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Fall Prevention

Get survey-ready: 6 key takeaways from the phase 3 guidance to surveyors

What does phase three enforcement mean for your care community and how can you make sure you’re ready for your next survey? Let’s find out.

If you find yourself wondering if you have everything covered ahead of your next survey window, then you’re not alone. No one wants a survey or audit to reveal unexpected deficiencies in your work processes resulting in dreaded fines or rushed correction plans. So, to make sure you’re fully aware of what surveyors will be looking out for under phase three enforcement, we’ve asked our compliance expert, Rebecca DeRousse MBA, MHA, CNHA, to give us her take on the latest guidance to surveyors and what the management of senior care communities need to be conscious of when their survey window is approaching.

This article outlines six elements of phase three standards which have been defined in the latest guidance to surveyors. For a more comprehensive overview of what phase three enforcement means for your facility, you can watch our free, on-demand webinar at your convenience. Timestamps will be used throughout this article to reference at which point in the video recording you can find out more on this topic.

New interpretations from the latest phase three guidance to surveyors

1.      Abuse and retaliation

We all know that as a care community we are required to protect residents from sources of abuse including staff, visitors, and other residents, and to implement corrective action to prevent future abuse where allegations of abuse have been made. But in terms of compliance, one of the most important actions to take should abuse occur is to alter the care plan of those affected to reflect an informed response to that abuse. Allegations of abuse must be treated seriously and the procedures must support a right to file a complaint for retaliation to the state agency. Having retaliation complaint procedures visible to both staff and residents in the form of signage is vital to this (9:57 – 10:46).

2.     New timelines for reporting crimes

Your facility is now required to develop and implement written procedures regarding the correct process for reporting disclosures of abuse or criminal suspicions and annually notify any covered individuals of their obligation to follow these procedures. There are also new guidelines on how long after forming a suspicion of abuse you should report it to both the state agency and law enforcement entities.

a flowchart showing the timelines for reporting abuse in long term care facii

If the alleged abuse resulted in serious bodily injury then you must report it within two hours and if it did not result in bodily harm you must report it within 24 hours. Criminal offenses and suspicions of abuse should always be reported immediately where possible, but these are the official standards that you would potentially be penalized for failing to meet (13:51 – 14:53).

3.     Investigating facility-initiated transfer or discharge

Here’s where Rebecca DeRousse claims the guidance to surveyors gets “a little scary” for nursing facilities (15:03 – 17:37). Under phase three enforcement, once admitted, residents are entitled to remain in that facility and return to that facility after temporary transfers to an acute care setting unless any of the following special limitations are met:

·       If the resident’s level of care requirements has changed and the facility can no longer meet their care need or if their care need has de-escalated enough for them to leave

·       If the health and safety of other residents would be compromised by a resident’s presence

·       If their costs are not being met

·       If the facility ceases to operate

These are the limited circumstances under which a facility can now initiate a discharge or transfer, therefore it is vital that every admission is carefully considered. Surveyors can investigate transfers and discharges even if an appeal did not occur, so caution and thorough documentation is advised for compliance.

4.     Culturally competent care

Rebecca DeRousse (18:04 – 18:45) defines this as “being respectful and responsive in regard to [a resident’s] health beliefs, their practices, and their culture.” As caregivers, we must be able to effectively care for the needs of those across diverse population groups such as racial, ethnic, religious, or social groups in a manner that aligns with the resident’s cultural identity. It is best practice to ensure care plans reflect the culturally competent care implementations and interventions where applicable, to demonstrate compliance.

around 70% of US adults have experienced at least one traumatic event in their lives

5.     Trauma-informed care

The guidance to surveyors define trauma-informed care as an “essential part of person-centered care” as it aims to individualize each person’s care plan based upon individual experiences and reactions (18:46 – 21:26). Again, any investigation into instances of past trauma and adjustments made in light of those findings should be recorded in that resident’s care plan to demonstrate compliance and competent care planning.

We now fully understand that trauma and symptoms of trauma are interconnected with health conditions and a general state of well-being. Therefore, we must not only be sensitive to the present effects of past trauma but also be proactive in preventing re-traumatization and in identifying individual triggers.

The Substance Abuse and Mental Health Services Administration claims that around 70% of US adults have experienced at least one traumatic event in their lives, so trauma-informed care planning is vital in the majority of care plans, not the minority.

6.      Bed rails – The last resort

Bed rails have been a “hot topic” for a while now and although guidelines still differ somewhat by state, it is clear that using bed rails as a go-to fall prevention system is fundamentally flawed. The guidance now suggests that a “facility must attempt to use appropriate alternatives before installing a side or bed rail.” This means that they are considered to be the last resort.

Rebecca gives us her insight on bed rail alternatives that could fulfill that requirement (25:43 – 29:02).

“What are some alternatives? It could be a roll guard, it could be bumpers, lower beds, and concave mattresses. Accora has a FloorBed which has an adaptable height and width which goes down to 3.9 inches which is very, very low but also it will raise to 31.5 inches to provide nursing care and that is an example of a great alternative for bed rails.” – Rebecca DeRousse

Should you decide that there is no alternative to a bed rail then you must assess for entrapment, justify this in documentation, and obtain informed consent from the resident or their representative before installation.

Final thoughts

While these six topics are far from a comprehensive guide to phase three enforcement, they are the points that stand out most to us as the new elements not to be overlooked if you want a smooth survey. However, if you're interested in a more thorough introduction to the interpretive guidelines and guidance to surveyors then you can find our on-demand free webinar on readiness for phase three enforcement here. Our compliance expert, Rebecca DeRousse covers training and staffing requirements, binding arbitration agreements, QAPI guidelines, and much more.  

Watch it anytime and if you find it insightful and informative then please feel free to share it with a colleague.


Webinar recording timestamps:

Part 1 – Resident’s rights 6:31 – 17:37

In part one, we discuss abuse, retaliation, the rights of residents regarding discharge and transfers, and reporting crimes.

Part 2 – Comprehensive care plans 18:04 – 29:03

Part 2 covers culturally competent care plans, trauma-informed care, and the new guidance around bed rails.

Part 3 – Other requirements 29:05 – 44:54

Part 3 covers staffing requirements, controlled medications, binding arbitration agreements, performance improvement projects (PIPs), your call system, and general QAPI guidelines under phase 3.

Part 4 – Training 44:55 – 52:55

Part four outlines the various forms of training your facility must provide and which members of your team must complete the different types of training.  



Accora Team
FloorBed technology to help skilled nursing, rehabilitation and long term care facilities prevent falls and fall-related injuries.
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