February 9, 2018
Missed the first session in the series? Access the recording here!
Comprehensive Review of Regulations and Interpretive Guidance for Infection Control/Antibiotic Stewardship F880-F881
This session focuses on F-Tag 880-881 with a review of the regulation and an analysis of the associated Interpretive Guidance. A review of survey procedures, such as the Infection Prevention, Control, and Immunization Critical Element Pathway and/the Surveyor Probes shared and discussed. Tools to assist the facility interdisciplinary team in monitoring compliance and incorporating into the facility QAPI processed will be discussed.
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During this year long series, we will focus on the top deficiencies cited nationally with the new Long Term Care Survey Process (LTCSP). Each session will concentrate on top-cited F-tags with a review of the regulation and an analysis of the associated Interpretive Guidance. Survey procedures, such as associated Critical Element Pathways and/or Surveyor Probes used to guide the investigative process will be discussed. Actual citation examples will be shared and examined. Tools to assist the facility interdisciplinary team in monitoring compliance and incorporating performance improvement activities into the facility QAPI processes will be a focal point.
Projected Learning Outcomes/ Course Objectives:
- Identify the regulatory requirements related to the monthly F-Tag topic
- Identify survey procedures that describe how the F-Tag topic is reviewed for compliance during the annual survey process
- Identify examples of how the F-Tag is commonly citied in the new LTCSP
- Identify tools for the leadership team to use for monitoring compliance with the F-Tag topic
- Explain strategies for incorporating survey preparedness into facility QAPI processes
- Overview of the F-Tag Regulations and Interpretive Guidance
- Survey procedures for assessing compliance with the F-Tag and citation examples
- Strategies for monitoring compliance and incorporating survey preparedness into facility QAPI processes
- Closing Comments/QA
Target Audience: Director of Nursing, Assistant Director of Nursing, Nurse Managers, Nursing Home Administrators, Nursing Staff and Leaders, Quality Assurance Director, Social Services, Rehabilitation Services.
Instructional Level: Intermediate
NAB Approved Contact hours: 1.25 for live event and 1.5 for recording (includes post-test). Check your state association registration page for details on additional CE accreditations.
Based on CASPER Data from 2017 Standard Health Inspection Surveys the Monthly F-Tag Topics will be:
Note: Topics are tentative and subject to change based on CASPER data for surveys occurring after November 28, 2017 to ensure series focuses on top citations in the new LTCSP
January Infection Control/Antibiotic Stewardship F880, F881 (former F441) February Food Safety F812 & F813 (Former F371) March Accidents/Bed Rails F689 & F700 (Former F323) April Quality of Life/Quality of Care F675, 684, 697, 698, 744 (Former 309) May Pharmacy Services F755, F761 (Former F431) June Comprehensive Care Plans F656 (Former F279) July Unnecessary Drugs F757-758 (Former F329) August Resident Records F842 (Former F514) September Resident Assessments/Accuracy of Assessments F641 (Former F278) October Dignity and Respect of Individuality F550 (Former F241) November Treatment/Services to Prevent/Heal Pressure Ulcers F686 (Former F314) December Services Meet Professional Standards F658 (Former F281)
Shelly Maffia, MSN, MBA, RN, LHNA, QCP
Director of Regulatory Services for Proactive Medical Review
Shelly Maffia is Registered Nurse and Nursing Home Administrator with over 15 years of experience serving in the long term care leadership and consulting positions, including positions as Director of Nursing, Administrator, and Corporate Nurse Consultant and Training Positions. She earned the QAPI Certified Professional (QCP) credential form the American Association of Nurse Assessment Coordination (AANAC), which was established to promote the highest standards for QAPI program implementation in the long-term care profession.
Proactive Medical Review & Consulting assists post-acute care providers in ensuring compliance with regulatory standards and promotion measureable care excellence. Proactive specializes in SNF mock survey, QAPI, Compliance Programs, MDS/Supportive Documentation Audits and Staff Development to promote 5 star quality and reimbursement compliance. Proactive offers consulting for Medial Review and Medicare Appeals, and is uniquely positioned to assist SNF providers with therapy oversight and the defense of skilled rehab services through their team that includes Therapist consultants in addition to Nurse, Health Facility Administrator, MDS and SNF/NF billing experts.