Using Quality in Focus as the foundation, Polaris Group highlights the nationwide Top Five Citations of 2024 and prevention tips.
CMS developed the Quality in Focus Program as a resource for all long-term care facilities in the country in an effort to assist the promotion of safe environments within LTC facilities, and to educate the general public about why regulations in nursing facilities are seemingly strict and sometimes restrictive. Using Quality in Focus as the foundation, Polaris Group highlights the nationwide Top Five Citations of 2024 and prevention tips.
F880 Infection Prevention and Control
Persistent issues with practices related to PPE usage, EBP, hand hygiene.
- Implore leadership team to perform random audits.
- Conduct routine audits.
- Provide staff with education monthly.
- Create contests or teams to measure and celebrate successes.
- Review the Infection Prevention Program and communicate contents with all staff
F689 Free of Accident Hazards/Supervision/Devices
Inadequate supervision and awareness. Lack of knowledge by team members.
- Communicate accident prevention is everyone’s focus.
- Create QI rounds checklists and engage all staff in conducting.
- Fully support Risk Meetings routinely.
- Identify trends at QAPI meetings.
- Develop Safety Committee oversight with trends and patterns.
- Ensure Fall huddles are held after each incident.
F812 Kitchen Sanitation/Store/Prepare Foods
Deficiencies in food storage, preparation, and sanitation protocols.
- Conduct routine kitchen cleanliness audits.
- Watch tray line service and delivery.
- Ensure sanitation class is provided to all dietary employees.
- Document the status of FSM if certification is in process.
- Ensure resident complaints are addressed via Resident Council, Grievance log, and reviewed at QAPI.
- Ensure sanitation process for dish machine, sanitation buckets for tables, and pH level documentation is followed.
- Ask Polaris Group for our Kitchen Sanitation Tool.
F684 Quality of Care
Usually cited for shortcomings in addressing residents’ physical, mental, and psychosocial well-being.
- Evaluate the activities program to ensure it is robust and includes weekend and evening activities.
- Ensure care plans reflect residents' individual needs, including food preferences, culture issues, language barriers, and preference for care specific to food.
- Ensure consistent communication with families through available avenues – care conferences, therapy services, and activity interaction.
F656 Comprehensive Care Plans
Cited most often due to care plans not being updated or not reflective of the current situation.
- Audit care plans to ensure details necessary for services, i.e., Hospice care, dialysis treatment and communication, and appointments with specialists, are included.
- Avoid the practice where care plans are often “cut and pasted”.
- Update care plans to reflect changes in info specific to Advance Directives, DPOA, guardianship, Allergies, and updated DX.
- Develop interventions based on CAA’s.
- Ensure focus on safety and fall prevention is included in care plans.
Polaris Group provides mock surveys and compliance audits to help ensure your facility meets regulatory requirements and minimizes the risk of citations and penalties.
For further information on how partnering with Polaris Group can keep your community compliant, reach out to us today.
