Past noncompliance citations may become more common in nursing homes, and community leaders should be paying attention. A recent article in McKnight’s Long-Term Care News raises an important question. Just because your community corrected a problem, does that mean it is behind you? Not necessarily!
Past noncompliance occurs when a community fails to meet a federal requirement but corrects the problem and returns to substantial compliance before surveyors arrive. Three criteria must apply. The community failed to meet a regulatory requirement, the event occurred between the last standard survey and the current survey, and the community completed corrective action before the current survey. However, meeting these criteria doesn’t automatically determine whether surveyors will issue a citation.
Think about that for a moment. Your community identifies a problem, takes corrective action, educates staff, and puts monitoring in place. By the time surveyors arrive, everything is working as it should. That’s good news, right? Absolutely! However, surveyors may still identify and cite the original deficiency.
And here’s another important consideration. Past noncompliance citations can carry financial consequences, including civil money penalties. Surveyors also need sufficient evidence that the community corrected the deficiency and achieved substantial compliance before the current survey.
So, what does this mean for your community? Documentation, documentation, documentation! When an incident occurs, how does your community document the investigation, identify contributing factors, and demonstrate effective corrective action? Are you considering other residents who may face similar risks? Do you monitor those changes over time? Can you show when you identified the problem, what actions you took, and when your community restored substantial compliance?
Corrective action should go beyond addressing the immediate concern. Community leaders need to identify underlying causes, implement system changes, and evaluate whether those changes work. Regular audits, staff education, and Quality Assurance and Performance Improvement (QAPI) follow-up can help demonstrate sustained compliance. And remember, if an intervention isn’t working, it’s time to make adjustments!
At the end of the day, identifying and correcting problems is an essential part of providing quality resident care. But correcting the issue is only part of the process. Community leaders must also demonstrate what happened, how they responded, and what measures they implemented to prevent recurrence.
Take a moment to review your incident investigation and corrective action processes. Do your records tell the complete story? Can staff members explain the changes your community made? HealthCap’s Past Non-Compliance Guide and Corrective Action Checklist can help you evaluate your processes and document corrective actions. Remember, past noncompliance citations remind us that what happened yesterday can still affect your community tomorrow.
Stay well and stay informed!
