Assistance when you need it

PAST-NONCOMPLIANCE- What is it really?

CMS defines it as: Past Noncompliance means a deficiency citation at a specific survey data tag (F-tag or K-tag), that meets all of the following three criteria: 1) The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific F-tag or K-tag) at the time the situation occurred; 2) The noncompliance occurred after the exit date of the last standard (recertification) survey and before the survey (standard, complaint, or revisit) currently being conducted, and 3) There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific F-tag or K-tag

Translation: Past non-compliance is an event happened, facility identified it immediately, corrected the problem completely BEFORE the DOH walked in the door. It carries less penalties, no POC and can save thousands in fines, costs, and reputation. Save your star rating!

You get a phone call 11 PM on a Saturday. Something happened, an elopement, a fall with staff present injury, an incident of some type. What do you do?  The clock IS ticking. Remember your reporting requirements. ERS is just a click away. How long do you have before they read it and show up?- not long at all. Tick. Tick. Tick.

Start your investigation. It cannot wait until Monday. What are all the components that came together that the event occurred? What interventions should have/would have been in place to prevent it? Time to dig deep into that root cause analysis. Aide documentation, care plans, behavior tracking, facility policy and procedures, staff education, staffing, nursing notes, etc.

Very rarely is it a clear cut “it just happened” type of incident. There usually is a facility factor in there (door unlocked/not latched, staff member rolled them off the bed, coffee was served hot…) that is a root cause or a contributing factor. What processes weren’t in place?  I always look at the CMS pathways- think of them as your cheat sheet guidance. After all, it’s the standards that CMS uses for surveyor investigations. Print it and use it to guide you. Pull your facility policies. What do they say? Look again, it’s likely several policies.

Now that you have identified what processes failed, start your education. EVERY STAFF MEMBER, including agency. The only times you wouldn’t do every staff member is a truly isolated incident such as a medication error. Think of it this way- if your staff can see it and possibly intervene, they are included. For example, a housekeeper can potentially walk in on a resident left unattended in a lift.   

I know what your thinking- “But how am I supposed to train everyone in 24-48 hours?” Email is great. I read and understand XX policy. Print it.  Text works as well. Mark “VIA email/text/phone" with whomever confirmed and have the employee physically sign when they do come into the building. FMLA/leave and extended vacation people- mark them as such. No one is permitted to work until they are educated. 

Look at your “like residents”- does anything need corrected with them too?

Update your ERS event. Put your corrective measures in it.

Put it all together into a binder and have it waiting- they’re going to want it. 

Just remind the surveyor there’s a little box in “the system” in the top right corner that says “past noncompliance” they’ll need to click.

The CMS pathways plus many other goodies is located in a zip file on CMS website and can be found here: Survey Resources (ZIP) (cms.gov)