Nation = 15,648 Facilities Michigan = 433 Facilities

Nation = 15,648 Facilities Michigan = 433 Facilities
Lansing = 190 Facilities Detroit = 186 Facilities Gaylord = 57 Facilities F441 – Infection Control* 37% 47% F441 – Infection Control F323 - Accidents 51% 46% F371 – Sanitary Conditions* 35% F323 – Accidents* 40% F371 – Sanitary Conditions 43% 48% 29% 38% 30% F226 – Policy & Procedure on Abuse 25% F309 – Quality of Care* F329 – Unnecessary Drugs* 28% F329 – Unnecessary Drugs F309 – Quality of Care 23% F465 – Other Environmental Conditions 22% F431 – Control, Labeling & Storage of Drugs 21% F431 – Control, Labeling & Storage of Drugs* 20% 24% F314 – Pressure Sores 26% F279 – Comprehensive Care Plans 19% 12% F241 – Dignity 16% F332 – Medication Errors 5% or greater 18% 9% F514 – Clinical Records 15% F282 – Services by Qualified Persons 14% 13% 2% This chart represent the top ten Federal Health Citations for the Nation, Michigan, and State Regional Offices This include data from the 3rd Quarter CASPER File as of September 2014 (rolling data) The 6* most frequently cited regulations across the Nation were also cited in Michigan although the frequency of 4 of the tags in Michigan were greater. They were: F441 by 10%, F371 by 3%, F323 by 11%, F329 by 5%. F309 was same and F431 was 1% less than all facilities. Approximately half of the nursing homes in Michigan and across the nation have been out of compliance with infection control regulations. Approximately one third of the nursing homes across the Nation and in Michigan have not been incompliance with handling resident food in a sanitary manner. Approximately one quarter of the nursing homes in Michigan failed to be incompliance with abuse policy & procedure requirement. Accidents – remains high on every ones list.

Rolling data – CASPER file March 2014 June 2014 September 2014
Michigan QTR 1st 2nd 3rd 4th Rolling data – CASPER file March 2014 June 2014 September 2014 December 2014 Infection Control – F441 48% 47% Accidents – F323 44% 40% Sanitary Conditions – F371 39% 37% Unnecessary Drugs – F329 36% 33% 28% Quality of Care – F309 23% 25% P&P on Abuse – F226 21% 24% Pressure Sores – F314 22% Control, Labeling & Storage of Drugs – F431 18% 19% Other Environmental Conditions – F465 20% Medication Errors 5% or greater – F332 16% Comprehensive Care Plan – F279 This quarterly trending report reflects regulatory noncompliance with: Infection control citation remains high – with such high concentration of vulnerable residents and potential for infection d/t MRSA, VRE, C-Diff, Pneumonia, Influenza, EBOLA?, a lack of due diligence could develop into an immediate jeopardy situation quickly. Among the 433 nursing homes in Michigan, this requirement was not met in 47% of the facilities surveyed during this fiscal year as of September This regulation ranked 1st in citation frequency in Michigan and 1st across the Nation. There were no citations that rose to the harm or IJ severity level. 2. Accident prevention citations improved in 2nd quarter and unchanged in 3rd. Among the 433 nursing homes in Michigan, this requirement was not met in 40% of the facilities surveyed during this fiscal year as of September This regulation ranked 2nd in citation frequency in Michigan and 3rd across the Nation. Within Michigan, 29 of the citations were at level of harm (28 isolated & 1 pattern), 6 were isolated Immediate Jeopardy and 1 pattern at IJ level. 3. Unsanitary food service citations remain high. Among the 433 nursing homes in Michigan, the sanitary food service regulation was cited in 38% of the facilities surveyed during this fiscal year as of September This regulation ranked 3rd in citation frequency in Michigan and 2nd across the Nation. There were no citations that rose to the harm or IJ severity level. 4. National effort focusing on dementia care with reductions of antipsychotic medications may have positive impact on the reduction of unnecessary drugs citations. 5. The rise in noncompliance with Abuse protocol is consistent with OIG report indicating the lack of facility reporting allegations of abuse.

Partnership to Improve Dementia Care in Nursing Homes Antipsychotic Drug use in Michigan’s Nursing Homes trend update Quarterly Prevalence of Antipsychotic Use for Long-Stay Residents Source – CMS Quality Measure, based on MDS 3.0 Data *Rank – lower = better 2011 Q2 Q3 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 Rank in 2014 16.2% 16.0% 16.4% 15.8% 15.5% 14.9% 14.4% 14.1% 13.9% 13.7% 13.4% 2 National effort focusing on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individuals needs may have had positive impact on the reduction of the unnecessary drugs tag – F329. So, let’s rejoice in this good news for Michigan’s Nursing home staff and their residents. Michigan was only second to Hawaii (and, who needs antipsychotics there – joke!) Rankings within Region V ; Michigan – 2nd, Wisconsin – 4th, Minnesota – 9th, Indiana – 32nd, Ohio – 42nd, Illinois – 49th

Infection Control - F The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility must establish an Infection Control Program under which it – Investigates, controls, and prevents infections in the facility; Decides what procedures, such as isolation, should be applied to an individual resident; and Maintains a record of incidents and corrective actions related to infections. Among the 433 nursing homes in Michigan, this requirement was not met in 47% of the facilities surveyed during this fiscal year as of September 2014. This regulation ranked 1st in citation frequency in Michigan and 1st across the Nation. There were no citations that rose to the harm or IJ severity level. Across the nation (15,648 nursing homes), 37% of them were out of compliance and were cited with F441 during the same time period. The intent of this regulation is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. NEXT

Infection Control - F441 (b) Preventing Spread of Infection
When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice Personnel must handle, store, process and transport linens so as to prevent the spread of infection. When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice, AND Personnel must handle, store, process and transport linens so as to prevent the spread of infection. NEXT

Infection Control - F441 Overview
Infections result in an estimated 150,000 to 200,000 hospital admissions per year. When a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40%. An effective facility-wide infection prevention and control program can help contain costs and reduce adverse consequences. Critical aspects include: Recognizing and managing infections at the time of a resident’s admission to the facility and throughout their stay Following recognized infection control practices while providing care. Infections result in an estimated 150,000 to 200,000 hospital admissions per year. When a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40%. An effective facility-wide infection prevention and control program can help contain costs and reduce adverse consequences. It relies upon the involvement, support, and knowledge of the facility’s administration, the entire interdisciplinary team, residents, and visitors. NEXT Critical aspects include recognizing and managing infections at the time of a resident’s admission to the facility and throughout their stay and following recognized infection control practices while providing care.

Infection Control - F441 Program Development and Oversight
Involves: Establishing goals and priorities for the program Planning and implementing strategies to achieve the goals Identify the staff’s roles and responsibilities Develop, train, and implement infection control policies and procedures Monitoring the implementation of the program – includes infection control practices Document the tracking/analyzing outbreaks of infection including the actions taken to resolve related problems Define and manage appropriate health initiative – influenza and pneumonia immunizations, tuberculosis screening Manage food safety, pest control, waste disposal and employee health and hygiene Responding to errors, problems or other identified issues An effective Infection Control Program includes the planning, organizing, implementing, operating, monitoring and maintaining all of the elements of the program and Ensuring that the facility’s interdisciplinary team is involved in infection prevention and control. NEXT

Infection Control - F441 Policy and Procedures
Policies and procedures are reviewed periodically and revised as needed to conform to current standards of practice or to address specific facility concerns. Establish the program’s expectations and parameters - i.e.; Specify the use of standard precautions facility-wide and use of transmission-based precautions when indicated Define the frequency and nature of surveillance activities Require staff to use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Prohibit direct resident contact by an employee who has an infected skin lesion or communicable disease. Procedures guide the implementation of the policies and performance of specific tasks – i.e.; How to identify and communicate information about residents with potentially transmissible infectious agents Must have written Infection Control P&P’s These can promote consistent adherence to evidence-based infection control practices Next

Infection Control - F441 Policy
Policies and procedures are reviewed periodically and revised as needed to conform to current standards of practice or to address specific facility concerns. Establish the program’s expectations and parameters - i.e.; Specify the use of standard precautions facility-wide and use of transmission-based precautions when indicated Define the frequency and nature of surveillance activities Require staff to use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Prohibit direct resident contact by an employee who has an infected skin lesion or communicable disease. The Administrative team of the facility – specifically the Medical Director, the DON, the Administrator and the designated Infection Control Nurse are to periodically review and revise as needed the Infection Control program to ensure it conforms to current standards of practice and it address’s any facility specific infection control issue. Policy’s establish the program’s expectations and parameters - i.e.; Specifying the use of standard precautions facility-wide and use of transmission-based precautions when indicated Defining the frequency and nature of surveillance activities Requiring staff to use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Prohibiting direct resident contact by an employee who has an infected skin lesion or communicable disease. NEXT

Infection Control - F441 Procedures
Procedures guide the implementation of the policies and performance of specific tasks – i.e.; How to identify and communicate information about residents with potentially transmissible infectious agents How to obtain vital signs for a resident on contact precautions and what to do with the equipment after its use Essential steps and considerations (including choosing agents) for performing hand hygiene The facility has to have procedures which guide the implementation of the infection control policies. Such as how to identify and communicate information about residents with potentially transmissible infectious agents, or How to obtain vital signs for a resident on contact precautions and what to do with the equipment after its use What are the essential steps and considerations (including choosing agents) for performing hand hygiene? NEXT

Infection Control - F441 Surveillance
Essential elements of a surveillance system include: Use of standardized definitions and listings of the symptoms of infection - Use of surveillance tools such as infection surveys and data collection templates Walking rounds throughout the facility Identification of segments of the resident populations at risk for infection Identification of the processes or outcomes selected for surveillance Statistical analysis of data that can uncover an outbreak Feedback of results to the primary caregivers so they can assess the residents for signs of infection. This slide describes the essential elements of a surveillance system. The first of which is using standardized definitions and listing of the symptoms of infection. A link is provided. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria (2012) These definitions are an update to the surveillance definitions for long-term care (i.e., the McGeer Criteria), which have not been revised since These definitions are intended to serve as a national standard for infection surveillance in long-term care facilities and include significant changes to criteria defining urinary tract and respiratory tract infections as well as new definitions for norovirus gastroenteritis and Clostridum difficile infections.

Infection Control - F441 Process Surveillance
Determines whether the facility - Minimizes exposure to a potential source of infection Uses appropriate hand hygiene prior to and after all procedures Ensures that appropriate sterile techniques are followed when indicated Uses personal protective equipment when indicated Ensures that reusable equipment is appropriately cleaned, disinfected or reprocessed Uses single-use medication vials and other single use items appropriately Process surveillance reviews practices directly related to resident care in order to identify whether the practices comply with established procedures and policies. NEXT

Infection Control - F441 Outcome Surveillance
Consists of – Collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections. Reports describe the types of infections Descriptive documentation provides the facility with summaries of the observed staff practices and/or the investigation of the causes of an infection or trends The IP (Infection Preventionist) or other designated staff reviews data to detect clusters and trends such as antibiotic orders, antibiotic susceptibility profiles, medication regimen review reports, physician progress reports and transfer summaries of newly admitted residents. All residents are monitored for current infections and infection risks Review of outcome data helps the facility to identify the number of residents who develop infections within the nursing home. Outcome surveillance is designed to identify and report evidence of an infection. The facility can then evaluate whether it needs to change processes or practices to enhance infection prevention and minimize the potential for transmission of infections. It is important that the surveillance reports be shared with appropriate individuals including, but not limited to, the DON and Medical Director. As well as sharing the reports with staff and practitioners that are relevant to their practices to help them recognize the impact of their care on infection rates and outcome. NEXT

Infection Control - F441 Education
Both initial and ongoing infection control education help staff comply with infection control practices. Essential topics of infection control training include: Routes of disease transmission Hand hygiene Sanitation procedures MDROs (multi-drug resistant organisms) Because of increases in MDROs, review of the use of antibiotics (including comparison of prescribed antibiotics with available susceptibility reports) is a vital aspect of the prevention and control program Transmission-based precaution techniques Federally required OSHA education Essential topics of infection control training include: (and, this is not new) Routes of disease transmission Hand hygiene Sanitation procedures MDROs (multi-drug resistant organisms) Because of increases in MDROs, review of the use of antibiotics (including comparison of prescribed antibiotics with available susceptibility reports) is a vital aspect of the prevention and control program Transmission-based precaution techniques Federally required OSHA education NEXT

Infection Control - F441 Preventing the Spread
Modes of transmission include - Contact Droplet Airborne The modes of infection spread can be via contact, in droplets and through the air. NEXT

Infection Control - F441 Factors of the Spread
Individual Corticosteroids and chemotherapy Decreased function of the heart, lungs and kidneys Decreased/absent cough reflex, thinning skin, decreased tear production, vascular insufficiency, impaired immune function Coexisting chronic diseases – diabetes, cancer, COPD, anemia Institutional Pathogen exposure in shared communal living space – handrails & equipment Common air circulation Transfer of residents to and from hospitals or other settings Improper hand hygiene, improper glove use, improper food handling Many factors contribute to a substantial severity and frequency of infections and infectious diseases in nursing homes. Residents may have: Decreased/absent cough reflex – predisposing to aspiration pneumonia Thinning skin – associated with pressure ulcers Decreased tear production – predisposing to conjunctivitis The facility factors include pathogen exposure due to shared living space (includes handrails and equipment), the air, transferring of residents in and out of a hospital and improper hand hygiene and food handling practices. NEXT

Direct transmission (Person to Person) Contaminated hands of staff are often implicated Examples include (but not limited to) - MRSA, VRE, and Influenza Indirect transmission Resident care devices – thermometers or glucose monitoring devices Clothing, uniforms, lab coats etc., i.e. – MRSA, VRE, Clostridium difficile Toilets and bedpans, i.e. – salmonella, shigella, E. coli, norovirus and C-diff. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting) of resident equipment, medical devices, and the environment. Direct transmission occurs when microorganisms are transferred from an infected/colonized person to another person. Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting) of resident equipment, medical devices, and the environment. NEXT

Critical items – equipment must be sterile when used such as needles, intravenous catheters, indwelling urinary catheter.s Semi-critical items – equipment that require meticulous cleaning followed by high-level disinfection tx or sterilized such as thermometers, podiatry equipment, electric razors. Non-critical items – equipment that require low level disinfection by cleaning periodically and after visible soiling with an EPA disinfectant detergent or germicide such as stethoscopes, blood pressure cuffs, over-bed tables. Single dose/single use equipment is an alternative to sterilizing medical instruments. They must be discarded after use and are never used for more than one resident. The CDC has adopted the Spaulding classification system that identifies three risk levels associated with medical and surgical instruments. Critical items normally enter sterile tissue or the vascular system or through which blood flows. Semi-critical items touch mucous membranes or skin that is not intact. Non-critical items come into contact with intact skin or do not contact the resident. Revisions to the Surveyor protocol and interpretative guidelines are again noted in RED print. NEXT Nursing homes may purchase reprocessed single-use devices when these devices are reprocessed by an entity or a third party reprocessor that is registered with the FDA. The nursing home must have documentation from the third party reprocessor that indicates that it has been cleared by the FDA to reprocess the specific device in question. NEXT

Single dose/single use medications – must not be used for multiple residents due to the risk of spreading infections diseases. Medications labeled as single-use or single dose by manufacturers typically lack antimicrobial preservatives and once a SDV is entered, the contents can support the growth of micro-organisms. The risk of infection transmission associated with using SDVs for multiple residents is well documented, with evidence accumulated from the investigation of multiple outbreaks. Administering drugs from on SDV to multiple residents without adhering to USP standards is not acceptable. Single dose/single use medications – must not be used for multiple residents due to the risk of spreading infections diseases. Medications labeled as single-use or single dose (SDV) by manufacturers typically lack antimicrobial preservatives and once a SDV is entered, the contents can support the growth of micro-organisms. The risk of infection transmission associated with using SDVs for multiple residents is well documented, with evidence accumulated from the investigation of multiple outbreaks. Administering drugs from on SDV to multiple residents without adhering to USP standards is not acceptable. NEXT USP = United States Pharmacopeia

Insulin Pens are designed to permit self-injection and are intended for single-person use, using a new needle for each injection. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Insulin pens must be clearly labeled with the resident’s name or other identifiers to verify that the correct pen is used for the correct resident. Policy and procedures and staff education should be provided when facility’s use insulin pens. If it is discovered that insulin pens are shared between residents, the facility’s plan of correction should include notification of the local health department. Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. Insulin Pens are designed to permit self-injection and are intended for single-person use, using a new needle for each injection. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Insulin pens must be clearly labeled with the resident’s name or other identifiers to verify that the correct pen is used for the correct resident. Policy and procedures and staff education should be provided when facility’s use insulin pens. If it is discovered that insulin pens are shared between residents, the facility’s plan of correction should include notification of the local health department NEXT

Infection Control - F441 Linens
It is important that all potentially contaminated linen be handled with appropriate measures to prevent cross-transmission. If the facility handles all used linen as potentially contaminated (i.e., using standard precautions), no additional separating or special labeling of the linen is recommended. No special precautions (double bagging) or categorizing is recommended for linen originating in isolation rooms. Double bagging of linen is only recommended if the outside of the bag is visibly contaminated or is observed to be wet through to the outside of the bag. Leak-resistant bags are recommended for linens contaminated with blood or body substances. For the routine handling of contaminated laundry, minimum agitation is recommended to avoid the contamination of air, surfaces, and persons. It is important that laundry areas have hand washing facilities and products (PPE) available for workers to wear while sorting linens. It is recommended that damp linen is not left in machines overnight. Nothing new here.

The CDC recommends leaving washing machines open to air when not in use to allow the machine to dry completely and to prevent growth of microorganisms in wet, potentially warm environments. Laundry detergents used within facilities are not required to have state anti-microbial claims. Facilities should closely follow manufacturer’s instructions for laundry detergents used. CMS and CDC have determined that ozone cleaning systems are acceptable methods of processing laundry. Ozone cleaning systems also should be used per manufacturer’s instructions. An effective way to destroy microorganisms in laundry items is through hot water washing at temps about 160 degrees Fahrenheit (F) for 25 minutes. Alternatively, low temp washing at degrees F plus a 125-part-per-million (ppm) chlorine bleach rinse has been found to be effective and comparable to high temperature wash cycles. The CDC recommends leaving washing machines open to air when not in use to allow the machine to dry completely and to prevent growth of microorganisms in wet, potentially warm environments. Laundry detergents used within facilities are not required to have state anti-microbial claims. Facilities should closely follow manufacturer’s instructions for laundry detergents used. CMS and CDC have determined that ozone cleaning systems are acceptable methods of processing laundry. Ozone cleaning systems also should be used per manufacturer’s instructions. NEXT

Laundry washing within facilities typically occurs in a low water temperature environment. Many laundry items are composed of materials that cannot withstand a chlorine bleach rinse and remain intact. A chlorine beach rinse is not required for all laundry items processed in low temperature washing environments due to the availability of modern laundry detergents that are able to produce hygienically clean laundry without the presence of chlorine beach. However, a chlorine bleach rinse may still be used for laundry items composed of materials such as cottons. Laundry washing within facilities typically occurs in a low water temperature environment. Many laundry items are composed of materials that cannot withstand a chlorine bleach rinse and remain intact. A chlorine beach rinse is not required for all laundry items processed in low temperature washing environments due to the availability of modern laundry detergents that are able to produce hygienically clean laundry without the presence of chlorine beach. However, a chlorine bleach rinse may still be used for laundry items composed of materials such as cottons. NEXT

Hot water washing at temps greater than 160 degrees F for 25 minutes and low temp washing at 71 to 77 degrees F with a 125 ppm chlorine bleach rinse continue to be effective ways to wash laundry. If a facility chooses to process laundry using a hot water temp environment, the temp maintained for 25 minutes should be at or about 160 degrees F. Facilities are not required to maintain a record of water temps during laundry processing cycles. Facilities are required to follow manufacturer’s instructions for all material involved in laundry processing. Facilities should consider resident’s individual needs (allergies) when selecting methods for processing laundry. Hot water washing at temps greater than 160 degrees F for 25 minutes and low temp washing at 71 to 77 degrees F with a 125 ppm chlorine bleach rinse continue to be effective ways to wash laundry. If a facility chooses to process laundry using a hot water temp environment, the temp maintained for 25 minutes should be at or about 160 degrees F. Facilities are not required to maintain a record of water temps during laundry processing cycles. Facilities are required to follow manufacturer’s instructions for all material involved in laundry processing. Facilities should consider resident’s individual needs (allergies) when selecting methods for processing laundry. NEXT

If linen is sent off to a professional laundry, the facility should obtain an initial agreement that stipulate the laundry will be hygienically cleaned and handled to prevent recontamination from dust and dirt during loading and transport. An ozone laundry cleaning system is a method which may require a professional laundry service. The facility will need to obtain such an agreement. Whether laundry processing is completed within or outside the facility, facilities should have written policies & procedures which should include training for staff who will handle linens and laundry. An ozone laundry cleaning system is a method which may require a professional laundry service. The facility will need to obtain such an agreement. Whether laundry processing is completed within or outside the facility, facilities should have written policies & procedures which should include training for staff who will handle linens and laundry. NEXT

Regarding standard mattresses and pillows - patches for tears and holes in mattress covers do not provide an impermeable surface over a mattress – therefore it is recommended that mattress covers with tears/holes be replaced. - And it is recommended that moisture resistant mattress covers be cleansed and disinfected between residents with an EPA approved germicidal detergent to help prevent the spread of infections and fabric mattress covers be laundered in a hot water laundry cycle between residents. Nothing revised regarding standard mattresses and pillows. NEXT

Infection Control - F441 Recognizing and Containing Outbreaks
It is important that facilities know how to recognize and contain infectious outbreaks. An outbreak is typically one or more of the following: One case of an infection that is highly communicable; Trends that are 10% higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or Occurrence of three or more cases of the same infection over a specified length of time on the same unit or other defined areas. Once an outbreak has been identified – it is important that the facility take the appropriate steps to contain it. Notification of your Medical Director and the State and local health department for guidance and regulations regarding responding to the outbreak. Plans for containing outbreaks usually include efforts to prevent further transmission of the infection while meeting the needs of all the residents. NEXT

Infection Control - F441 MDRO’s
MDRO’s found in facilities include (but not limited to) MRSA – Methicillin resistant staphylococcus aureus VRE – Vancomycin resistant enterococcus C. Diff - Clostridium difficile Transmission-based precautions are employed for residents who are actively infected with a MDRO. MDRO = Multi-Drug resistant organisms Aggressive infection control measures and strict compliance by healthcare personnel can help minimize the spread to other susceptible residents. NEXT

Staphylococcus is a common cause of infections in hospitals and nursing homes and increasingly in the community. Common sites of MRSA colonization include the rectum, perineum, skin and nares. Colonization may precede or endure beyond an acute infection. MRSA is transmitted (most commonly) by person to person and on inanimate objects (i.e. stethoscopes etc) *MRSA infection is commonly treated with vancomycin – which, in turn can lead to increased enterococcus antibiotic resistance. Therefore – preventing an infection with MRSA and the limited use of antibiotics for residents who are only colonized can also help prevent the development of VRE! NEXT

C. Difficile is an organism which normally lives benignly in the colon in spore form. When antibiotic use eradicates normal intestinal flora, the organism may become active and produce a toxin that causes symptoms such as diarrhea, abdominal pain, and fever. More severe cases can lead to additional complications such as intestinal damage and severe fluid loss. Treatment options include stopping the antibiotics and starting specific anticlostridial antibiotics such as metronidazole (flagyl) or oral vancomycin. Contact precautions are instituted for residents with symptomatic C. difficile infection. When a resident has diarrhea due to C. diff, large numbers of the C. diff organisms will be released from the intestine and into the environment – which increases the potential to be transferred to other residents etc. C. diff can survive in the environment – on floors, bed rails, or around toilet seats in its spore form for up to 6 months. Rigorously cleaning the environment removes C. diff spores and can help prevent the transmission of the organism. Cleaning equipment used for residents with C. diff with a 1:10 dilution of bleach/water will also reduce the spread. NEXT

Infection Control - F441 Intravascular devices
Devices such as central venous catheters, PICC lines, dialysis catheters etc. may increase the risk for local and systemic infections. Surveillance consistently includes all residents with vascular access to reduce risk for infection. What does this mean? Observation of the insertion sites Observation of the dressing changes Observation for use of appropriate PPE and hand hygiene during the care and tx of residents with venous catheters. Review of medical record for evidence of infection It is imperative to ensure appropriate infection control measures are maintained when caring for residents with vascular access catheters. Surveillance consistently includes all residents with vascular access to reduce risk for infection. What does this mean? Observation of the insertion sites Observation of the dressing changes Observation for use of appropriate PPE and hand hygiene during the care and tx of residents with venous catheters. NEXT

Infection Control – F441 Surveyor Investigative Protocol
Observations Linens handled in manner to prevent contamination Employees with cold symptoms, infections or open lesions on hands are prohibited from contact with resident(s) & food Adherence to infection control practices – use of PPE Hand hygiene and use of gloves when indicated Availability of gloves and products to perform hand hygiene Residents with S&S of infections Cleaning and disinfecting practices The SA is expected to use this protocol with every initial certification and recertification survey, and abbreviated survey when triggered. Expect survey team to conduct observations, interviews with staff, residents and visitors, and review records – P&P’s, surveillance data, education records. Observations of various discipline to determine if they follow appropriate infection control practices and transmission based precaution procedures. Hand hygiene should occur before and after putting on sterile gloves and after taking off all gloves during all resident care that requires use of gloves, i.e. – administration of eye drops, sublinguals and injections, dressing changes, insertion/removal of a catheter etc. NEXT

Interview(s) of Direct care staff concerning; Whether they are aware of and have reported any signs/symptoms exhibited by the resident that may be associated with an infection Whether they have been instructed on any special precautions that are applicable to a resident on transmission based precautions How staff know which residents are covered by transmission-based precautions and, what specific actions are required for each type of transmission based precautions. Interviews intended to determine whether education and information was provided about infection control practices applicable to meet the resident’s needs Transmission based precautions include contact, droplet, and airborne Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct/ indirect contact with the patient or the patient’s environment Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. A single patient room is preferred for patients who require Droplet Precautions Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., measles, chickenpox, TB. The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). NEXT

Record Review Resident’s medical record reveals an evaluation of factors which may increase the risk of infection (i.e. – urinary catheters, trache tube etc.) and if an infection is present, documentation indicating potential causes/contributing factors Resident’s plan of care includes interventions to prevent transmission of infection when applicable Surveillance records reflect pertinent data – date of infection, sign/symptoms meet criteria of infection, treatment ordered, precautions implemented, date resolved, review of antibiotic appropriateness/effectiveness Infection control policies meet current professional standards of practice and are defined by departments i.e. – nursing, dietary, laundry Expect a Surveyor to review resident’s medical records, including the resident’s plan of care – looking for interventions to prevent the transmission of an infection when applicable. They will review surveillance records for pertinent data such as the date of infection, whether there are sign/symptoms documented which meet criteria of infection, what the treatment ordered was, whether or not precautions were needed and implemented, the date the infection resolved, and a review of antibiotic appropriateness/effectiveness. Aside from breaches with infection control practices – F441 is most frequently cited due to the facility’s failure to maintain adequate and consistent infection control surveillance records. The surveyor will review your infection control policies and procedures to determine if the facility has periodically reviewed the P&P’s and if the procedures are consistent with current standards of practice NEXT

Infection Control - 441 Criteria for Compliance
This is determined if the program/facility demonstrates; Ongoing surveillance, recognition, investigation and control of infections to prevent the onset and the spread of infection; Practices to reduce the spread of infection and control of transmission-based precautions; Practices and process consistent with infection prevention and prevention of cross-contamination (i.e. -catheter care etc.); That it uses records of incidents to improve its infection control processes and outcomes by taking corrective action; Processes and procedures to identify and prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food; Consistent adherence with appropriate hand hygiene practices; Handling, storage, processing and transporting of linens so as to prevent the spread of infection. Criteria for Compliance – not new NEXT

Infection Control - 441 Deficiency Categorization
Severity Level 2 - indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his or her highest practicable level of well being. The potential exists for greater harm to occur if interventions are not provided. The facility failed to ensure that their staff demonstrates proper hand hygiene between residents to prevent the spread of infections. The staff administered medications to a resident via a gastric tube and while wearing the same gloves, proceeded to administer oral medications to another resident. The staff did not remove the used gloves and wash or sanitized their hands between residents. The facility failed to implement a surveillance program including the investigation of infections or attempt to distinguish facility-acquired infections from community-acquired infections. The facility identified issues related to staff infection control practice but failed to identify the cause and institute measures to correct the problem Once the survey team has completed its investigation, analyzed the data, reviewed the regulatory requirements, and determined that noncompliance exists, the team must determine the severity of the deficiency, based on the resultant effect or potential for harm to the resident(s). ****The failure of the facility to provided appropriate care and services for infection control practices places the resident at risk for more than minimal harm. Therefore, Severity Level I does not apply for this regulatory requirement.

Severity Level 3 - indicates noncompliance that results in actual harm that is not immediate jeopardy. The facility routinely sent urine cultures of asymptomatic residents with indwelling catheters, putting residents with positive cultures on antibiotics, resulting in two residents acquiring antibiotic-related colitis and significant weight loss. The facility failed to institute internal surveillance for adherence to hand washing procedures or pertinent reminders to staff regarding appropriate respiratory precautions during an influenza outbreak resulting in additional cases of influenza in residents on another, previously unaffected unit or section of the facility. Examples of harm level outcomes. NEXT

Severity Level 4 – immediate jeopardy is a situation… likely to result in serious injury, harm, impairment, or death to a resident AND requires immediate correction etc. The facility failed to restrict a staff member with a documented open, draining and infected skin lesion that was colonized with MRSA from working without adequately covering the area, resulting in MRSA transmission and infection of one or more residents under that staff person’s care. The facility failed to investigate, document surveillance of and try to contain an outbreak of gastrointestinal illness among residents; as a result, additional resident became ill. Examples of IJ severity level deficient practice. NEXT

Infection Control - 441 Summary Statement of Deficiency
On …. at 4:06pm, facility staff nurse (A) was observed using an ultra trak ultimate glucometer to place a blood tinged test strip into the device for a serum blood glucose reading for resident #20. Upon leaving resident #20’s room, staff nurse (A) failed to disinfect the glucometer and placed it back into the treatment cart. Then staff nurse (A) went to resident #21’s room. Taking out the same glucometer used for resident #20 serum glucose measurement from the treatment cart, staff nurse (A) then inserted a blood tinged test strip into the glucometer for a serum glucose measurement. After use of the glucometer, staff nurse (A) then placed the glucometer into the top right drawer of the treatment care without disinfecting it. At 4:25pm (same date), staff nurse (A) removed the same ultra trak ultimate glucometer from the treatment cart use for resident #21 and place a blood tinged test strip into it for measuring resident #3’s serum glucose level. Staff nurse (A) failed to sanitize this glucometer prior to and after use on resident #3. This is an example of a F441 citation during a recent standard survey. What did the facility fail to do? What severity level would you assign? (D) (DPS – Based on observation and record review, the facility failed to sanitize a multi-resident use glucometer prior to using for two of two residents observed from a total sample of 19 resulting in a potential for contamination of the glucometer and transmission of infectious organisms to these residents.) What (if anything) is wrong with this citation? Does it clearly demonstrate a deficient practice? Did the surveyor corroberate the evidence with interview? Is this challengeable? NEXT

An observation of pericare for Resident #X on x/xx/xx at 3:00pm Certified Nurse Aide (CNA) entered with Resident #X into her room. CNA did not wash hands prior to applying gloves before transferring Resident #X into her bed. When Resident #X was in bed, CNA, with same gloves on, checked Resident #X’s brief to check if Resident #X was soiled. CNA stated that Resident #X would need to be changed. CNA then with same gloved hands, proceeded to Resident #X’s closet to retrieve a clean brief. CNA removed gloves and left the room without washing hands to get washcloths. CNA returned to room without washing hand to and applied clean gloves, filled wash basin, and retrieved Resident#4’s body wash from her bedside stand. CNA placed the wash basin directly on Resident #X’s bedside table….CNA removed gloves, and without washing hands, applied clean gloves and proceeded to clean Resident #X back side. Once Resident #X pericare was complete and a clean brief applied, CNA went across room and with gloved hand turned on air conditioner for room…. (DPS – Based on observation, interview, and record review, the facility failed to implement principles of infection control (follow appropriate handwashing and glove use during a dressing change and resident care, female peri care and properly clean and disinfect glucometer) in 1 of 23 residents resulting in the potential spread of infection.) NEXT

…during an observation of the dressing change to Resident #x’s right heel on X/XX/XX at X:XX pm, Assistant Director of Nursing was observed with gloved hands to remove the dressing from Resident #X’s right heel, then, with her right gloved hand, reached into her left pocket to get a measuring tool to measure Resident #X’s heel ulcer. (DPS – Based on observation, interview, and record review, the facility failed to implement principles of infection control (follow appropriate handwashing and glove use during a dressing change and resident care, female peri care and properly clean and disinfect glucometer) in 1 of 23 residents resulting in the potential spread of infection.) This and the previous example reflect improper infection control practices by staff member at a CNA level and, at the Assistant Director of Nursing level. NEXT

…An interview was conducted with the Director of Nursing (DON) on 7/23/14 at 9:00am, pertaining to the Infection Control Program. A review of the Infection Control Program documentation from April 2013 through July XX, 2014 revealed: No “Employee Infection Logs” No documentation showing employee illnesses were monitored and compared with resident infections in the monthly summaries No monthly summaries showing infection control information gathered had been analyzed with appropriate recommendations to prevent the potential spread of infectious organisms. The maps of the facility showing the locations of residents with infections by color-coding was not consistently completed to include all of the infections… DPS – Based on interview and record review, the facility failed to establish a complete infection control program which compared employee and resident infections, consistently identified and analyzed clusters of organisms timely and make appropriate recommendations to prevent the potential spread of infectious organisms.) This example reflects the facility failure to maintain complete records. NEXT

Let’s take a pause here for any questions or comments regarding the
Infection Control tag – F441 Please type in any question or comment regarding this regulation. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. NEXT

Accidents – F (h)(1)(2) The facility must ensure that the resident remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying, evaluating and analyzing hazards and risks Implementing interventions to reduce the hazards and risks Monitoring for effectiveness and modifying interventions as necessary Among the 433 nursing homes in Michigan, this requirement was not met in 40% of the facilities surveyed during this fiscal year as of September 2014. This regulation ranked 2nd in citation frequency in Michigan and 3rd across the Nation. Across the nation (15,648 nursing homes), 29% of them were out of compliance and were cited for F323 during the same time period. Within Michigan, 29 of the citations were at level of harm (28 isolated & 1 pattern), 6 were isolated Immediate Jeopardy and 1 pattern at IJ level. What is required to be in compliance with F323? Identifying, evaluating and analyzing hazards and risks Implementing interventions to reduce the hazards and risks Monitoring for effectiveness and modifying interventions as necessary NEXT

Accidents – F323 Definitions
“Accident” – refers to any unexpected or unintentional incident which may result in injury or illness to a resident. (This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in in accordance with current standards of practice, i.e. drug side effects). “Avoidable Accident” – means that an accident occurred because the facility failed to identify environmental hazards and individual resident risk of an accident including the need for supervision, and/or failed to implement intervention, including adequate supervision, consistent with a resident’s needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident and/or failed to monitor for effectiveness and modify interventions as necessary. “Unavoidable Accident” – means that an accident occurred despite facility efforts to identify, evaluate and analyze the hazards and risks, and to implement interventions to reduce the hazards and risks, and to monitor for effectiveness and modify interventions as necessary. No change in definitions for Accident, Avoidable Accident or Unavoidable Accident NEXT

Accidents – F323 “Assistance Device” or “Assistive Device” – refers to any item (handrails, grab bars, transfer lifts, canes, wheelchairs etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety. “Fall” – refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force i.e. – resident pushes another resident. An episode where a resident lost their balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. “Hazards” – refer to element of the resident environment that have the potential to cause injury or illness. Or with Assistive Device, Fall or Hazards. NEXT

Accidents – F323 Definitions
“Free of accident hazards as is possible” – refers to being free of accident hazards over which the facility has control. “Supervision/Adequate Supervision” – refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. And, there is not change in these definitions either but I want to highlight the definition of adequate supervision – can be quite subjective but when it comes to the resident’s plan of care, you will be better served (as well as the resident) if you very clearly spell out exactly what and when this is to occur. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident’s assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. i.e less direct hands-on supervision in am than in pm due to increase level of resident fatigue or confusion. NEXT

Numerous and varied accident hazards exist in everyday life.
Accidents – F323 Overview Numerous and varied accident hazards exist in everyday life. It is important that all facility staff understand the facility’s responsibility, as well as their own, to ensure the safest environment possible for residents. The facility is responsible for providing care to residents in a manner that helps promote quality of life. This includes respecting residents’ rights to privacy, dignity and self determination, and their right to make choices about significant aspects of their life in the facility. The responsibility to respect resident’s choices is balanced by considering the potential impact of these choices on other individuals and the facility’s obligation to protect the residents from harm. Incorporating a resident’s choice into the plan of care can help the facility balance interventions to reduce the risk of an accident while honoring the resident’s autonomy. Consent by resident or responsible party alone does not relieve the provider of its responsibility to assure the health, safety, and welfare of its residents, including protecting them from avoidable accidents. The regulations hold the facility ultimately accountable for the resident’s care and safety. NEXT

Accidents – F323 Identification of Hazards and Risks
Identification of Hazards and Risks - sources may include; Quality assurance activities Environmental rounds MDS/CAAs data Medical history and physical exam Individual observation This information is to be documented and communicated across all disciplines. This slide gets to establishing and utilizing a systematic approach to resident safety helps facilities comply with the regulations. And, a key element of the systematic approach is consistent application. NEXT

Accidents – F323 Evaluation and Analysis
Evaluation and Analysis - may include; Considering the severity of hazards The immediacy of risk Trends such as time of day, location etc. Evaluation and analysis is the process of examining data to identify specific hazards and risks and then, to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. NEXT

Accidents – F323 Implementation of Interventions
Implementation of Interventions which are consistent with relevant standards of care including evidence-based practices – process includes; Communicating the interventions to all relevant staff Assigning responsibility Developing or revising policies and procedures Providing training as needed Repairing devices/equipment Documenting interventions Ensuring the interventions are put into place. As stated, interventions are based on the result of the evaluation and analysis of the information about hazards and risks. Implementation refers to using specific interventions to try to reduce a resident’s risks from hazards in the environment. NEXT

Accidents – F323 Monitoring and Modification
Monitoring and Modification – processes include; Ensuring that interventions are implemented correctly and consistently Evaluating the effectiveness of interventions* Modifying or replacing interventions as needed Evaluating the effectiveness of new interventions *When a facility implements accident prevention measures for a resident and has reason to know that those measures are substantially ineffective in reducing the risk of accidents, the facility must act to determine the reasons for the ineffectiveness and to consider/implement more effective measures. This regulation gets at the expectation to use reason and professional judgment in assessing what can be done to make residents safe. An example of a facility specific modification is additional training of staff when equipment has been upgraded. An example of a resident specific modification is revising the plan of care to reflects the resident’s current condition and risk factors that may have changed since the previous assessment. NEXT

Accidents – F323 Supervision
Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. What is adequate supervision? It is defined by type and frequency, based on the individual resident’s assessed needs, and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Tools or items such as personal alarms can help to monitor a resident’s activities, but they do not eliminate the need for adequate supervision. A focus here on the use of Supervision as indicated in this regulation. Let’s talk about the “adequate supervision” intervention frequently seen on resident’s safety care plans. It is not uncommon to see on a care plan, an intervention that reads, “transfer with 1 – 2 assist as needed” or “supervise resident during ambulation to dining room as needed”. What does that mean? As needed. Who is expected to determine that? The CNA? Are they by law allowed to assess? This is an illustration about knowing/observing your residents over time. Does their supervision needs change throughout the day? The plan of care is expected to list resident specific interventions. Your residents will benefit from more specificity regarding safety concerns and so will you when surveys are conducted. NEXT

Accidents – F323 Supervision & Resident Smoking
NFPA 101, the Life Safety Code reads, “…shall include not less than the following provisions: Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. Smoking by patients classified as not responsible shall be prohibited. The requirement of (3) shall not apply where the patient is under direct supervision. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. On May 1, 2010, Michigan's smoke-free law went into effect. The law covers public places, including, but not limited health facilities and nursing homes. If you have a resident who wants to smoke, assessment and care plans should be completed addressing hazards and risk mitigation interventions. Not new. NEXT

Accidents – F323 Supervision & Resident to Resident Altercations
Assess, Care Plan, Implement, Monitor, and Evaluate Certain situations or conditions may increase the potential for altercations; A history of aggressive behaviors including striking out, verbal outbursts, or negative interactions with other resident(s). Behavior that tends to disrupt or annoy others such as constant crying, yelling, calling out for help, making negative remarks, restlessness, repetitive behaviors, taking items that do not belong to them, going into others’ rooms, drawers, or closets, and undressing in inappropriate areas. Although these behaviors may not be aggressive in nature, they may precipitate a negative response from others, resulting in verbal, physical, and/or emotional harm. Supervision & Resident to Resident Altercations – what to do? Assess, Care Plan, Implement, Monitor, and Evaluate FYI ****CMS requires that an incident involving a resident who willfully inflicts injury upon another resident, it should be reviewed as abuse under the guidance for F223. Which probably means it is a reportable. However, when there is an instance when a resident’s willful intent cannot be determined, the surveyor is directed to review the incident under the guidance of F323. The facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The facility is expected to identify factors (illness, environment etc) that increases the risks associated with individual residents that could trigger an altercation. NEXT

Accidents – F323 Supervision & Resident to Resident Altercations
Possible interventions that could address potential/actual negative interactions include; Providing safe supervised areas for unrestricted movement Eliminating or reducing underlying causes of distressed behavior such as boredom and pain Monitoring environmental influences such as temperatures, lighting and noise levels Evaluating staffing assignments to ensure consistent staff who are more familiar with the resident and who thus may be able to identify changes in a resident’s condition and behavior Evaluating staffing levels to ensure adequate supervision* Ongoing staff training and supervision, including how to approach a resident who may be agitated, combative, verbally or physically aggressive and how/when to obtain assistance in managing a resident with behavior symptoms The care planning team reviews the assessment along with the resident and/or their representative to identify interventions to try to prevent altercations. If staffing is adequate, the resident’s needs are being met. NEXT

Accidents – F323 Resident Risks and Environmental Hazards
In order to be considered hazardous, an element of the resident environment must be accessible to a vulnerable resident. Resident vulnerability is based on risk factors including the individual resident’s functional status, medical condition, cognitive abilities, mood, and health treatments such as medications. Resident vulnerability to hazards may change over time – hence, ongoing assessment helps to identify when elements pose hazards to a resident. The physical plant, devices and equipment described may not be hazards by themselves. But, they can become hazardous when a vulnerable resident interacts with them. NEXT

Accidents – F323 Environmental Hazards
Improper actions or omissions by staff can create hazards in the building/grounds, environment, and/or with devices and equipment, i.e. – Fire doors that have been propped open Disabled locks or latches Nonfunctioning alarms Buckled or badly torn carpets, cords on floors, irregular walking surfaces Improper storage and access to toxic chemicals Exposure to unsafe heating unit surfaces and/or water temperatures Furniture that is not appropriate for a resident – chairs/beds that are too low/high or unstable as to present a fall hazard Lighting that is either inadequate or so intense as to create a glare Devices such as pumps, ventilators, assistive devices may be hazardous when they are defective, disabled, or used in a manner that is not per manufacturer’s recommendations or current standards of practice* These examples of environmental hazards are not new and I would be you probably have observed many of them from time to time. Unfortunately, these problems become citable when facility complacency does not address these hazards and someone gets injured. *Such as mechanical transfer lifts including the slings and hydrocollator NEXT

Accidents – F323 Resident Vulnerabilities
Falls - contributing factors can include; Environmental hazards Underlying medical conditions Medication side effects Lower extremity weakness Balance disorders Poor grip strength Functional and cognitive impairment Visual deficits As you all know, there are a lot of factors that contribute to a resident vulnerability for an accident. Falls and unsafe wandering/elopement are of particular concern. Falls – can have psychological and social consequences, including the loss of self-confidence to try to ambulate. NEXT

Accidents – F323 Resident Vulnerabilities
Proper actions following a fall include: Ascertaining if there were injuries and providing needed treatment; Determining what may have caused or contributed to the fall; Addressing the factors for the fall; Revising the resident’s plan of care and/or facility practices as need Evaluation of the causal factors leading to a resident fall helps support relevant and consistent interventions to try to prevent future occurrences. NEXT

Accidents – F323 Unsafe Wondering or Elopement
…is random or repetitive locomotion. It may be goal-directed such as searching for something like an exit or it may be aimless. The non-goal-directed wandering requires a response in a manner that address both safety issues and an evaluation to identify root caused to the degree possible. Moving about the facility aimlessly may indicate that the resident is frustrated, anxious, bored, hungry or depressed. Wandering and Elopement – most every facility has had experience with meeting these resident’s needs. Each resident is unique as to their motivation. The facility’s challenge is identifying the resident’s triggers and then consistently implementing interventions to mitigate the risk for an altercation or elopement. NEXT

Accidents – F323 Unsafe Wondering or Elopement
Unsafe wandering may occur when the resident at risk enters and area that physically hazardous or that contains potential safety hazards such as chemical, tools, equipment or out an exit door. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of or has the potential to experience heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. Resident’s who are at risk for wandering should have interventions in their care plan to mitigate the risk. The facility’s disaster and emergency preparedness plan should include a plan to locate a missing resident. While alarms can help to monitor a resident’s activities, they do not replace necessary supervision. NEXT

Accidents – F323 Physical Plant Hazards
For a material to pose a safety hazard to a resident, it must be; Toxic, caustic, or allergenic; Accessible and available in a sufficient amount to cause harm Examples of materials that may pose a hazard to a resident could include; Chemicals used by the facility staff in the course of their duties (housekeeping) and chemicals/or materials brought into the resident environment by staff, other residents or visitors; Drugs and therapeutic agents; Plants and other “natural” materials found in the resident environment Supervision and/or containment of hazards are needed to protect residents from harm caused by environmental hazards – such as common cleaning agent, hot water or improper use of an electrical device. Know where your Material Safety Data Sheets are kept and know the poison control telephone number. NEXT

Accidents – F323 Physical Plant Hazards – Water temperature
Many residents in long-term care facilities have conditions that may put them at increased risk for burns, for example; Decreased skin thickness Decreased skin sensitivity Peripheral neuropathy Decreased agility/reaction time Decreased cognition Decreased mobility Decreased ability to communicate Many residents in long-term care facilities have conditions that may put them at increased risk for burns. Water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersions. NEXT

Accidents – F323 Water Temperature Time required for a
3rd degree burn to occur 155°F 1 sec 148°F 2 sec 140°F 5 sec 133°F 15 sec 127°F 1 min 124°F 3 min 120°F 5 min The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. ***Please note – burns can occur even at water temperatures below those identified in the table – all depends on an individual’s condition and length/degree of exposure. NEXT

Accidents – F323 Thermal burns
First-degree burns involve the top layer of skin such as a minor sunburn. These may present as red and painful to touch and the skin may show mild swelling. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless, dry and leathery skin (pain may be caused by presence of 1st & 2nd degree burns in the area surrounding the 3rd degree tissue damage). Skin may appear charred or have patches that appear white, brown or black. This slide just defines first, second, and third degree burns. Not new. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn. NEXT

Accidents – F323 Electrical Safety
Extension cords should not be used to take the place of adequate wiring in a facility. If extension cords are used, the cords should be properly secured and not be place overhead, under carpets or rugs, or anywhere that the cord can cause trips, falls, or overheat. Extension cords should be connected to only one device to prevent overloading of the circuit. The cord itself should be of a size and type for the expected electrical load and made of material that will not fray or cut easily. Electrical cords including extension cords should have proper grounding if required and should not have any grounding devices removed or not used if required. Any electrical device, whether or not it needs to be plugged into an electric outlet, can become hazardous to the residents through improper use or improper maintenance. This slide and the next one also deals with Life Safety Code. NEXT

Accidents – F323 Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips are not designed to be used with medical devices in patient care areas. Please read CMS S&C memo: LSC regarding categorical waiver for power strips use in patient care areas. Precautions needed if power strips are used include; Installing internal ground fault and over-current protection devices Preventing cords from becoming tripping hazards Using power strips that are adequate for the number and types of devices used. Electric blankets and heating pads Should not be tucked in or squeezed – constriction can cause the internal wires to break. Manufacturer’s instructions for use should be followed closely. Reference here to the Life Safety Code - CMS is permitting resident rooms in long-term care that do not use line-operated electrical appliances for diagnostic, therapeutic, or monitoring purposes are not subject to the more restrictive NFPA 99 requirements regarding the use of power strips in patient care areas/rooms. In this setting, power strips may be used in the resident rooms in accordance with the standard precautions and Underwriter Laboratory (UL) listings. However, Resident rooms using line-operated patient-care-related electrical equipment in the patient care vicinity must comply with the NFPA 99 power strip requirement and may elect to utilize a categorical waiver. “General care area — Patient bedrooms, examining rooms, treatment rooms, clinics, and similar areas in which it is intended that the patient will come in contact with ordinary appliances, such as a nurse-call system, electric beds, examining lamps, telephones, and entertainment devices.” “Critical care area — Those special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient care-related electrical appliances.” If it's intended that patients will, at some point, be subjected to invasive procedures and connected to line-operated, patient care-related electrical appliances (thus meeting the definition of critical care area), the area or room must be wired not only to meet requirements of a general care area, but also to some additional electrical requirements as listed for critical care areas. It's also important to note that these terms are facility independent Power strips may be used for a computer, monitor, and printer. Use of these items need monitoring – injury burns have been attributed to prolonged use (resident falling asleep) or inappropriate temperature setting and, deaths have been attributed to fires. NEXT

Accidents – F323 Assistive Devices/Equipment Hazards
Training of staff, residents, family members and volunteers on the proper use of assistive devices/equipment is crucial to prevent accident. Communicate clearly the approaches identified in the care plan to all staff, including temporary staff. NOTE – The Safe Medical Devices Act of 1990 (SMDA) requires nursing home to report deaths, serious illness, and injuries associated with the use of medical devices to manufacturers and the Food and Drug Administration. Assistive devices and equipment can help residents move with increased independence, transfer with greater comfort and feel physically more secure. Which is all good . But, they don’t come without some risks. So, risks associated with the use of devices/equipment need to be balance with the benefits gain from their use. Training of staff, residents, and family member on the use of an assistive device is crucial to prevent an accident as well as very clear documentation of the approaches/intervention in the resident’s plan of care. A reminder - The Safe Medical Devices Act of 1990 (SMDA) requires nursing home to report deaths, serious illness, and injuries associated with the use of medical devices to manufacturers and the Food and Drug Administration. NEXT

Accidents – F323 Mobility devices include items such as canes, standard and rolling walkers, manual and powered wheelchairs. Factors that may be associated with an increased accident risk related to mobility devices include; Resident condition Personal fit and device condition Staff practices Mechanical assistive devices for transferring a resident include items such as total body lifts, sit-to-stand devices and transfer/gait belts. Factors that may influence a resident’s risk of an accident during a transfer may include; Staff availability Resident abilities Staff training Mobility devices include items such as canes, standard and rolling walkers, manual and powered wheelchairs. Factors that may be associated with an increased accident risk related to mobility devices include; Resident condition - Lower extremity weakness, gait disturbances, decreased range of motion, or poor balance. These deficits combined with a cognitive or behavior impairment increases the risk for a fall Personal fit and device condition - The personal fit or how well the assistive devices meets the resident’s needs may influence the likelihood of an avoidable accident. Staff practices - Walkers/wheelchairs left out of reach of a resident (but within eyesight) who needs transfer assistance may create a hazardous situation – need to know the residents. NEXT

Accidents – F323 Devices with Entrapment Risks
Residents most at risk for entrapment may include – those who are frail or elderly and/or; those who have conditions such as Agitation Delirium Confusion Pain Uncontrolled body movement Hypoxia Fecal impaction Acute urinary retention Devices can be therapeutic and beneficial – however, they are not necessarily risk free. So, the relative risks must be weighed against the expected benefits. Basically – conditions/situations that may cause the resident to move about the bed or try to exit from the bed, so the timeliness of toileting, appropriateness of positioning, and other care-related activities can contribute to the risk of entrapment. NEXT

Accidents – F323 Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Resident beds must have proper fitting mattresses and when side rails are applied, they need also to be sturdy without wide spaces between the bars. The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that is different from rail entrapment with a regular mattress. Precautions may include following manufacturer equipment alerts and increasing supervision. What is entrapment? When does it look like? Entrapment occurs when a resident is caught between the mattress and bed rail or in the bed rail itself. Resident beds must have proper fitting mattresses and when side rails are applied, they need also to be sturdy without wide spaces between the bars. The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that is different from rail entrapment with a regular mattress. Precautions may include following manufacturer equipment alerts and increasing supervision. NEXT

Accidents– F323 Surveyor Investigative Protocol
Expect the SA to use this protocol when; A sampled resident is at risk for (or who has a history of) accidents, falls, or unsafe wandering/elopement A sampled resident is a risk to create a risk to others When hazards/risks have been identified Expect the SA to use this protocol when: A sampled resident is at risk for (or who has a history of) accidents, falls, or unsafe wandering/elopement – to determine if the facility provided care and services – including assistive devices as necessary, to prevent an avoidable accident and to reduce the resident’s risk A sampled resident is a risk to create a risk to others - to determine if the facility has provided adequate supervision When hazards/risks have been identified - to determine if there are facility practices in place to identify, evaluate and analyze hazards/risks, implement interventions, and monitor the effectiveness. If, during initial tour and throughout the survey week, surveyors identify care delivery hazards or potential hazards, or history of resident accident, expect the survey team to investigate the facility’s systems for identifying, evaluating and preventing avoidable accidents or hazards. They will review resident records, facility policies/procedures, staffing levels, staff training, equipment manufacturer’s information as well interview residents, families, staff, management etc. NEXT

Accidents– F323 The survey team is expected to make observations for and investigate potential hazards. This includes: Accessibility of chemicals, toxics or other hazards such as housekeeping chemicals/supplies, medications, sharp utensils, and smoking materials; Environmental conditions such as unstable or slippery floor surfaces, loose hand rails, excessive water temperatures, electrical hazards, insufficient or excessive light, arrangement of living spaces, obstacles in corridors, unsupervised access into or egress out of the facility, low or loose toile seats, defective or nonfunctioning beds; Staff responses to verbal calls for help and alarms and response to potential/actual hazards such as cleaning of spilled liquids in a resident care area Assistive devices (mechanical lifts etc.) that are defective or not used properly (according to manufacturer’s specifications For sampled residents identified as a safety risk hazard, expect the SA to make observations for and investigate potential hazards - all the physical plant hazards previously identified. NEXT

Accidents– F323 The survey team is expected to conduct interviews to determine the relationship between the resident’s risk and hazards. Resident, family and/or responsible party; To identify if they had reported or help identify the resident’s risk for an accident or hazard How and when staff responded to a hazard once it was identified Staff; To determine if they were aware of planned interventions to reduce a resident’s risk for an avoidable accident If they reported potential resident risks or environmental hazards to the supervisor according the facility policy If they are aware of and follow facility procedures correctly to remove or reduce hazards. They will interview your staff, residents and family members to determine if pertinent risk hazards have been identified and addressed. Actual Example - ***resident who ate very very quickly – CNA’s reported the resident stuffed food in mouth, often times seen coughing/choking. No swallowing assessment completed, no care plan review discussion or revision. Resident self fed a peanut butter sandwich – found slumped over, hemlich performed – expelled food bolus, resident did not respond – expired. Resident with cognitive impairment – known to not wait for assistance to ambulate to toilet in room. Housekeeper washed floor while resident in bathroom – no sign or safety precaution provided. Resident came out of bathroom, slipped, fell, broke hip. Had surgery, returned to facility. Care plan revised to include use of walker and one person assist. Facility self identified – revised housekeeping protocol. Abbreviated survey conducted – at the time of the survey, housekeeper seen washing the floor, did not provide sign or additional safety/supervision precautions. IJ called. NEXT

Accidents– F323 The survey team is expected to conduct record review of the resident assessment instrument * to determine if the facility identified a risk(s), evaluated/analyzed the risk(s), implement interventions to try to prevent accidents and monitor/modify interventions as needed. Risk factors such as; Unsafe wandering, elopement, ingesting nonfood items, altercations Hearing, visual, and sensory impairments Impaired physical functioning, balance or gait problems Diagnoses/conditions that could relate to safety awareness or safety practices such as dementia, Parkinson’s, seizure disorder, vertigo, postural hypotension Use of physical restraints and/or other devices that might limit movement Medications such as antidepressants, anticholinergics, diuretics, psychotropics History of falls They will review the RAI *and other documents such as progress notes, physician orders, and nurses/consultant notes regarding the assessment of risk factors. NEXT

Accidents– F323 Surveyor Investigative Protocol
The survey team is expected to conduct record review of the resident’s plan of care to determine if the facility developed interventions based on the risks and if the plan was modified as needed based on the response, outcomes, and needs of the resident. If it is found that a resident has had an accident, the surveyor is expected to determine if the accident is the result of; An order not being followed; and/or A care need was not being addressed; and/or A plan of care not being implemented They will review the resident’s plan of care to determine if the facility developed interventions based on the risks and if the plan was modified as needed based on the response, outcomes, and needs of the resident. If it is found that a resident has had an accident, the surveyor is expected to determine if the accident is the result of; An order not being followed (possible F281 tag); and/or A care need was not being addressed (possible F272 and/or F279); and/or A plan of care not being implemented (possible F281 or F282) In addition to F323. Yikes!

Accidents – F323 Criteria for Compliance
For the resident who has had an accident or was assessed at risk for an avoidable accident, the facility is in compliance if staff have: Identified the hazards and risks based on the facility’s assessment of both the resident and the environment (including need for supervision and/or assistive devices); Evaluated/analyzed the hazards/risks; Implemented interventions consistent with resident’s needs and current standards of practice; Provided assistive devices consistent with the resident’s assessed needs Properly deployed and maintained resident specific equipment – lifts, canes, wheelchairs etc. Provided a safe environment such as monitoring for chemicals, wet floors, and trip hazards Operated equipment in accordance with manufacturers recommendations Provided and maintain a secure environment to prevent negative outcomes for residents who exhibit unsafe wandering Monitored the effectiveness of the interventions and modified the interventions as necessary, in accordance with current standards of practice. To recap, F323 has three aspects. 1. Resident’s environment remains as free of accident hazards as possible. 2. The facility provides adequate supervision. 3. The facility provides assistive devices to prevent accidents. NEXT

Accidents - F323 Deficiency Categorization
Severity Level 2 - indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his or her highest practicable level of well being. The potential exists for greater harm to occur if interventions are not provided. Bruising, minor skin abrasions, and rashes; Pain that does not impair normal activities; 1st degree burn; Medical evaluation or consultation may or may not have been necessary, and tx such as first aid may been required; Fall(s) which resulted in no more than minimal harm because the facility had additional established measure(s) that limited the injury or potential for injury; Unsafe wandering and/or elopement which resulted in no more than minimal harm because of established measures that limited the resident’s exposure to hazards, i.e.-resident with Alzheimer’s left locked unit but found quickly unharmed on another unit. Once the survey team has completed its investigation, analyzed the date, reviewed the regulatory requirements, and determined that noncompliance exists, the team must determine the severity of the deficiency, based on the resultant effect or potential for harm to the resident(s). First, the team must rule out whether Severity level 4 – IJ to a resident’s health or safety, exists by evaluating the deficient practice in relations to immediacy, culpability and severity. The failure of the facility to provide a safe environment and adequate supervision place residents at risk for more than minimal harm. Therefore, severity level 1 does not apply for this regulatory requirement. Severity level 2 indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach their highest practicable level of well being. NEXT

Severity Level 3 - indicates noncompliance that results in actual harm and can include but may not be limited to clinical compromise, decline, or the resident’s ability to maintain and/or reach their highest practicable well-being. Examples of compromise include: Short-term disability; Pain that interfered with normal activities; 2nd degree burn; Fracture or other injury that may require surgical intervention and does not result in significant decline in mental and/or physical functioning; Medical evaluation was necessary, and tx beyond first aid was required; Fall(s) that resulted in actual harm such as short-term disability, pain that interfered with normal activities, fx or other injury that may require surgical intervention and does not result in significant decline in mental and/or physical functioning and the facility had established measure or practices to limit the resulting impact; Unsafe wandering and/or elopement that resulted in actual harm and the facility had established measure or practices to limit the resulting impact. Severity level 3 is an outcome of actual harm. Please note the examples of compromise.

Severity Level 4 – immediate jeopardy condition; examples of negative outcomes that occurred or have the potential to occur as a result might include: Esophageal damage due to ingestion of corrosive substances; Loss of consciousness related to head injuries; 3rd degree burn, or a 2nd degree burn covering a large surface area; Fracture or other injury that may require surgical intervention and results in significant decline in mental and/or physical functioning; Electric shock due to use of unsafe or improperly maintained equipment; Entrapment Fall(s) with fracture or other injury that may require surgical intervention and/or significant decline in functioning and the facility had no established measure(s) or practice(s) or ineffective measure(s) that would have prevented the fall or limited the resident’s injury Unsafe wandering and/or elopement – resident leaves facility or locked unit unnoticed and sustained or had potential to sustain serious injury, impairment, harm or death and the facility had no established (or ineffective) measure(s) or practices(s), that would have prevented or limited the resident’s exposure to hazards Again, level 4 is IJ – do not have to have actual harm, but the SA must demonstrate there was potential to result in serious injury, impairment, harm or death. The systematic failures includes culpability and immediacy. ****resulted in or had the potential to result in serious injury, impairment, harm or death NEXT

Accidents – F323 Summary Statement of Deficiency
….Resident #XXX was observed sleeping in a low bed with a bed alarm in place. The ADON stated, “Resident #XXX has a history of falls and fracture of the nose….The resident’s minimum data set…dated 5/13/14 revealed that the resident’s cognition was severely impaired and required extensive assistance for most activities of daily living…the MDS noted that the resident had a history of falls and balance was unsteady, only able to stabilize with human assistance moving from seated to standing position and surface to surface transfers…Review of unplanned occurrence report dated 7/xx/13…revealed “resident calling for help. Observed resident lying on the floor near the foot of her bed…states she wanted to go to bed…The interdisciplinary post fall summary revealed…does not use call light, does not always ask for assist or wait for assistance. Staff heard alarm sounding and resident calling for help. Intervention: Recommend asking resident after dinner when she would like to go to bed to meet her bedtime preference and continue with alarms….Review of unplanned occurrence report dated 9/xx/13…resident yelling for help, alarm sounding, observed resident on floor…Preventative measures and/or corrective action: Resident to be put in carefoam chair for a nap after lunch, resident to stay in hallway… DPS – Based on observation, interview and record review, the facility failed to consistently implement and/or document interventions and provide close supervision for the prevention of multiple falls….resulting in a hematoma, fracture and pain.

…review of unplanned occurrence report dated 10/xx/13…revealed resident fell forward out of wheelchair as a staff member began to move her chair through the dining room doorway…preventative measures …assist to and from dining room. Assure resident sitting safely in wheelchair when assisting from the dining room….IDT met and concurred that not only does resident need assist in and out of dining room but assure she is sitting safely in wheelchair when assisting her. The ADON was queried as to what took place as stated, “they (staff) were assisting her out of the dining room. She went forward in her chair. Sometimes she scoots up and tries to stand”. When queried as to if staff was educated on ensuring the resident is sitting properly in chair before attempting to assist resident from the dining room, the ADON stated, “No, we didn’t feel that the staff did anything wrong. They were to assist her.”

…Review of unplanned occurrence report date 1/xx/14…revealed that resident was observed sitting on the floor mat on side of her bed. The post fall intervention was for the resident to be “up in carefoam chair. Naps to be in carefoam chair in hallway for monitoring.” The ADON was queried as to why resident was not in a carefoam chair for her after lunch nap at the time of the fall, and she stated, “That’s a problem. That was a previous intervention. I am not sure why it was not implemented….Review of unplanned occurrence report dated 2/xx/14 revealed resident found sitting on floor bedside bed. Preventative measures and/or corrective actions taken: when alarm sounds and resident at side of bed, get resident up in chair…Review of unplanned occurrence report dated 4/xx/14 revealed bed alarm sounding…resident sitting on the floor…Stated “I don’t know what happened. I was turning, turning, turning…” Preventative measures taken: ordered a winged mattress.

…Review of unplanned occurrence report dated 4/xx/14 revealed “called to dining room by activities aide. Resident observed on floor face down with chair alarm sounding…”during activities, writer called down…observed resident lying on right side face down on floor with blood coming out and from her nose…pain verbalized from resident on right lower extremity…resident has fractured nose from fall…conclusion from investigation:…fall happened after group activities was over. Activity assistant in dining room-not close enough to prevent fall….staff interview revealed “…didn’t see fall. I heard the fall. I was talking to (another resident and resident husband) and I heard the thump. Did you hear the alarm sounding? After I heard the thump…”…On 5/xx/14..the ADON stated, “there was no CNA education for the fall…(when staff assisted the resident out of the dining room). We felt there was no need for education…there is no documentation as to whether the bed was in low position or the mat in place for the incident on 2/xx/14 and no documentation as to why the resident had not been in the carefoam chair as ordered (incident on 1/xx/14)….” What to say about this? The facility failed to demonstrate the interventions which they identified to reduce the risk of an accident for this resident was consistently implemented. Was adequate supervision/monitoring of this resident’s plan of care done? *When a facility implements accident prevention measures for a resident and has reason to know that those measures are substantially ineffective in reducing the risk of accidents, the facility must act to determine the reasons for the ineffectiveness and to consider/implement more effective measures. This regulation gets at the expectation to use reason and professional judgment in assessing what can be done to make residents safe. What are the relevant standards of care missing here? Communicating the interventions to all relevant staff. Assigning responsibility. Providing training as needed. Developing or revising policies/procedures. Documenting interventions. Ensuring the interventions are put into place. The facility’s report does not show that an evaluation/analysis of data was done adequately to identify specific hazards and risks and then, to develop targeted interventions to reduce the potential for accidents. NEXT

Let’s take a pause here for any questions or comments regarding the
Accident tag – F323 Please type in any question or comment regarding this regulation. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. NEXT

Sanitary Conditions - F371 483
Sanitary Conditions - F (i)(1)(2) The facility must procure food from sources approved or considered satisfactory by Federal, State or local authorities and store, prepare, distribute and serve food under sanitary conditions Nursing home residents risk serious complications from food-borne illness as a result of their compromised health status. Among the 433 nursing homes in Michigan, this requirement was not met in 38% of the facilities surveyed during this fiscal year as of September 2014. This regulation ranked 3rd in citation frequency in Michigan and 2nd across the Nation. There were no citations that rose to the harm or IJ severity level. Across the nation (15,648 nursing homes), 35% of them were out of compliance and were cited for F371 during the same time period. The intent of this requirement is to ensure that the facility obtains food for resident consumption from sources approved or considered satisfactory by Federal, State, or local authorities and the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling begins when food is received and continues throughout the facility’s food handling process. Words highlighted in RED indicates a change in the interpretative guideline and/or surveyor protocol. NEXT

Sanitary Conditions - F371
CMS recognizes the U.S. Food and Drug Administration’s (FDA) Food Code and the Centers for Disease Control and Prevention’s (CDC) food safety guidance as national standards to procure, store, prepare, distribute and serve food in long term care facilities in a safe and sanitary manner. May access the Michigan modified 2009 food code via the website listed May access the FDA 2013 food code via the website listed

Sanitary Conditions – F371
Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in food service establishments as contributing to food-borne illness: Improper holding temperatures Inadequate cooking, such as undercooking raw shell eggs Contaminated equipment Food from unsafe sources, and Poor personal hygiene Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in food service establishments as contributing to food-borne illness: Improper holding temperatures Inadequate cooking, such as undercooking raw shell eggs Contaminated equipment Food from unsafe sources, and Poor personal hygiene NEXT

Types of Food Contamination Biological – pathogenic bacteria, viruses, toxins, and spores Chemical – glass and oven cleaners, soaps, and insecticides. Physical – foreign objects (staples, fingernails, jewelry, hair, glass, metal shavings from can openers, or pieces of bones) that may inadvertently enter the food. Most common types of disease producing organisms are bacteria and viruses. Not all bacteria in food cause illness in human such as live cultures of Lactobacillus that is added to yogurt to enhance digestion. If a spray cleaner is used on a worktable surface while food is being prepared, it becomes exposed to a chemical. NEXT

Sanitary Conditions – F371 Factors which may influence bacteria growth
Certain foods are considered more hazardous than other and are called “potentially hazardous foods (PHF) or Time/Temperature Controlled for Safety (TCS)” food (i.e. ground beef, poultry, chicken, seafood, cut melon, unpasteurized eggs, milk, yogurt and cottage cheese) Time in conjunction with temperature controls of the food is critical. The longer food remains in the danger zone, the greater the risks for growth of harmful pathogens. Bacteria multiply rapidly in a moist environment in the danger zone. Freezing does not kill bacteria. Rapid death of most bacteria occurs at 165 degrees Fahrenheit (F) or above. Factors influencing the growth of bacteria include the acidity (pH <5) of the food (acidic foods like pineapple or vinegar inhibit growth) and the percentage of water in the food (fruits and vegetables) tend to encourage bacterial growth. Recent revision to interpretative guideline allows use of raw or unpasteurized eggs as long as they are cooked until all parts of the egg are completely firm and be eaten promptly after cooking. Waivers to allow undercooked unpasteurized eggs for resident preference are not acceptable. Pasteurized shell eggs are available and allow for safe consumption of undercooked eggs. NEXT

Sanitary Conditions - F371 Other risk factors contributing of foodborne illness
Poor personal hygiene – employee health and hygiene are significant factors in preventing foodborne illness (e.g. – Norovirus) Proper hand washing techniques and exclusion of infectious workers from handling food are critical in prevention Bare hand contact with foods is prohibited. Staff should have access to proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can contribute to cross-contamination. Dietary staff must wear hear restraints – hairnet, hat, and/or beard restraint. Nails are to be kept clean and neat Other risk factors contributing of a foodborne illness include “Infectious” individuals (persons capable of transmitting an infection or communicable disease whether they be colonized or infected) are a source of Norovirus. Education, training and monitoring of all staff & volunteers involved in food service as well as establishing effective infection control and quality assurance programs help maintain safe food handling practices. Antimicrobial gel cannot be used in place of proper hand washing techniques in a food service setting. Disposable gloves are a single use item and should be discarded after each use. NEXT

Food from unsafe sources – those that are not approved or considered satisfactory by Federal, State, and local authorities. Nursing homes are not permitted to use home-prepared or home-preserved (canned or pickled) foods for service to residents. All residents have the right to accept food brought by any visitor for any resident. Dry food storage – the focus of protection is to keep the items free from contaminants. Recommended that foods stored in bins (i.e. four or sugar) be removed from their original packaging. Keep food off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes. When food is brought into the nursing home, inspection for safe transport and quality upon receipt and proper storage helps ensure its safety. Keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer is indicated. Desirable practices include managing the receipt and storage of dry food, removing foods not safe for consumption, keeping dry food products in closed containers and rotating supplies. NEXT

Sanitary Conditions – F371
Refrigerated storage – PHF/TCS foods must be maintained at or below 41 degrees F (unless otherwise specified by law). Prudent practices include: Monitoring food temps and functioning of the refrigeration equip. daily and at routine intervals during all hours of operation Placing hot food in containers (i.e. shallow pans) that permit food to cool rapidly Separating raw animal foods (i.e. beef, fish, lamb, pork, poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by day, or frozen (where applicable) or discarded. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microorganisms. Frozen foods must be maintained at a temp to keep the food frozen solid Inadequate temperature control during refrigeration can promote bacterial growth. Adequate circulation of air around refrigerated products is essential to maintain appropriate food temperatures. Foods in a walk-in unit should be stored off the floor. NEXT

Sanitary Conditions – F371 Safe food preparation can reduce the risk of a foodborne illness
Cross-contamination can occur when harmful substance or disease-causing microbes are transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not cleaned after touching raw food and then touch ready-to-eat goods. Additional ways to help prevent cross-contamination include: Between uses, store towels/cloths used for wiping surfaces during the kitchen’s daily operation in containers filled with sanitizing solution at the appropriate concentration per the manufacturer’s specifications. Wash and sanitize cutting boards made of acceptable materials (e.g. hardwood, acrylic) and food processors, blenders, preparation tables, knife blades, can openers and slicers between uses. The identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. Periodically testing the sanitizing solution helps assure that it maintains the correct concentration. NEXT

Thawing frozen foods is often the first step in food prep.
Sanitary Conditions – F371 Thawing foods properly can reduce the risk of a foodborne illness Thawing frozen foods is often the first step in food prep. Recommended methods to safely thaw frozen foods include: In a refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination. (anybody remember what that looks like?) Completely submerging the item under cold water, at a temp of 70 degrees F or below, and the water is running fast enough to agitate and float off loose ice particles. Using microwave to thaw the item then cooking and serving immediately. Thawing as part of a continuous cooking process. Thawing food at room temp is NOT acceptable because the food is within the danger zone for rapid bacterial proliferation. NEXT

Sanitary Conditions – F371 Final Cooking Temperatures can reduce the risk of a foodborne illness
Foods should reach the following internal temperatures: Poultry and stuffed foods – 165 degrees (°) Fahrenheit (F) Ground meet (beef, pork), ground fish and eggs held for service – 155 ° F Fish and other meats – 145 ° F Unpasteurized eggs when cooked to order in response to resident request and to be eaten promptly after cooking must be cooked until all parts of the egg are completely firm. When cooking raw animal foods in the microwave, foods should be rotated and stirred during the cooking process so that all parts of the food are heated to a temp of at least 165 ° F and allowed to stand covered for at least 2 minutes after cooking to obtain temp equilibrium. Fresh, frozen or canned fruits/vegetables – 135 ° F. Cooking is a critical control point in preventing foodborne illness. Cooking to heat all parts of food to a specified temperature and time will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking. A revision to the interpretative guidelines is - unpasteurized eggs. When cooked to order in response to resident request and to be eaten promptly after cooking, they must be cooked until all parts of the egg are completely firm. Monitoring the food’s internal temp for 15 seconds determines when microorganisms can no longer survive and food is safe for consumption. NEXT

Sanitary Conditions - F371 Reheating foods properly can reduce the risk of a foodborne illness
The PHF/TCS food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 ° F for at least 15 seconds before holding for hot service. Ready-to-eat foods that require heating before consumption are best taken directly from a sealed container (secured against the entry of micro’s) or an intact package from an approved food processing source and heated to at least 135 ° F for holding for hot service. Note – using the steam table to reheat food is unacceptable since it does not bring the food to the proper temperature within acceptable timeframes. Reheated cooked foods present a risk because they have passed through the danger zone multiple times during cooking, cooling, and reheating. PHF (Potentially Hazardous Food) / TCS (Time/temperature controlled for safety) Although proper reheating will kill most organisms of concern, some toxins, such as that produced by Staphylococcus aureus, cannot be inactivated by reheating food. NEXT

Sanitary Conditions – F371 Cooling foods properly can reduce the risk of a foodborne illness
Foods that have been cooked and held at improper temperatures promote the growth of disease-causing microorganisms that may have survived the cooking process (i.e. – spore-formers) Cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 to 70 ° F, and within 4 more hours to the temp of approx. 41° F. The total time for cooling from 135 to 41 ° F should not exceed 6 hours. Improper cooling is a major factor in causing foodborne illness. Large or dense food items such as roasts, turkeys, soups, stews, legumes, and chili may require interventions such as placing foods in shallow pans, cutting roasts into smaller portions, utilizing ice water baths, and stirring periodically in order to be chilled safely within an allowed time period. NEXT

Sanitary Conditions - F371 Foods with “modified consistently” can increase the risk of a foodborne illness When pureed, ground, or diced food drop into the danger zone (below 135° F), the mechanically altered food must be reheated to 165° F for 15 seconds. Foods with “modified consistently” can increase the risk of a foodborne illness The risk stems from the increased number of food handling steps required when preparing pureed or other modified consistency foods. NEXT

Sanitary Conditions - F371 Pooled Eggs can increase the risk of a foodborne illness
The facility should crack only enough eggs for immediate service in response to a resident’s request or as an ingredient immediately before baking. Salmonella infections associated with unpasteurized eggs cans be prevented by using pasteurized shell eggs or be substituted for raw eggs in the preparation of foods that will not be thoroughly cooked (i.e. Caesar dressing, Hollandaise sauces, egg fortified beverages, ice cream and French toast) Waivers to allow undercooked unpasteurized eggs for resident preference are not acceptable. Pasteurized shell eggs are available and allow for safe consumption of undercooked eggs. Pooled eggs are raw eggs that have been cracked and combined together. Raw eggs with damaged shells are also unsafe because of the potential for contamination. Revision to the interpretative guideline for F371 addresses Salmonella infections. Salmonella infections associated with unpasteurized eggs cans be prevented by using pasteurized shell eggs or be substituted for raw eggs in the preparation of foods that will not be thoroughly cooked (i.e. Caesar dressing, Hollandaise sauces, egg fortified beverages, ice cream and French toast) NEXT

Sanitary Conditions – F371 Food Service and Distribution also is a factor in the development of a foodborne illness Food safety requires consistent temperature control from the tray line to transport and distribution to prevent contamination (i.e. – covering food items). The length of time needed to transport trays is more critical when the food is simply covered and transported in open or closed carts without a heated or cooled environment. The maximum length of time that foods can be held on a steam table is a total of 4 hours. Monitoring of the temperature by food service workers while food is on the steam table is essential. Foods may be reheated (only once) to 165 ° F. Reheated foods are best discarded if not eaten within two hours after reheating. Various systems are available for serving and distributing food items to residents – tray lines, portable steam tables, open shelved food transport carts with covered trays etc. Some systems incorporate a heating element (pellet) under each plate of hot food. Food safety requires consistent temperature control from the tray line to transport and distribution to prevent contamination (i.e. – covering food items). The length of time needed to transport trays is more critical when the food is simply covered and transported in open or closed carts without a heated or cooled environment. The maximum length of time that foods can be held on a steam table is a total of 4 hours. Monitoring of the temperature by food service workers while food is on the steam table is essential. Foods may be reheated (only once) to 165 ° F. Reheated foods are best discarded if not eaten within two hours after reheating. NEXT

Sanitary Conditions – F371 Food Service and Distribution also is a factor in the development of a foodborne illness Potential food handling problems/risks associated with food distribution include: Staff distributing trays without first properly washing their hands. Serving food to residents after collecting soiled plates and food waste, without proper hand washing. Food / Snacks left on trays or countertops beyond safe time and/or temperature requirements Food / Snacks left in refrigerators beyond safe “use by” dates – including foods that been opened but were not labeled Food / Snacks stored in open containers, without covers which allow for potential cross-contamination Foods not maintained at safe temperature levels in refrigerators. There are soooo many factors/opportunities to be cited with F371. The Surveyors will be watching for the breech of safe food handling practices. Frequently observed unaceptable practices include: Staff distributing trays without first properly washing their hands. Serving food to residents after collecting soiled plates and food waste, without proper hand washing. Food / Snacks left on trays or countertops beyond safe time and/or temperature requirements Food / Snacks left in refrigerators beyond safe “use by” dates – including foods that been opened but were not labeled Food / Snacks stored in open containers, without covers which allow for potential cross-contamination Foods not maintained at safe temperature levels in refrigerators. Dining locations include any area where one or more residents eat their meals – can be located adjacent to the kitchen or some ways away such as Resident’s rooms. Facility-sponsored special events such as cookouts and picnics where food may not be prepared in the facility’s kitchen and is served outdoors require the SAME food safety considerations. NEXT

Sanitary Conditions – F371 Potential food handling problems/risks associated with food distribution - continued Nursing homes with gardens are compliant with the food procurement requirements as long as the facility has and follows policies and procedures for maintaining the gardens. If residents take prepared foods with them out of the facility (i.e. – bag lunches for resident attending dialysis, clinics, or day treatment programs etc.), the foods must be handled and prepared for them with the same safe and sanitary approached used during primary food prep in the facility. Contamination risks associated with ice and water handling practices include staff who use poor hygiene, fail to wash hands adequately, or handle ice with their bare hands and failure to keep ice machines drained, cleaned and sanitized as needed/according to manufacturer’s specifications. Revised interpretative guidelines addresses Nursing home with gardens. They are compliant with food procurement requirements as long as the facility has and follows policies and procedures for maintaining the gardens. Note – the facility should immediately report any outbreaks of food borne illnesses, for any cause, to their local health department. NEXT

Sanitary Conditions – F371 Equipment and Utensil cleaning factors in the development of a foodborne illness Machine Washing and Sanitizing High Temp Dishwashing (heat sanitization) Wash: 150 – 165 ° F Final rinse: 180 ° F; or 165 ° F for a stationary rack, single temperature machine Low Temp Dishwashing (chemical sanitization) Wash: 120 ° F Final rinse: 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of contaminated equipment. Specific water temperatures must be obtained depending on if heat or chemical sanitization method is used. Protecting equipment from contamination via splash, dust, grease etc is indicated. NEXT

Sanitary Conditions – F371 Equipment and Utensil cleaning factors in the development of a foodborne illness Manual washing and Sanitizing First step – through washing using hot water and detergent after food particles have been scraped. Second step – rinsing with hot water to remove all soap residues. Third step – sanitizing with either hot water or a chemical solution maintained at the correct concentration, based on periodic testing, and for the effective contact time according to manufacturer’s guidelines. Hot water - at least 171 ° F for 30 seconds, or Chlorine – ppm minimum with 10 second contact time Iodine – 12.5 ppm minimum with 30 second contact time QAC space (Quaternary) – ppm concentration and contact time per manufacturer’s instructions. A 3-step process is used to manually wash, rinse, and sanitize dishware correctly. PPM = parts per million Be aware – a high concentration of sanitation solutions may be potentially hazardous – follow manufacturer’s instructions and use of improper test strips will yield inaccurate results when testing for chemical sanitation. NEXT

Cleaning Fixed Equipment
Sanitary Conditions – F371 Equipment and Utensil cleaning factors in the development of a foodborne illness Cleaning Fixed Equipment When cleaning equipment that cannot readily be immersed in water such as mixers and slicers, the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution at the correct concentration. Service area wiping cloths are cleaned and dried, or placed in a chemical sanitizing solution of appropriate concentration. The removable parts of fixed equipment are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution at the correct concentration. And don’t forget the service area wiping cloths. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. Service area wiping cloths are cleaned and dried, or placed in a chemical sanitizing solution of appropriate concentration. NEXT

Sanitary Conditions - F371 Surveyor Investigative Protocol
Observations Food procurement procedures Food preparation procedures Service of food during and after meal times Storage of food Surveyors are directed to adhere to proper hand washing when they enter the kitchen and between tasks and to use hair restraints when assessing the kitchen and meal service. Expect surveyors to be watching the kitchen and food service areas, review your planned menus to determine when to assess your food preparation processes. Expect surveyors to watch the kitchen/food services during times when food is stored, prepared, cooked, plated, transported and distributed to determine if safe food handling practices are being followed. They are directed to corroborate what was seen with interviews of staff and review of documents. NEXT

Interview(s) of: Staff who performs the task about the procedures they follow to procure, store, prepare, distribute, and serve food Dietary supervisor or dietician concerning: Practice for dealing with employees who come to work coughing, sneezing, diarrhea, vomiting or with open wounds. How the facility identifies problems with time & temperature control of PHF/TCS foods and what are the processes to address those problems. Whether the facility and follows a cleaning schedule for the kitchen and food service equipment. If there is a problem with equipment, how staff informs maintenance and follows up to see if the problem is corrected Is the facility aware of current CDC and FDA nursing home egg handling and preparation policies and does the facility have written egg storage and preparation policies that honor resident preferences safely. Surveyors are directed to corroborate what was seen with interviews of staff and review of documents. Interview with the Dietary Manager or Dietician may include questions such as: Practice for dealing with employees who come to work coughing, sneezing, diarrhea, vomiting or with open wounds. How the facility identifies problems with time & temperature control of PHF/TCS foods and what are the processes to address those problems. Whether the facility and follows a cleaning schedule for the kitchen and food service equipment. If there is a problem with equipment, how staff informs maintenance and follows up to see if the problem is corrected Is the facility aware of current CDC and FDA nursing home egg handling and preparation policies and does the facility have written egg storage and preparation policies that honor resident preferences safely - new interpretative guidance. NEXT

Review of records: Any facility documentation such as P&P’s related to compliance with food sanitation and safety. Determine if the food service employees have received relevant training Food temperature records from tray line, refrigerator/freezer dishwasher temp records Maintenance records such as work orders and manufacturer’s specifications Facility infection control surveillance records for foodborne illness and actions related to suspected or confirmed outbreaks of GI illnesses. The policies and procedures for maintaining nursing home gardens Record review could include: Facility documentation such as P&P’s related to compliance with food sanitation and safety. Determine if the food service employees have received relevant training Food temperature records from tray line, refrigerator/freezer dishwasher temp records Maintenance records such as work orders and manufacturer’s specifications Facility infection control surveillance records for foodborne illness and actions related to suspected or confirmed outbreaks of GI illnesses. The policies and procedures for maintaining nursing home gardens NEXT

Sanitary Conditions - F371 Criteria for Compliance
This is determined if staff; Procures, stores, handles, prepares, distributes, and serve food to minimize the risk of foodborne illness. Maintains PHF/TCS foods at safe temperatures, cools food rapidly, and prevents contamination during storage. Cooks food to the appropriate temperature and holds PHF/TCS at or below 41 °F (for cold foods) or at or above 135 °F (for hot foods). Utilizes proper hand washing and personal hygiene practices to prevent food contamination; and Maintains equipment and food contact surfaces to prevent food contamination. To recap, the surveyor will review the facility practices which includes Policy and Procedures for sufficient staffing, staff training, and following manufacturer’s recommendations. There should be no citation at F371 when your facility can demonstrate that it: Procures, stores, handles, prepares, distributes, and serve food to minimize the risk of foodborne illness. Maintains PHF/TCS foods at safe temperatures, cools food rapidly, and prevents contamination during storage. Cooks food to the appropriate temperature and holds PHF/TCS at or below 41 °F (for cold foods) or at or above 135 °F (for hot foods). Utilizes proper hand washing and personal hygiene practices to prevent food contamination; and Maintains equipment and food contact surfaces to prevent food contamination. NEXT

Sanitary Conditions - F371 Deficiency Categorization
Severity Level 2 - indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his or her highest practicable level of well being. The potential exists for greater harm to occur if interventions are not provided. Food service workers sliced roast port on the meat slicer. The meat slicer was not washed, rinsed, and sanitized after usage. The facility failed to educate and train staff on how to clean and sanitize all kitchen equipment. During the initial tour of the kitchen, two food service workers were observed on the loading dock. One was smoking and the other was emptying trash. Upon returning to the kitchen, they proceeded to prepare food without washing their hands. Once the survey team has completed its investigation, analyzed the data, reviewed the regulatory requirements, and determined that noncompliance exists, the team must determine the severity of the deficiency, based on the resultant effect or potential for harm to the resident(s). ****The failure of the facility to procure, prepare, store, distribute and handle food under sanitary conditions places this highly susceptible population at risk for more than minimal harm. Therefore, Severity Level I does not apply for this regulatory requirement. Examples of level 2 – generally at scope of F could be: Food service workers sliced roast port on the meat slicer. The meat slicer was not washed, rinsed, and sanitized after usage. The facility failed to educate and train staff on how to clean and sanitize all kitchen equipment. During the initial tour of the kitchen, two food service workers were observed on the loading dock. One was smoking and the other was emptying trash. Upon returning to the kitchen, they proceeded to prepare food without washing their hands. NEXT

Severity Level 3 - indicates noncompliance that results in actual harm that is not immediate jeopardy. The negative outcome can include but may not be limited to clinical compromise, decline, or the resident’s inability to maintain and/or reach his/her highest practicable level of well-being. Outbreak of nausea and vomiting occurs in the facility related to the inadequate sanitizing of dishes and utensils; Episode of food poisoning occurs because facility had an event in which tuna, chicken, and potato salads served in bulk were not kept adequately chilled and were still left out for eating after 5 hours Level 3 is when actual harm has occurred that is not an IJ. Example could be: Outbreak of nausea and vomiting occurs in the facility related to the inadequate sanitizing of dishes and utensils; Episode of food poisoning occurs because facility had an event in which tuna, chicken, and potato salads served in bulk were not kept adequately chilled and were still left out for eating after 5 hours NEXT

Severity Level 4 – immediate jeopardy is a situation in which the facility’s noncompliance with one or more requirements has allowed/caused/resulted in or is likely to result in serious injury, harm, impairment, or death to a resident AND requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventive or corrective measures. A roast (raw meat) thawing on a plate in the refrigerator had bloody juices overflowing and dripping onto uncovered salad greens on the shelf below. The contaminated salad greens were not discarded and were used to make salad for the noon meal. The facility had a recent outbreak of Norovirus after the facility allowed a food worker who was experiencing vomiting and diarrhea to continue preparing food. Observations and interviews indicate that other food services staff with GI illnesses are also permitted to prepare food. Level 4 is an IJ. The situation resulted in or is likely to result in serious injury, harm, impairment or death to a resident and requires immediate correction. Example of this could be: A roast (raw meat) thawing on a plate in the refrigerator had bloody juices overflowing and dripping onto uncovered salad greens on the shelf below. The contaminated salad greens were not discarded and were used to make salad for the noon meal. Or - The facility had a recent outbreak of Norovirus after the facility allowed a food worker who was experiencing vomiting and diarrhea to continue preparing food. Observations and interviews indicate that other food services staff with GI illnesses are also permitted to prepare food. ****The death or transfer of a resident who was harmed or injured as a result of facility noncompliance does not remove a finding of immediate jeopardy. The facility is required to implement specific actions to remove the jeopardy and correct the noncompliance which allowed or caused the immediate jeopardy. NEXT

Sanitary Conditions - F371 Summary Statement of Deficiency
On x/xx/xx at xx:xx a.m., during the initial tour of the kitchen with the Certified Dietary Manager (CDM) “C”, the small bucket of quaternary ammonia (QUAT) disinfectant solution stored in the dish machine room and used to clean food preparation surfaces was tested for the concentration level of the solution by Dietary Service Aide (DS) “H”. According to the test strip color when compared to the color chart on the test strip container, the concentration of the solution was less than 200 ppm (parts per million). DSA “H” stated the concentration should be at least 200 ppm to be effective. A second bucket under the steam table near the stove also tested with less than 200 ppm concentration of the disinfectant. Here are two examples of F371 being cited during a recent standard surveys. What did the facility fail to do? (DPS – Based on observation, interview, and record review, the facility failed to 1) ensure food was covered and discarded after use during service in the dining room and 2) maintain kitchen surface cleaning quaternary ammonia disinfectant solution at the appropriate concentration to sanitize food preparation surfaces resulting in the potential for contamination of food and food preparation surfaces and the development of foodborne illness for the 15 residents who ate in the dining room and all 22 residents receiving meals from the kitchen.)

On x/xx/xx at xx:xx p.m., the small bucket the QUAT disinfectant solution stored in the food preparation room and used to clean food preparation surfaces was tested for the concentration level of the solution by Cook “D”. According to the test strip color when compared to the color chart on the test strip container, the concentration of the solution was less than 150 ppm. Cook “D” stated the concentration should be at least ppm to be effective . During the same observation and interview, Cook “D” stated the disinfectant solution had been prepared at about 10:00 a.m. when she started her shift. Cook “D” stated the solution should be changed every 2 hours or when there was a lot of debris in it. On x/xx/xx at 2:47 p.m. on the same day CDM “C” provided the facility policy “Cleanliness & Sanitation…” for “sanitizer solution” dated x/xx/xx which reflected QUAT sanitizer must be mixed to 200 ppm and changed when dirty, cold or every 2 hours.

On x/xx/xx at xx:xx p.m., a small cup of coleslaw in the holding refrigerator in the kitchenette next to the dining room was tested and found to be at 53 degrees Fahrenheit. Dining Services Aide “F” stated she had just put the coleslaw in the refrigerator after removing it from a resident’s place setting at a table in the dining room. DSA “F” stated the coleslaw had been put at a resident’s place at a table in the dining room at approximately xx:xx a.m. and when the resident did not come for lunch, the coleslaw was removed from the table, covered with plastic wrap, dated x/xx and put in the refrigerator for use the same day. DSA “F” stated she usually put the salad of the day out on the tables at the beginning of the dining service (11:30 a.m.) The coleslaw was at a table in the dining room unprotected from contamination for approximately 45 minutes and above the safe holding temperature of 41 degrees Fahrenheit according to the Food and Drug Association…209 Food Code…then, returned to the refrigerator for potential use later the same day. Second example -

Questions / Comments Please type in any question or comment regarding this regulation. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. Nursing Home’s have a huge amount of regulatory responsibility. CMS holds the homes accountable for providing residents with appropriate standards of care that meets their physical, emotional, and psychological needs. The SA is responsible for ensuring the protection of resident’s health, safety and welfare. From my experience as a Licensing Officer, nursing home’s who continue to be cited with F441, F323, F271 could improve their resident’s stay and the facility’s outcome measures by altering how they are monitoring facility staff and processes associated with these three regulations. There are just so many opportunities to not be in substantial compliance.

Nation = 15,648 Facilities Michigan = 433 Facilities

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