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[Blog Series] Shaping Up for Survey Success: Part 1

July 10, 2019
Documentation, Billing, & Coding By Rodney Farley, Director

With all the upcoming regulatory changes impacting skilled nursing facilities (SNFs), it’s important to understand the impact these changes can have on your facility’s operations. There are seven new F-Tags that will be surveyed beginning November 2019 and existing F-Tags that require your focus. In our new blog series, “Shaping Up for  Survey Success,” we will review F-Tag deficiencies from the top 10 counties in Pennsylvania, take a deep dive into the top most commonly cited F-Tags, and provide actionable steps you can take to ensure your PA nursing home is compliant on survey day.

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PA Counties: F-Tags by the Numbers

Each month, LW Consulting, Inc. compiles data on the top 10 F-Tags nationwide. In the state of Pennsylvania, the counties of Philadelphia, Westmoreland and Lancaster were among the top 10 to receive F-Tags G or higher according to Nursing Home Compare data processed June 27, 2019 from the Centers for Medicare & Medicaid Services. Furthermore, F-Tag 689 was commonly cited with 54 instances of deficiency. See table below:


To mitigate these instances of deficiency, one key tool every facility should have in their arsenal is the mock survey which serves as your opportunity to gain a fresh perspective on systems, procedures and areas of possible non-compliance.

According to the numbers, there is still room for improvement in the state of Pennsylvania. Is your facility survey ready? Let’s take a deep dive into F-Tag 689, one of the most commonly cited tags per this month’s results, and how performing a mock survey can help your facility get in shape for survey success.

F-Tag 689: Are You Survey Ready?

Guidance for F-Tag 689 is found in the Code of Federal Regulations (CFR) §483.25(d) Accidents and went into effect in November 2017. According to the regulation, the facility must ensure that (1) the resident environment remains free of accident hazards as is possible; and (2) each resident receives adequate supervision and assistance devices to prevent accidents.

CMS understands that not all accidents are avoidable; however, facility staff should understand that the resident’s safety is just as much their responsibility as the safety of the facility. The State Operations Manual states “an effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents.” This includes a consistent application of any and all processes that are used to address and/or prevent hazards or risks. In doing so, facilities will be able to make appropriate adjustments and can improve training and testing for facility staff.

Facilities can follow the guidance below, as outlined in CFR §483.25(d), to assist with the prevention of nursing home accidents:

  • Identify environmental hazards and/or assess individual resident risk of an accident.
  • Evaluate/analyze the hazards and risks and eliminate them if possible.
  • Implement interventions, including adequate supervision and assistive devices consistent with resident needs, goals, care plan and current professional standards of practice.
  • Monitor the effectiveness of the interventions and modify the care plan as necessary and in accordance with current professional standards of practice.

How Can LW Consulting, Inc. Help?

LW Consulting, Inc. provides mock surveys that mirror the new federal survey process to support survey readiness. These mock surveys will measure your facility’s compliance with CMS’ standards and regulations. We use the results to generate a report that can be used to establish a plan of corrections. Our experts will discuss the findings with you and, if appropriate, will discuss ongoing training and educational opportunities.

Make sure your systems and processes are up-to-date and current, according to the new regulations and survey process. With all the upcoming regulatory changes, it could be easy for your facility to miss some important issues. Contact LW Consulting, Inc. for help.


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