Easily preventable and overlooked compliance issues in nursing homes often start in the kitchen and resident rooms, but there is another surprising source: Amazon deliveries. 

All the while, the category of infection prevention and control continues to lead in number of citations. and surveyors often see multiple failure points when it comes to person-centered care, too, including inconsistent practices tripping up staff and a failure to recognize resident preferences.

Overall, nursing homes that actively engage with available regulatory tools and prioritize consistent quality assurance while engaging staff and leaders will be better prepared for surveys, especially given the updates Centers for Medicare & Medicaid Services (CMS) implemented on April 28.

Skilled Nursing News connected with two compliance experts for their perspectives on key overlooked issues, common mistakes and practical advice for nursing homes to improve regulatory readiness in this first edition of a new quarterly series: The Compliance Radar.

Amy Stewart, Chief Nursing Officer, American Association of Post-Acute Care Nursing (AAPACN)

Overlooked compliance areas:

Stewart said that nursing home operators often overlook  “low-hanging fruit” that they can easily correct to avoid citations.

One of these low-hanging fruits cann often be found in the kitchen. Issues with expired food, improper storage and poor infection control practices, involving glove use, dishwashing and hand hygiene, are frequent and preventable with routine monitoring on a weekly basis, according to Stewart.

“[Surveyors are] going to go to the kitchen right away,” said Stewart. “Ensure people are using gloves when they’re supposed to use gloves, that they’re washing the dishes in the correct manner, that they’re washing their hands.”

Resident rooms also usually contain easily corrected issues. For example, personal refrigerators might contain spoiled or improperly stored food, or residents might have unsafe items like space heaters that haven’t been checked by maintenance, Stewart said. 

Other overlooked compliance areas include medication carts and rooms and oxygen storage; such spaces are often cited for expired or improperly stored medications, items that don’t belong and poor labeling of multi-use vials, Stewart noted. 

Amazon and package deliveries represent a more recent compliance risk. Delivered items are often left on the floor, violating storage regulations and creating potential citation risks, she said. Food deliveries from Amazon are also a concern if not stored properly.

“I was at a nursing home when Amazon packages came in for residents … the gentleman who brought them in just dumped them on the floor by the door. I think he had 15 packages for residents, all from Amazon, and so this is something new,” said Stewart. “I thought, my goodness, this is an easy citation.”

Common compliance mistakes:

Stewart said common compliance mistakes often involve two key areas: Enhanced barrier precautions (EBPs) and resident rights and preferences.

While not new, EBPs are now a greater focus for surveyors, particularly when it comes to citation F-880, or a federal citation that requires facilities to establish and maintain an infection prevention and control program. Staff need to understand which residents require EBPs and in what situations. For example, EBP is needed for longer ambulation but not for a brief wheelchair transfer.

Nursing home operators can run into confusion and inconsistency when implementing EBPs, including failure to wear all required protective equipment, Stewart said. Hand hygiene also remains a persistent issue and often contributes to deficiencies.

Surveyors also can cite facilities for not respecting or asking about resident preferences, a growing issue as expectations shift with new generations, Stewart said. Refusing to help a resident dress or apply makeup according to their gender identity or personal style is one example, or ignoring preferences on shower times, bathing methods, physician choice or activity interests.

Such issues show a failure to provide person-centered care as outlined in the Minimum Data Set, Section F.

Failure to honor dietary dislikes also can lead to weight loss and poor nutrition, she added.

Timely advice:

Understanding Critical Element Pathways (CEPs) is Stewart’s best advice for operators and staff. Notably, skilled nursing facilities should give mind to updated CEPs related to hospitalization and discharges that were in survey changes implemented on April 28.

During inspections, surveyors use CEPs, which contain the exact questions they ask residents and staff. Unfamiliarity with those questions can lead to citations if staff appear uninformed or unprepared, Stewart said. 

As such, knowing what residents and staff will be asked during admissions, transfers and discharges helps prevent surprises and improves compliance.

Nancy Tuders, Assistant Director of Education, Master Trainer, National Association of Directors of Nursing Administration in Long-Term Care (NADONA)

Overlooked compliance areas:

Infection prevention and control remains the top deficiency area in surveys, and issues often stem from the related F-tag citation, which covers multiple components. Facilities may pass some parts of this area but fail others, leading to citations.

“What we usually do is look at the top tags, we look at that every quarter,” said Tuders.

Discharge-related deficiencies are a growing concern and already appear in the top-10 list of deficiencies based on data collected by NADONA, suggesting a trend toward more scrutiny in that area as well. That was the case even before surveyor changes that were implemented on April 28.

Common compliance mistakes:

Tuders said nursing home operators must address staffing, sustainability of corrective actions, medication oversight, and medical director involvement to avoid common and increasing regulatory risks.

Facilities are generally good at fixing issues temporarily but fail to sustain improvements, causing recurring deficiencies in future survey cycles, said Tuders.

Nursing home operators are overlooking critical tasks due to understaffing and overworked employees. Infection preventionists, in particular, often wear multiple hats. Directors of nursing (DONs), assistant DONs and staff developers also wear many hats, which makes it difficult for them to focus on compliance and prevention as a result of “role overload,” Tuders said.

Overlooking the shifting role of the medical director is another compliance mistake to avoid, especially given the position’s importance in new surveyor guidelines, Tuders said.

Surveyors are going to be looking into the medical director’s involvement “deeper than they ever have,” Tuders added. In a lot of cases, medical directors are in and out of the buildings, she said, but surveyors want them more involved in the care of residents moving forward. Notably, surveyors are looking at medical directors’ participation in Quality Assessment and Performance Improvement (QAPI) meetings.

If issues arise during a survey, inspectors will investigate whether the medical director was aware of the issue and scrutinize the actions they took to find a solution. Facilities could be cited under multiple tags, including care plan tags, if the medical director isn’t informed or engaged in that process, she noted.

More generally, a review of the State Operations Manual (SOM) with medical directors can help ensure compliance and preparedness for deeper scrutiny during surveys.

Timely advice:

Tuders urged operators to strengthen their quality assurance programs and be proactive with compliance practices. It pays to go beyond minimum compliance and use tools like the SOM and CEPs to stay ahead of survey expectations, improve communication and ensure staff are prepared and confident for when the surveyor steps through that door, she said.

On the topic of communication, morning meetings and regular staff connections are essential but difficult considering ongoing staffing struggles. Quarterly quality assurance meetings aren’t enough, she added; they need to be more frequent.

Tuders also suggested a facility’s QAPI team be familiar with new regulations and expectations, and that prepping all staff with repeated, familiar questions builds confidence and reduces fear during surveys.

“I just think if we use those tools that we’ve been given, it would make life better for the nursing home staff,” said Tuders. “They would be more confident that they were doing what they need to be doing, and your staff wouldn’t be threatened.”