You are the consultant for a long term care facility that recently has undergone a long term care survey in which the facility received several deficiencies notations for noncompliance with federal requirement.

You are the consultant for a long term care facility that recently has undergone a long term care survey in which the facility received several deficiencies notations for noncompliance with federal requirement. The most significant deficiency involved a noted pattern (7 of 10 examples reviewed in the surveyor sample) in which comprehensive assessments (MDSs) were not completed within the required time frame (within 14 days of admission).

In addition, the surveyors identified that no documentation supported the use of triggered care areas in the assessment and care planning process. This resulted in related quality of care deficiencies for failure to adequately assess and manage urinary incontinence and psychosocial needs.

In the additional examples, the surveyors identified that residents had experienced a significant change in condition without evidence of a new assessment being done. Within the statement of deficiencies, the surveyors noted that the director of nursing stated that she was unaware that assessments had not been done. And the nursing staff members stated that they did not understand what the care area triggers were, and that they were unaware of the federal criteria for determining when a significant change had occurred. The administrator of this facility has asked you to develop a plan to correct these deficiencies. Here are the questions:

What would be your recommendations for overall system evaluation and revision?

What would be your recommendation for staff education?

How could the facility medical records designee be utilized to prevent similar problems from occurring in the future?