Does a facility’s failure to immediately begin correcting deficiencies after a state survey with issuance of multiple citations, including some for immediate-jeopardy-level noncompliance, constitute continuing to provide substandard quality of care? [F578 Request/Refuse/Discontinue Treatment and/or Formulate Advance Directives; F600 Free from Abuse and Neglect; F607 Develop/Implement Abuse/Neglect Policies; F610 Investigate/Prevent/Correct Alleged Violation; and F835 Administration]
Compliance Perspective – CMS Imposed Civil Money Penalty
Policies/Procedures: The Compliance and Ethics Officer, DON and the Administrator should review the facility’s policies and procedures to ensure that they instruct staff to immediately address and correct all deficiencies cited by state surveyors—especially those for immediate-jeopardy-level noncompliance.
Training: Staff must be trained to immediately begin correcting areas where deficiencies have been cited, with special emphasis on the steps to take for correcting immediate-jeopardy-level non-compliance deficiencies.
Audit: Audits will be conducted to determine if all areas where citations were issued have been corrected in a timely manner, and the facility has returned to and remains in substantial compliance.
Civil money penalties in the amount of $162,000 were imposed against a Kentucky health and rehabilitation center. Surveyors from the Kentucky Office of Inspector General, Division of Health Facilities and Services, conducted an initial and extended survey as part of a complaint survey of a health and rehabilitation center and found multiple violations regarding Medicare participation requirements that it determined placed residents in immediate jeopardy. The survey was completed on June 27, and a revisit survey in August determined the facility had returned to substantial compliance on July 31.
The Centers for Medicare & Medicaid Services (CMS) determined from the follow-up survey that “there were several areas where the facility was not in substantial compliance with certain participation requirements, including those at issue on appeal” that were all at a scope and severity level of “J” (Isolated instance of substantial noncompliance that poses immediate jeopardy to resident health and safety).”
Those requirements involved the following areas: F155 Right to refuse treatment; F223 Abuse and staff treatment of residents; F225 Investigate and report abuse; F226 Abuse and neglect policies and procedures; and F490 Administration (NOTE: The F-Tags cited were those in use prior to the November 28, 2017, update – see listing in Issue Statement above for current F-Tags for these areas).
The $162,600 Civil Money Penalty (CMP) assessed by CMS was based on an accrual of a per-day CMP of $5,300 for the immediate-jeopardy-level noncompliance that occurred from May 26 through June 24, plus a per-day CMP of $100 for noncompliance below the immediate jeopardy level for the period from June 25 through July 30.
