2017-2018 Harm and Immediate Jeopardy Survey Citation Review

2017-2018 Harm and Immediate Jeopardy Survey Citation Review

Washington State has dropped from #1 in the nation for Harm and IJ tags to #4. However, our overall percentage of re-cert surveys with harm or IJ has increased from 29% to 31.3% and remains three times higher than the national average.  These numbers include G and above citations.  MORE

A review of the first three quarters of 2018 against the same time period in 2017, suggests that IJ citations for both complaint and re-cert surveys have decreased. The top two immediate jeopardy citations are F689-Free of Accidents and Hazards and F757, Drug Regimen Free of Unnecessary Drugs.  The top complaint investigation citation is F689-Free of Accidents and Hazards. 

We will be looking at the G level citations now, doing a root cause analysis and focusing on how we can help our members avoid these citations.

LeadingAge Washington has been using the results of the top citations to plan our educational offerings throughout this last year.  We will continue to monitor survey trends and make available educational programming that will assist with decreasing the number of these citations.  Based on the review of the 2015-2017 immediate jeopardy citations earlier this year, we determined the supervision of staff and the development and understanding of policies and procedures, as well as systems management, were important training to be completed.  We followed this review with a very successful Director of Nursing Certification Course in July, focusing on how to effectively develop policies and procedures as well as systems management and supervision of staff to help provide guidelines for your staff to follow.  We just completed our third INTERACT training, focusing staff on how to identify a subtle change in condition and intervening before the change ends up in an admission or readmission to the hospital. We have received excellent feedback from these intensive training opportunities and will be repeating them in 2019. 

If you have questions or comments concerning survey or other regulatory compliance matters, please don’t hesitate to contact Laura Hofmann, MSN, RN, Director of Clinical and Nursing Facility Regulatory Services at  lhofmann@LeadingAgeWA.org