It sometimes seems like F-Tags are moving and changing all the time, like game pieces on a chess board. Keeping up with the changes and updated guidance can be challenging. But there are a few tips and trends that make it easy to keep up with F-Tags and strategize an effective gameplan. These tips were recently shared by Susan LaGrange, Chief Nursing Officer from Pathway Health, during Forum’s annual symposium. 

Tag Updates

There are updates to several F-Tags, including (but not limited to):

• F557: Respect and Dignity. Updates to procedures on possible illegal substance use.
• F561: Self-determination. New guidance and changes on smoking policy to include electronic cigarettes.
• F563: Visitation. Updates on visitation considerations during a communicable disease outbreak.
• F600: Freedom from Abuse. Updates regarding capacity to consent to sexual activity and to policies on neglect.
• F607: Policies for Abuse and Neglect of Residents. Updates regarding coordination with QAPI and QAA.
• F608: Reporting of a Reasonable Suspicion of a Crime. Tag was eliminated.
• F609: Reporting of Alleged Violations. Facilities must develop and implement policies and procedures for reporting of crimes, including intent, definitions, guidance, reporting, and other information and documentation.
• F622: Transfer and Discharge. There are updates throughout this tag, including changes in deficiency categorization.
• F623: Notice Before Transfer. Updates in wording.
• F624: Orientation for Transfer or Discharge. “Facility-initiated” was added in several areas.
• F626: Permitting Residents to Return to Facility. There are changes in wording and guidance, among other things.
• F671: Accuracy of Assessments. Updates address the acknowledgement that practitioners have misdiagnosed residents with a condition for which antipsychotics have an approved use. CMS notes that this practice may require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing.

There are also changes to a number of other tags including F656: Comprehensive Care Plans; F658: Services Meet Professional Standards of Quality; F659: Services Provided by Qualified Persons; and F675: Quality of Life.

New tags have been introduced, as well. For instance, F699: Trauma-Informed Care. This has been highly anticipated and addresses intent, definitions, guidance, assessment, trauma, triggers, culture and cultural competencies, care planning to address past trauma, and care planning to address cultural preferences. Other new tags include F940: Training Requirements; F944: QAPI Training; F945: Infection Control Training; and F946: Compliance and Ethics Training.

Process Changes

The Centers for Medicare and Medicaid Services (CMS) implemented a new nursing home survey process in 2017, but it is important to note that they continue to make tweaks and revisions “to improve the consistency, accuracy, and efficiency of the survey process.” For instance, CMS is testing a risk-based survey approach “that allows consistently higher-quality facilities to receive a more focused survey that takes less time and resources than the traditional standard recertification survey, while ensuring compliance with health and safety standards. Higher quality could be indicated by a history of fewer citations for noncompliance, higher staffing, fewer hospitalizations, and other characteristics.” The agency says that only a limited number of nursing homes would be qualified, but the survey resources saved by a “more focused review” in higher quality facilities would enable them to perform more timely oversight of facilities where there are risks to resident health and safety. CMS is working with states to test this process in the coming months and will offer updates as available. 

In the meantime, it is important to understand survey-related tasks such as the facility entrance survey process. These steps include:

• Meeting with the administrator.
• Conducting a brief entrance conference to communicate to the administrator what is needed.
• Request for the administrator to contact the medical director.
• Request for the facility assessment up front.
• Request for a client roster noting new admissions in the past 30 days.
• Inquiry as to whether the facility has asked a resident/representative to enter into a binding arbitration agreement.

Assigned surveyors will immediately go to the kitchen based on the critical element pathway. All other surveyors will go to their assigned areas, which may include medication administration, medication storage, QAA/QAPI review, staffing (sufficient and competent staff), dining, and infection prevention and control programs.

Emergency Prep, Infection Control

With so many recent weather-related emergencies happening across the country, surveyors will likely be taking a closer look at life safety and emergency preparedness. To get your ducks in a row, have documentation for common safety concerns at the ready. This might include the automatic fire alarm system, annual fire door and sprinkler inspection, a range hood suppression system, fire drills in the last 12 months, flame-resistant materials, water outages, a smoking policy, and — of course — a detailed disaster plan.

Infection prevention continues to be a top priority for surveyors, and it is important to understand new guidance on enhanced barrier protections (EBP). For instance, note that EBP is necessary when staff are performing high-contact resident care, including:

• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use (eg, urinary catheters and feeding tubes)
• Wound care

CMS states that gowns and gloves generally are not recommended “when performing transfers in the common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration.” Outside of the resident’s room, EBP is necessary “when performing transfers or assisting during bathing in a shared/common shower room and when working with a resident in the therapy gym….” The agency stresses that residents are not restricted to their rooms or limited from participation in group activities.

Tips for Survey Success

Preparation will help ensure that there are no surprises that send staff scrambling for information or assistance. To get ready, consider the following:

• Have your survey book ready.
• Ensure ongoing education with all departments.
• Conduct daily interdepartmental rounding.
• Conduct audits.
• Use survey tools.
• Maintain transparent communication.
• Have an effective, active QAA/QAPI Committee.
• Have an ongoing program/policy of service excellence for both internal and external customers.

Audits should focus on high-risk areas, such as infection prevention, abuse prevention, falls/accidents/injuries, wound care, and food storage/procurement. Elsewhere, develop a pre-survey checklist that tracks documentation and actions regarding issues such as falls and accidents, pressure ulcers, medication administration, and vaccinations.

Build, Engage Teams for Great Surveys

Make survey preparedness a normal part of everyone’s roles and responsibilities. As a team leader, review information such as QA Committee minutes and fall log. Make sure medication pass audits are scheduled with the consultant pharmacist, dining service and room trays are monitored, and assessments are completed per facility policy. Check to see if you have ‘yes’ answers for questions such as:

• Are wheelchairs and set cushions clean and free from odor?
• Are staff answering call lights within 3-5 minutes?
• Are noise levels low?
• Do employees know how to respond to complaints, concerns, and resident grievances?
• Are all licenses and certifications current?
• Are residents well groomed?
• Are med carts clean?

Surveys can be stressful for everyone. Get staff ready and build their confidence with creative, engaging activities such as a scavenger hunt for survey preparedness, mock surveys, survey quizzes, frequent rounding where staff have an opportunity to have input and ask questions, and programs/lunches with a topic of the week.

Knowing that you and your team are prepared for surveys and have resident health and safety as a top priority every day is like being a chess master. You know what’s coming, are ready for the next move, and are confident about your ability to succeed — which is a win for your residents, staff, and community.