Preparing for Survey….F800 Infection Prevention and Control Program – Still the Top Deficiency Being Sited 

It’s not new news that providers were required to have an Infection Prevention and Control Program (IPCP) by Nov. 28, 2016 (Phase I) and an Antibiotic Stewardship program by Nov. 28, 2017 (Phase 2). What is surprising is that this remains the top sited deficiency and many providers are still working on getting these programs and other new regulatory programs in place.

One of the opening questions I ask when teaching SNF leadership teams is, “How are you doing with Phase 1?” Even as recent as last week, there continues to be only a handful of hands raised. So of course, the next question is, “How are you doing with Phase 2?” As expected, about half of the number of hands raised for the first question go up waving in the air.

My next strategic step to try and keep them from running out of the training is to acknowledge the machine gun effect of change everyone is facing and letting them know there is a light at the end of the tunnel. However, that light is only lit if they can identify their priorities and develop realistic plans to address them.

Two keys to prioritizing are: 1) know what the deficiency trends are, and (2) to have your Critical Element Pathways (CEPs) by your side. The survey process is an open book test and the CEPs are your study guide. We know that the top five citations nationally to date for FY2018 are:

1. F880: Infection Prevention & Control

2. F689 Free of Accident Hazards/Supervision/Devices

3. F656 Develop/Implement Comprehensive Care Plan

4. F812 Food Procurement, Store/Prepare/Service Sanitary

5. F684 Quality of Care

Consider using the corresponding CEPs for these areas to see how your facility is performing. Take a look through the eyes of a surveyor. I always encourage cross-auditing (i.e., environmental services manager audits infection control, business office manager audits the dietary department, etc.) to bring new eyes to improvement opportunities that may be overlooked by the manager assigned to that area. Tying audit results to your QAA/QAPI program will promote thorough analysis and assist with identifying process improvement opportunities that lead to sustainable improvement.

This November your survey results again begin impacting your CMS Five Star Rating. If you haven’t had survey preparedness on the top of your to-do-list, now is a great time to do so. Create a QAPI project using your CEPs or reach out to us if you would like to schedule a Survey Readiness Audit.

Amy Lee, RN, BSN, MSN, CRRN
President/CEO