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Long-Term Care Survey Alert

Survey Trends:

Sidestep An 'OSCAR' Award For Worst Survey Performance

Published on Wed Apr 27, 2005

Study data show disturbing survey trends ... here's how to combat them.

What's the best predictor of a facility's odds of getting hit with F tags? Location, location, location.

That's according to a presentation by Richard Butler, JD, at the February 2005 American Health Lawyers Association long-term care conference in San Diego.

Citing results of a government study, Butler handed out "awards" for survey performance based on OSCAR (Online Survey, Certification, and Reporting) system data.

For example, the three states ringing up the largest increases in percentage of deficiencies in the last four years ranged from the "winner" with 134 percent followed by runner-ups posting 112 percent and 93 percent more deficiencies, respectively.

States with the highest percentage of deficiency-free surveys: New Hampshire at 27 percent and Massachusetts with 17 percent.

The take home message: Surveys vary considerably (even within the same state in some cases, Butler said) - and deficiency-free surveys are hard to come by in all cases. Not only that, but deficiency trends in some clinical areas are likely to take an even sharper turn into F-tag territory, Butler predicted.

"Since the Centers for Medicare & Medicaid Services is unhappy with the pressure ulcer prevalence nationwide, facilities will likely see skyrocketing of F314 tags over the next 12 to14 months," Butler said. He predicts facilities will also see more survey focus related to weight loss, a clinical issue that's "probably the biggest risk to a good nursing facility."

Go Proactive to Head Off F Tags

These strategies can help your facility steer clear of unfair deficiencies regardless of its zip code.

  • Use the revised F314 (pressure ulcer) guidelines to your advantage by showing surveyors how the facility has followed the survey interpretive guidance to the T to prevent avoidable pressure ulcers.

  • Code the MDS to capture residents' true risks for skin breakdown to avoid triggering the quality indicator for low-risk pressure ulcers. The QI classifies all residents as low risk except those with impaired transfer or bed mobility (G1a or b = 3 or 4 - Box A), those who are comatose or have an ICD-9 code of malnutrition in I3 of the MDS - or a resident with end-stage disease checked in J5c. (The latter requires the physician to certify in writing that the resident has a life expectancy of six months or less.)

  • Capture all wound treatments on the MDS - for example, new RAI manual instructions taking effect May 1 say facilities can code pressure-relieving or pressure-reducing devices in the bed or chair (Section M5a or b).

    Make sure to code a turning and repositioning program, as well, or your facility will look as if it's not providing this essential service to prevent pressure ulcers.

    Remember: To code this item, the facility has to have a program that is "organized, planned, documented, monitored and evaluated," according to an August 2003 RAI manual update.

  • Include realistic outcomes in residents' care plans related to unavoidable outcomes. "We have to get a grip on clinical realities" in long-term care, said Butler. For example, if a resident has terminal cancer and is losing weight, the care plan might state: "resident expected to continue to lose weight due to terminal condition in spite of nutritional interventions."

    If the care plan goal says the resident dying of cancer will not lose weight, the facility is setting itself up for problems, agrees Pam Campbell, RNC, CRNAC, MDS operations director for software developer LTC Solutions in Camdenton, MO.  "That's like saying someone who is paraplegic will, with therapy, walk again," Campbell says.

    "Care plan goals should be realistic and measurable," she adds.

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