Long-Term Care Survey Alert

Renew attention to F441 guidance and news of antibiotic resistance.

Renewed attention to the problem of antibiotic resistance may be the best prescription for improved survey results in the coming year, as feds sharpen their focus on the major threat to public health. 

Make no mistake, nursing homes will be on the key players in the battle against superbugs — and survey citations are sure to fly if providers fail to meet the feds’ expectations for antimicrobial stewardship.

Trending: F-441 is the #1 most cited deficiency for the first half of 2015, and was the most highly cited for 2014 as well, reports Brandi Elizaitis, director of marketing for the Melville, NY-based CMS Compliance Group, which issued an updated, “What’s Trending: Top 5 National Long-Term Care Survey Deficiencies” report in June.

“After reviewing a sample of this year’s citations, it’s clear that many facilities could benefit from staff reeducation on the policies and procedures for infection control,” notes report author Linda Elizaitis. In particular, citations sprang from contact procedures, isolation, and cross contamination issues — all doubly important in an environment in which some organisms may be antibiotic resistant.

Concerns about antimicrobial resistance are amplified in long-term care, experts stress. Antibiotics are the most commonly prescribed class of medications in nursing homes, notes Kirk Seale, MS, PharmD, of AlixaRx, a Plano, TX-based firm providing pharmacy services to post-acute facilities nationwide. By different estimates, 25 percent to 75 percent of these prescriptions are unnecessary or inappropriate, he reports in a recent guidance on survey tag F-441. 

Add to that a population that is typically immune compromised and living in close quarters, and it’s easy to see why every facility should be concerned with infection control and antibiotic stewardship.

Other examples of F411-related deficiencies include:

• The lack of standard policies and procedures related to the use of antibiotics,

• Policies and procedures that are not in keeping with current standards of practice, and

• Failure to follow policies.

Providers must also be concerned with survey strikes involving F-tag 329, stresses Christopher J. Crnich, MD, PhD, a leader in antimicrobial stewardship in long-term care and co-leader of a new $1.5 million national trial to examine methods to reduce the use of antibiotics in post-acute and long-term care facilities (see shaded box).

Must know: One key to avoiding F329 citations is a good understanding and application of standardized surveillance definitions. That’s because the F329 red flag is often thrown when facilities fail to recognize inappropriate antibiotic use. 

The standard that surveyors generally look to is the McGeer Criteria available at www.jstor.org/stable/10.1086/667743. First published in 1991, the definitions were updated in 2012 and are intended to provide standardized guidance for infection surveillance in long-term care facilities, explains Crnich. 

Reassess Your Antibiotic Stewardship

But he and others believe that they are a less-than-perfect fit for the post-acute setting. “We believe their integration as minimum criteria for starting antibiotics may have detrimental consequences,” he and co-author Paul Drinka, MD, write in a 2014 article in the Annals of Long Term Care. 

Savvy providers, therefore, should be familiar not only with McGeer but also other published standards and algorithms. Especially in the coming years, fine-tuning the tools providers use to guide stewardship programs will be essential. 

Wisconsin is one state leading long-term care efforts in antimicrobial stewardship. They seek to reduce the use of unnecessary antibiotics through education and the development and enhancement of formal antibiotic stewardship programs.

Resource: Check out the Wisconsin Department of Health Services’ position paper, “Antibiotic Use in Nursing Homes” at www.dhs.wisconsin.gov/publication/p00886.pdf.

Defined, antibiotic stewardship is “a commitment to use antibiotics only when necessary to treat and, in some cases, prevent disease, to choose the right antibiotics, and to administer them in the right way in every case,” according to the Wisconsin Healthcare-Associated Infections in Long-Term Care Coalition.

That group has taken aim at improving nursing home response to urinary tract infections, one of the most common reason antibiotics are prescribed.

“Studies have consistently shown that about 30 to 50 percent of frail elderly nursing home residents have asymptomatic bacteriuria, a state in which bacteria colonize the urine but do not cause symptomatic infection,” states the position paper. “Unfortunately, many of these residents are treated inappropriately with antibiotics.”

Three strikes: Fail to ramp up your stewardship program and that reality could well lead to citations at not only F441 (infection control), F329 (unnecessary drugs), but also at F428 (medication regimen review).

But given the high stakes in staving off a “post-antibiotic era” wrought with untreatable, sometimes deadly infections, survey citations may be the least of your worries.

As Crnich noted recently in his commentary, “Effects of Excessive Antibiotic Use in Nursing Homes” (JAMA Internal Medicine, see Resources), “business as usual is no longer an option.”

Editor’s Note: Look for additional coverage of Antibiotic Stewardship Programs in an upcoming issue of Long-Term Care Survey Alert.