Deficiencies are a nursing home’s failure to meet a federal participation requirement, problems that are detrimental to the health and safety of residents. The United States averages 10 nursing home deficiencies per certified nursing facility with New Mexico having the highest average at 16.7 and Vermont with lowest average at 2.3. Enforcement remedies are taken against nursing homes that have a worrying amount of deficiencies. The remedies are in line with the severity of the deficiencies. In exceptional cases, the state may take over the nursing facility. 

While state takeovers were once a rare occurrence, they are expected to become more common due to the impact of the COVID-19 pandemic. “These are tough times for quality operators,” says one temporary manager, Jerry Seelig.

Seelig warned of a looming tidal wave of bankruptcies on account of the pandemic, specifically with the ending of funding care homes received through the Coronavirus Aid, Relief, and Economic Security (CARES) Act.  “Yes, it’s true that COVID increases the everyday cost of running a facility enormously. Yes, it’s true that your highest-paid skilled days have gone down. However, it’s also true that states and the federal government have dumped a considerable amount of money into the industry and saved many of you. That money is going to go away.” 

He recently joined the LTC Heroes podcast to share his advice about creating a checklist and communicating policies to staff members in order to avoid deficiencies:

The 10 most common deficiencies in nursing homes were identified in a 2019 study by the Office of the Inspector General. While statistics and F-Tags help give a bigger picture about the status of care homes, examples show how these deficiencies look in practice. We will, thus, include examples from the OIG to help facilities better avoid these pitfalls:

1. Free of Accident Hazards/Supervision/Devices (F689), 36,000 such deficiencies recorded: Care providers are to take the necessary steps to minimize accidents. One example of a failure to do so that was mentioned by the OIG is a stop sign that was placed across a room door. A resident hit the stop and had to be transported to the hospital emergency department. 
2. Infection Prevention & Control (F880), 34,000 deficiencies: Even before the advent of COVID-19, infection and prevention control was one of the most frequently-cited deficiencies. Facilities are required to put in place a system for preventing, identifying, reporting, investigating, and controlling infections. The OIG gave the example of an incident in which a nursing home’s medication refrigerator was contaminated with a sticky, powdery substance. A nurse touched the contaminated refrigerator with gloves. Without removing the gloves or washing their hands, they then prepped an oral syringe and administered the medication.

3. Quality of life (F675), 29,900 deficiencies: Although “quality of life” seems a bit vague, it refers to outcomes that lead to immediate jeopardy.  One such example is an incident in which a fluid and potassium-restricted diet was prescribed to a resident who had end-stage renal disease. The resident required only 120 ml of fluids at breakfast but was served 540 ml of fluids and a banana (a high-potassium fruit).
4. Food Procurement, Store/Prepare/Serve ‐ Sanitary (F812), 29,500 deficiencies: Food must be kept safe and fresh, just like in your home. In one incident, a nursing home had stored expired milk and pudding in a nutrition refrigerator.
5. Maintain 15 Months of Resident Assessments (F639),  19,500 deficiencies: Insufficient or inaccurate documentation is a fundamental deficiency, which we will return to below. Fifteen months of data are required to be kept for each patient, including Minimum Data Set (MDS) records and Care Area Assessment (CAA), which are to be used to review and revise the resident’s comprehensive care plan.  The OIG cites one deficiency in which a resident developed a pressure ulcer at the base of the spine because a nursing home did not develop a care plan.
6. Drug Regimen is Free From Unnecessary Drugs (F757), 19,100 deficiencies: Only medication that is necessary for the patient must be given. Excessive doses, excessive duration, and lack of monitoring of drugs are extremely dangerous. One example of such a deficiency is that a nursing home mistakenly gave medications to a resident for 14 days when the resident’s systolic blood pressure fell below the ordered parameter of 60.
7. Label/Store Drugs & Biologicals (F761), 18,100 deficiencies: Drugs must be kept secure and labelled accurately. One nursing home received a deficiency when a nurse left a medication cart unlocked.
8. Resident Records – Identifiable Information (F842), 16,500 deficiencies: This is related to proper documentation as well. The facility must keep medical records that are complete, accurately documented, readily accessible, and systematically organized. One example of a deficiency is when nursing staff provided wound care to a resident for five days but did not document it.

9. Resident Rights/Exercise of Rights (F550), 15,200 deficiencies: Much like the rights of all citizens, residents have a right to dignity and self-determination. One facility was given a deficiency when an assistant left the room while a resident was brushing his teeth without providing him with the means to spit or rinse. The resident called for assistance, but the assistant returned 21 minutes later. The resident stated that staff treated him disrespectfully. 
10. Not Employ/Engage Staff with Adverse Actions (F606), 14,800 deficiencies: While it is crucial to not employ staff that are abusive, neglectful or exploitative, it is also necessary to keep residents and staff safe from other potentially dangerous residents. The OIG gives an example of a facility in which it was reported that a resident had made threats to shoot and stab staff members after being discharged. This was never reported to law enforcement.

Three Tips in Long Term Care Management to Overcome Deficiencies in a Post-COVID World

Now more than ever, leaders are looking for advice and tips to keep their facilities afloat. In order to avoid being sanctioned or even shut down, long term care facility owners will need to learn from the mistakes of others as well. Seelig, the founder and CEO of Seelig+Cussigh HCO LLC (S+C), offers management, evaluation, and monitoring services to healthcare providers and government agencies. He was also recently assigned as the temporary manager of two failing nursery homes in California by the state. 

So what has Seelig learned in his extensive experience? Here we present his tips for avoiding deficiencies:  

1. Prepare for the Survey by Prioritizing the Most Important Goals

The most important thing for operators is that they are survey-ready. “Take a deep breath, see where you are,” advised Seelig before urging caregivers to make a checklist of the most important items. He recommended using Atul Gawande’s Checklist Manifesto to devise a checklist approach towards long term health care that can help organizations prioritize and effectively meet their goals. “Your gun only has only so many bullets,” he said, meaning that you should pick your missions and your priorities carefully, because you can only do so much.

2. Long Term Care DocumentationShould Tell a Story

Proper documentation is the single most important factor in avoiding deficiencies. That means there should be consistency throughout a resident’s file. “You got to tell the story,” said Seelig. “So include what you did and your feeling about what has to happen next.” 

Seelig’s first priority when his team is about to take managerial responsibility for a provider is to go through the documentation. Seelig emphasized that there is a “very thin line” between accurate charge capture and a false claim. “A false claim is a criminal act by a facility,” he said. “Charge capture means that you get paid fully for what you’re going to do, what you have done, and what you’re going to do in the future.”

Lack of documentation is a common deficiency 

The OIG labeled a lack of proper documentation as the eighth most common deficiency. Regulation regarding documentation is largely related to medical records. Providers must maintain professional, accurate, and accessible medical records for each patient or resident.  Electronic health records (EHRs) facilitate the process of documentation and are an important part of the survey process. 

Facilities are required to give access to their EHRs at the beginning of each survey. The OIG gave an example of a deficiency in which a patient was treated for wounds for five days but the treatment was not documented. Such inconsistencies can result in fines or even sanctions. It is for this reason that Seelig maintains that documentation is the foundational deficiency that affects the entire operation. 

3. Implement Effective Policies

Administrators and facility owners must have effective policies in place when they bring in new staff members. These are actionable and updated protocols that are made evident to all members of the staff. Part of implementing policies is getting everyone on the same page and establishing a strong culture. 

The state of a nursing home’s policies is one of the first things examined by Seelig and his team. A toxic work culture, in which certain staff members resist policy changes because “things have always been done this way,” can be an impediment to giving care. Disagreements among experts are also an issue. “You don’t want an environment where someone says another doctor told them to do this a certain way,” he said. Seelig argued that it was important to sit with the staff to implement policies together, so the staff can better understand why the policies are important and how to implement them. 

Summary

The COVID-19 pandemic has created new difficulties for nursing homes. It is important, at this juncture, when funding from the CARES Act is coming to end, to learn to be survey-ready. By knowing how to avoid the most common deficiencies, long term care facilities can prioritize their goals and effectively meet regulatory requirements. Being survey-ready, formalizing a process for documentation, and implementing effective policies are three ways in which operators can stay afloat during these turbulent times.