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[Blog Series] Shaping Up for Survey Success: Part 3

October 03, 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.


Shaping up for Survey Success_Part 3

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, Allegheny and Westmoreland were among the top 10 to receive F-Tags G or higher according to Nursing Home Compare data processed August 29, 2019 from the Centers for Medicare & Medicaid Services. Once again, this month’s most cited F-Tag is F-Tag 689 with 66 instances of deficiency and F-Tag 600 is the second most cited received, with 35 instances of deficiency.  

In part 3 of our “Shaping Up for Survey Success” blog series, we will focus on F-Tag 684. For more information on F-Tag 689, you can read part 1 of the series and for more information on F-Tag 600, read part 2 of the series.

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

Survey Success Paer 3


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 684, one of the third most commonly cited F-tag per this month’s results, and how performing a mock survey can help your facility get in shape for survey success.

F-Tag 684: Are You Survey Ready?

Guidance for F-Tag 684 can be found in the Code of Federal Regulations (CFR) §483.25 Quality of care and went into effect in November 2017. Quality of care applies to all treatment and care provided to facility residents. Facilities are to identify and provide needed care and services that are resident centered. According to the regulation, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident’s choices.

CFR §483.25 guidance of F-Tag 684 should be used for review of concerns which have caused or have a potential to cause a negative outcome to a resident’s physical, mental or psychosocial health and guidance for end of life and hospice care. Nursing homes must place a priority on identifying what each resident’s highest practicable well-being is in each of the areas of health.

This regulation guides facilities on the (1) Review of a Resident with Non Pressure-Related Sin Ulcer/Wound and the (2) Review of a Resident at or Approaching End of Life and/or Receiving Hospice Care and Services.

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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