The Office of the Inspector General (OIG) released a March 2016 report, “Oregon Properly Verified Correction of Deficiencies Identified During Surveys of Nursing Homes Participating In Medicare And Medicaid” that gives the Oregon Department of Human Services a great review. The purpose of the audit was to verify if Oregon nursing home surveyors were verifying nursing homes’ correction of survey deficiencies for 2014 as per Federal regulations.
The data used in the review initially included 681 Oregon survey deficiencies that required a Plan of Correction in 2014. 187 deficiencies were removed because they were not cited under resident care, but instead were related to administration, physical environment, residents’ rights, admissions, transfers, discharges, dietary and quality of life. A review of 100 sampled deficiencies found that the SA verified the correction of deficiencies as required by regulation, and had no recommendations.
However, the results include two tips on how Oregon’s SA may have ensured it was in compliance with requirements – follow up surveys for all S/S D/E/F without SQC and surveyor forms to use for verification.
- Oregon’s Tag Review/Consensus Form is an optional tool for their surveyors to use to summarize their findings. It is used to document the deficiencies reviewed. It instructs surveyors to reach a consensus on whether each tag is met or not met, and to decide which team member will cite examples for each tag.
- Oregon’s Nursing Home Entrance Conference Information Request Form is an optional tool to request specific data needed for follow up surveys to verify compliance. It looks for information on:
- List of residents by room number
- Administrator’s email
- List of residents with changes in condition since X date
- List of residents with wound care orders since X date (identify if new orders)
- List of newly admitted residents since X date
- List of re-admitted residents since X date
- Copies of In-Services noted in POC
- Copies of audit tools