Nursing Home and Hospitals are responsible for ensuring their systems are correct and are working. This involves quality improvement activities. Nursing homes and hospitals have federal and state regulations that address quality assessment and assurance.  The nursing home and hospital surveyors will use these regulations and the guidance at the regulations to determine if a nursing home or hospital is indeed in compliance with the regulations.

In nursing homes these regulations are located at CFR 483.75(o), which is F-tag 520.

The nursing home regulation states:
(1) A facility must maintain a quality assessment and assurance committee consisting of –
(i) The director of nursing services;
(ii) A physician designated by the facility; and
(iii) At least 3 other members of the facility’s staff.
(2) The quality assessment and assurance committee –
(i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

What this says, in a nutshell, is that the facility is responsible for finding out what its problem areas are and then is responsible for fixing them.

When a surveyor goes into a nursing home they will be looking to see that the nursing home has a quality assessment and assurance committee that includes the director of nursing, a physician, and at least three other staff. The physician on the committee does not have to be the Medical Director of the facility. The other staff, in a really good facility, will include staff who have the authority to change systems that need changing. This would include the administrator or the assistant administrator. It would also include the medical director, since part of his/her responsibilities includes guiding the facility in developing, implementing, and coordinating resident care & medical care. Other staff who should be involved in a good Quality Assessment and Assurance committee includes “front line” staff who do actual care for the residents. A nurse’s aide or two can provide valuable insight to help the committee determine where its weaknesses are. Therapy representatives, dietary staff, activity personnel, maintenance, housekeeping, and laundry staff would all be a part of an effective quality committee.

The nursing home and hospital surveyor will also look to see that the committee meets at least 4 times a year. In reality a good committee would me more frequently than that, usually once a month, but the requirement is only 4 times a year.

The committee needs to identify the problems in the facility and develop and implement policies and procedures to correct these problems. The committee also needs to monitor the things they implement to ensure they do correct the problem and that they continue to keep the problem corrected.

The committee looks at the entire facility, not just nursing areas, it looks at all levels of the facility staff, meaning the lowest person to the highest manager. It especially looks at all the issues that affect residents, meaning all issues, since all issues affect residents in one way or another. It looks at contracted services as well as services provided in house. The reason a good quality assessment and assurance committee looks at all these areas is to continually evaluate facility systems with in order to keep systems functioning satisfactorily and consistently. The committee is charged with preventing problems with care processes in the facility, and for correcting care processes that are not correct.

The QAA committee should be keeping minutes and documents to show the problems it identifies and the fixes it put into place to correct the problems, as well as documentation on the ongoing monitoring and surveillance that is performed throughout the facility. It is this ongoing monitoring and surveillance that will help the committee determine where the problems are and if the fixes are working. The committee’s minutes should include a thorough analysis of the problem(s) as well as action plans designed to correct the problem.

When a nursing home and hospital surveyor goes into the nursing home, he/she may not review the minutes of the committee, unless the committee chooses to provide them. It is usually suggested even if the facility provides them, that the surveyors not look at them. It is better for the surveyors to fid the problems through good methods of investigation than to rely on what the facility found. Not reviewing the facility minutes will help the survey agency if the facility decides to “fight” the deficiencies. They can’t say that the surveyors found the problems by looking at the facility’s own quality improvement activities.

What the nursing home and hospital surveyor does need to do, though, is look at the process the committee has in place and the types of documents they use to collect data.  When a facility has repeated, systemic problems, the quality regulation at F 520 is also usually in non compliance too. This is basically because a well functioning quality assessment and assurance committee should have found the problem and corrected it before the state survey agency did.

We will discuss Hospitals in the next post.


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Kathy left a comment with some questions that I am going to address in my post today, instead of in the comments. She has some valid questions, and I hope this will help Kathy, as well as anyone else with the same concern, understand why a nursing home and hospital surveyor asks the questions they do and what any facility, whether nursing home or hospital, can do to help reduce restraints. You can see Kathy’s comment at the post titled “Surveying Restraint Regulations in Hospitals or Nursing Homes – Part I“.

Hi Kathy,

CMS doesn’t look for a “diagnosis”, but for the MEDICAL reasons for a restraint. The interpretive guidelines at the restraint regulations in Appendix PP of the SOM (State Operations Manual) gives a lot of guidance and additional thoughts on what you might consider. Every nursing home should have a copy of the SOM. In addition, activities will be a huge help for you. When a person is participating in activities, that keeps them busy, but, of course, activities that that person would be interested in. That is where your investigative and creative skills come in with each resident. What interests him or her?

Also ask, WHY is the resident getting up? What does he or she want to do? What is the pattern? Is it all the time or at specific times? Does he or she need to use the bathroom, or perhaps the resident is hungry, or bored. Is the chair comfortable or is the resident so uncomfortable he or she has to get up (we all know how uncomfortable some chairs can be). What did the person do as a career? Is that why he or she is getting up. Is he or she looking for something specific to do? Maybe the resident worked the night shift and is used to staying up all night and sleeping in the afternoon. These are just a few of the questions you can consider to help you figure out how to keep the resident safe while at the same time keeping the resident as free from restraints as possible. Perhaps your resident just needs someone with him or her all the time to interact, provide companionship, and stimulating conversation (whether or not the resident can respond).

I would also suggest you network with other nursing homes (I’m assuming you are working in a nursing home) and gather ideas and information about what works for them, how their activities departments help and how they keep residents with dementia safe while allowing them to walk. A resident who walks is going to be maintaining stronger muscles and better walking ability than one who is forced to sit in a chair all day.

There is no pat answer to the regulations and how to stay in compliance. Each situation requires its own determination of what will work. That is one of the great challenges and opportunities that nursing home staff have. This is also one area that nursing home and hospital surveyors will continue to review and question.


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After the nursing home survey team has finished with the survey, the members will then write the issues they found. This writing is done on the “Statement of Deficiencies”, commonly referred to as the “2567”. The number “2567” refers to the number CMS has assigned to the statement of deficiencies form.
The statement of deficiencies is written in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met. This is when the team will also make a final determination of the level of Severity and Scope. You can refer to my previous post on “The A to L of Nursing Homes” to understand a little more about how surveyors grade a nursing home.
So that is just a little bit about how a nursing home surveyor prepares to conduct a nursing home survey and the tasks they must perform during the course of the survey.
Now you must remember that because of the process of sample selection, the nursing home survey team does not look at every resident or patient in a nursing home or hospital. Because of this, there are many times that problems within a nursing home or hospital are not found. This is where it becomes so important for you, the public healthcare consumer, report the problems you find to the local licensing & certification agency who conducts these surveys. You are, in essence, a second set of eyes to help the survey agency know where to look and who to ask. Even then, though, it can become quite difficult to “prove” anything. It is becoming frequently more common for nursing homes and hospitals to challenge the findings from a survey. If the nursing home team does not have all the information to show the failure to follow the regulation the deficiency can be “thrown out”. So when you do report your complaints to a survey agency, give them as much information you can, including names, dates, specific times, actions, etc. The more you can tell them the better the nursing home surveyors chances are in substantiating your complaint.

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As mentioned in the other posts talking of this issue, CMS has guidance in the SOM for nursing home surveyors to follow. The third piece of the investigation is the review of the resident’s record and other facility documents. The nursing home surveyor will review the resident’s assessment, the history and physical and other portions of the clinical record. These items should include the information needed to determine the resident’s needs and the interventions needed to meet the resident’s needs. The surveyor should be looking for consistency among the various parts of the record as well as with the observations that have been made and the interviews that were conducted.

The plan of care should be reviewed to see if it contains the detail needed to meet the resident’s needs. Each care plan should be individualized to each resident, so the surveyor is going to be looking to see that the care plan is not the same for most residents in the facility. An example of this would be “Toilet the resident before and after meals and at bedtime”. When I see this as a surveyor it starts ringing bells. Again, as mentioned before in this series of posts, everyone has their own pattern of needing to use the bathroom. Residents don’t fit into a cookie cutter. The plan should be based upon the goals, needs, and strengths specific to the resident and it should reflect the comprehensive assessment. It should identify objectives, timeframes, potential complications, and even environmental obstacles that affect the resident. Every care plan, whether for this issue or another, should identify specific approaches and interventions and should include input by the resident and/or the responsible person.

The information I have provided in the posts on this topic are just the “tip of the iceburg”. You will find much more information in the SOM and I encourage you to take some time to read and review it, especially if you are in a nursing home or have a loved one in a nursing home.

Be safe and informed!


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