10/17/2018

Survey Tip of the Week: Q2 IJ/ Prove Unavoidable

According to the Ohio Department of Health (ODH), they cited one organization for immediate jeopardy (IJ) citation in F686 for an avoidable pressure ulcer during the second quarter of 2018. Quality of Care is the top cited category for annual surveys, and F686 is third highest cited F- tag within the Quality of Care category. The Centers for Medicare & Medicaid Services define “avoidable” versus “unavoidable” as follows:

• “Avoidable” means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.
  
  
• “Unavoidable” means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident’s clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

The burden of proof is on the facility to prove that a quality of care issue was unavoidable. The survey process instructs surveyors to evaluate whether a facility ensures that a resident:

1. Receives care, consistent with professional standards of practice, to prevent pressure ulcers; and
   
   
2. Does not develop pressure ulcers unless the resident’s clinical condition demonstrates that they were unavoidable; and
   
   
3. Receives the necessary treatment and services to promote the healing of a pressure ulcer, prevent an infection, and prevent new ulcers from developing.

The pressure ulcer pathway can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

As the new survey process continues underway, LeadingAge Ohio is sharing tips each week to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.  

Monitoring the quality measure triggers will assist an organization in ensuring coding is accurate and the plan of correction can be implemented immediately. LeadingAge Ohio members have access to the Quality Apex tool which can assist an organization in obtaining better outcomes.

Please join us for the monthly In The Know Long Term Care Survey Process call which occurs on the second Wednesday of every month at 1pm. LeadingAge Ohio members are also invited to join a 30-minute bi-weekly “Tuesday Stand-Up” call offered by LeadingAge Maryland.