June, 2004

Information Bulletin 04-9
NH-100

Federal SNF/NF Deficiencies Related to Outcome, Assessment and/or Care Planning Findings
Effective Date – June 21, 2004

Background:

The Minnesota Department of Health has identified deficient practices that create non-compliance with more than one federal regulation and issues federal deficiencies under each requirement.

Concerns have been raised that federal citations issued for related findings under both the outcome tag and the assessment and/or care planning related tags are duplicative and unnecessary.

Minnesota has identified that different state survey agencies issue different patterns of citations with some issuing only the outcome tag and others issuing outcome, assessment and/or care planning tags.

Policy

Nursing homes are expected to help residents attain and/or maintain their highest practicable physical, mental and psychosocial well-being.

The key to achieving this outcome is through individualized resident assessment, and individualized plan of care development and implementation.

The Minnesota Department of Health conducts surveys and/or complaint investigations consistent with federal guidelines for the purpose of determining a facility’s compliance with federal standards. This involves reviewing all components of resident care implemented by a nursing facility including implementation of individualized assessment, care planning and interventions.

Issuance of Federal Deficiencies Related to Outcome, Assessment and/or Care Planning Tags

MDH will approach issuing federal deficiencies related to outcome, assessment and/or care planning tags as follows:

The Minnesota Department of Health will identify deficient findings under assessment, care planning and outcome tags. If a related deficient practice is found under an assessment and/or care planning tag(s) AND an outcome tag, MDH will cite the finding under the appropriate outcome tag and will NOT include that finding in an assessment and/or care planning deficiency.

MDH will continue to issue assessment and/or care planning tags for findings where an outcome tag is not issued.

Evaluation of Policy

MDH will evaluate outcome(s) of this policy change in October, 2004.

If you have any questions regarding this Information Bulletin, please contact in writing:

Minnesota Department of Health
Compliance Monitoring Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900
St. Paul, MN 55164-0900
Telephone: (651) 215-8701

CM/07-28-2005Tuesday, 16-Nov-2010 12:25:10 CST