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[Blog Series] Shaping Up for Survey Success: Part 2

August 09, 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.


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 July 9, 2019 from the Centers for Medicare & Medicaid Services. While F-Tag 689 was, once again, the most cited F-Tag with 60 instances of deficiency, F-Tag 600 received 30 instances of deficiency.  

In part 2 of our “Shaping Up for Survey Success” blog series, we will focus on F-Tag 600.  For more information on F-Tag 689, you can read part 1 of the series here.

See table below for a snapshot of all top 10 PA counties to receive F-Tags G or Higher:

Survey _Success_Part2_edited


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 600, 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 600: Are You Survey Ready?

Guidance for F-Tag 600 is found in the Code of Federal Regulations (CFR) §483.12 Freedom from Abuse, Neglect and Exploitation and went into effect in November 2017. According to the regulation, the facility must (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion.

The Code of Federal Regulations (CFR) Intent §483.12(a)(1) states that each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Staff should monitor for any behaviors that provoke a reaction by residents or others. These include verbally aggressive behavior; physically aggressive behavior; sexually aggressive behavior; taking, touching or rummaging through other’s property and wandering into other’s rooms/space.

Facility characteristics that could increase the risk for abuse include negative attitudes, staffing problems, lack of administrative oversight, inadequate preparation or training, deficiencies of the physical environment and facility policies operating in the interests of the institution rather than the residents.

If there is an alleged violation of abuse, physical punishment or allegation of an individual depriving a reside of care or services, steps should be taken immediately to review these concerns. If an unreported allegation of abuse is received or discovered, it should be reported immediately to the facility administrator or person in charge.

Facilities can follow the guidance below, to assist with investigations fro abuse and neglect or allegations of abuse:

  • Identify if there is an alleged violation of abuse, physical punishment or allegations of an individual depriving a resident care and services
  • Use observations, interviews and record review to gather and corroborate information related to:
    • The alleged abuse
    • Any injuries
    • Details of actions taken
    • Whether there is any indication that retaliation may have occurred
    • Types of training and/or orientation staff may have received
  • Interview staff and review facility policies and procedures

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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