This tag refers to ensuring that the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents.
Tip on how to stay in compliance: Use a systems approach to identify hazards, including inadequate supervision, as well as implement resident-centered approaches and engage all staff, residents, and families in discussions on resident safety training. Facilities should also monitor data related to care processes that lead to accidents.
This tag ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident’s preferences and goals for care and meet professional standards that will meet each resident’s physical, mental and psychological needs.
Tip on how to stay in compliance: Review care plans and documentation to establish they are resident centered. The clinical assessment process should be fluid. Staff should be completing ongoing clinical assessment and identifying changes in condition. Create a performance improvement plan that includes a communication link and documentation monitoring. Do not forget to ensure resident and/or resident representatives are included in the care plan.
In this FTag, each facility must inform the resident, consult with the resident’s physician or representative when there is an accident or injury, significant change, after a significant treatment change and the decision to transfer or discharge.
Tip on how to stay in compliance: During COVID-19, residents must be transferred or discharged due to positive cases. Make sure your organization is documenting and alerting the resident and resident representative about the reason of the decision, not simply that the decision has been made. This also includes room changes or roommate change or status. Ensure that the resident record has the most up to date mail address, email, and phone number of the resident representative – this is a great opportunity for a performance improvement project! Residents in memory care units are often not transferred due to challenges with PPE compliance. If this is the case in your facility, make sure to include the situation in your monthly QAPI meeting, with discussion notes specific to monitoring processes and daily health assessments.
Under the infection prevention program section of FTags, a facility must develop policies and procedures for immunization programs for influenza and pneumococcal. The policies and procedures must contain an education component for residents and resident representatives.
Tip on how to stay in compliance: Documentation is key to compliance for this F-tag. Your organization must offer the vaccines to all residents and educate them on the vaccines and the side effects. However, the resident or resident representative has the opportunity to refuse and any refusal must be documented in the resident record.
This is a new FTag, established during the pandemic, which states a facility must inform residents, representatives, families, and staff by 5pm the next calendar day if there is a positive case in the facility or three or more residents or staff have new onset respiratory systems.
Tip on how to stay in compliance: Ensure that you have a policy and procedure for informing residents, representatives, families, and staff that includes the time frame, how the communication will be completed and by whom, and specify a back-up staff member for communication. Facilities should also document the information along with the specifics of the process including the modes of communication and mechanisms for ensuring staff can relay he process back to surveyors.
This F-tag focuses on the prevention and treatment of pressure ulcers.
Tip on how to stay in compliance: Since this F-tag could link and have cross tagging to MDS, care plans or physician orders, documentation is the key for compliance. Documentation should include whether the pressure ulcer was avoidable, if the team communicated skin integrity, as well as risk factors to avoid pressure ulcers, and ensuring accurate wound staging. Facilities should offer thorough in-service training on wound staging and can reference the CMS Critical Element Pathway for pressure ulcers as a tool for mock survey.
This FTag relates to reporting of alleged violations for abuse, neglect, mistreatment, injuries of unknown origin and misappropriation of resident property. This F-tag has a time frame of reporting for 2 hours and 24 hours depending on the injury or non-injury of the resident.
Tip on how to stay in compliance: Check staff knowledge of reporting alleged violations to residents including that staff know the process and who the report would be communicated to and in what time frames. It is critical that staff in all shifts and all days understand this information. As a reminder, the facility cannot make the determination that abuse may or may not have occurred; the determination on abuse falls under the state agency’s jurisdiction.
Polaris Group is well-positioned to create measurable, sustainable, and timely performance improvement plans to ensure regulatory compliance. Our consultants are equipped with results-driven tool kits and have the expertise necessary to support your team in any areas you find challenging. If you are struggling with addressing FTags, please reach out to us here!