Avoid a F921 citation by promoting a comfortable, clean, and safe environment in your facility.
This month’s FTag is F921: Safe/Functional/Sanitary/Comfortable Environment, part of FTags in the Physical Environment Regulatory group. F921 relates to issues around the facility’s responsibilities to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Polaris Group consultants are citing F921 on mock surveys and nationwide data shows that F921 is often involved in complaint investigations. Further, visitors and families pay attention to the physical conditions in which their loved ones live. The cleanliness, safety, and comfortability of a facility can influence a facility’s online reviews, reputation, and in the case of an issue, can warrant a citation and fine.
Examples of issues Polaris Group consultants have seen that may cause F921 to be cited at a severity of IJ or higher include:
- Ceilings in hallways and resident rooms with water damage and mold (Complaint survey S/S: L)
- Water faucets running to ‘keep the pipes from freezing’ (Complaint survey S/S: K)
- Stained grout in shower stall with broken shower chairs and stains on shower curtains with a report of resident tipping out of a broken chair. (Annual survey S/S: IJ)
- Active/live bugs in ceiling lights in resident bathrooms. (Annual survey S/S: IJ)
- Electrical tools accessible in the memory care unit, including box cutters, power drills, and hammers. (Complaint survey S/S: IJ)
- Clorox in gallon-size bottle noted in a cupboard in the activity/dining area readily available to residents. (Annual survey S/S: IJ)
- Resident sock was used to plug a hole in the window screen in the shower room that staff report has been there for months, with dead bugs/spiders noted on the windowsill and floors. (Annual survey S/S: G)
While these cases sound egregious, in today’s staffing crisis, it is easy for issues to pile up and quickly become severe if they are not remedied immediately.
A more recent trend Polaris Group consultants have noted is that surveyors are citing F921 for issues related to cleanliness of staff-only areas of the facility or areas only used by the public. This includes areas such as break rooms, the kitchen (despite there being FTag 812 specifically for the kitchen) and facility parking lots that may be used by visitors or others. While facilities may heavily focus on resident areas in preparation for a survey, staff need to be mindful that surveyors are also focused on staff and public use areas, and these may be areas for citation if they are overlooked.
To ensure F921 compliance at your facility, here are several tips and strategies:
- Ensure routine environmental rounds are completed by housekeeping and maintenance staff, with an emphasis on proper repair and cleaning of objects in the resident zone – i.e., bedrails, chairs, toilets, doorknobs, sinks, and privacy curtains.
- Ensure third-party vendors complete repairs as required. Educate your business office personnel not to pay a bill until it’s been signed off by the department manager that repairs were completed appropriately.
- Educate all employees of the expectation that residents who live in the facility should have an environment that they themselves would live in.
- Ensure all facility complaint investigations are logged and identified with action steps and reviewed at monthly QAPI meetings.
- Teach your staff to look up. Staff should routinely look at what’s happening with ceilings, door frames, overbed lights, window treatments, and blinds. Make sure that all staff know how to complete a work order for necessary repairs.
Polaris Group consultants are knowledgeable and can help identify areas of opportunities related to F921. Our consultants can assist in the formation of action plans with measurable and time-stamped components to ensure compliance. To learn more about how Polaris mock surveys can identify issues with F921 and other FTags, contact us here.
