Ftag of the Week – F840 Use of Outside Resources

We anticipated that for this Ftag of the Week and those in the near future that we would be trying to read through a tremendous amount of new Interpretive Guidance related to the newly effective Phase 3 Ftags. However, as you are aware, the Centers for Medicare & Medicaid Services (CMS) announced last week that Phase 3 would be effective as planned on November 28, 2019, but that Interpretive Guidance for these Ftags will not be available until Q2 2020. So, this is a friendly reminder to all skilled nursing providers that you need to be complying to the best of your ability with the entirety of the Requirements of Participation right now, although we should not expect to see the IG until sometime between April and June of next year. The Phase 3 RoPs had the longest lead time of all the Requirements since they were considered the most complex, so choosing to wait to implement them until you see the updated Guidance is not a good plan – try to be compliant with these regulations as they are stated.

In the meantime, this week’s Ftag of the Week is part of the Administration regulatory group, F840 Use of Outside Resources. Some CMS Regions have not cited this Ftag at all, and in the Regions where it has been cited, it tends to be clustered amongst a few states. Let’s look at the regulatory requirement. F840 requires that:

  • If a facility does not employ a qualified professional to furnish a service to be provided by that facility, it must have an arrangement in place to ensure that service is furnished to residents by an outside resource.
  • The arrangements made must specify that the facility is responsible for obtaining these services and that the services meet the professional standards and principles that are practiced by employees of the facility.
  • The arrangements must also specify that the facility is responsible for the timeliness of services. “Timeliness” in this regard, is when services are completed and results are provided within timeframes specified in facility policies, by medical orders, or by professional standards of practice. The facility is also responsible for ensuring that the resident’s physician (or PA/NP), dentist or clinical nurse specialist are notified as directed in the medical order.

Here are some examples of how failure to meet these requirements has been cited on survey in 2019:

  • An agency staff member was not provided with orientation prior to providing care for a resident. That resident was left unattended, fell out of bed and was injured. The facility was unable to provide documentation that all agency nursing staff received facility orientation before they worked there (S/S: E)
  • Upon interview with a surveyor, a resident told the surveyor that he had a tooth pulled approximately 6 months ago and was supposed to receive dentures. The facility had changed dental providers in that timeframe and the note from the prior service provider was not carried over to the new one (S/S: D)
  • A resident went for a urology consultation, and upon return, the urologist’s recommendations stated that the resident’s catheter should be changed in “96 weeks”. The facility did not follow up to clarify the order of the outside medical provider (S/S: D)
  • A facility failed to have an agreement with an outside resource for mental health services needed for multiple residents. The outside company did not document or leave documentation when residents received visits. While the services were being provided, the agreement had not been reviewed since initiation (S/S: E)

These citations point to system “holes” that can happen in many facilities. All staff need to receive proper orientation in order to be able to follow facility policies. The use of agency staff is often a band-aid to fill staffing gaps, but there is an expectation that all staff understand the facility’s policies and procedures and follow them. Since we all know this is the case, it is more a matter of ensuring proper coordination between the agency and the facility so agency staff receive orientation prior to starting. Likewise, for the citations related to lack of dentures and lack of order follow up, these show the difficulty in having a sound system in place to ensure orders from outside professionals are followed up on in the same manner and timeframes that orders from professionals within the facility are.

Finally, the last citation regarding outside mental health services should provide a good reminder that facilities are responsible for coordinating the necessary behavioral health services for their residents. This includes ensuring there is documentation in place of outside support resources that cannot be provided within the facility. The Phase 3 Interpretive Guidance may not be fully available yet, but there is an increased emphasis on meeting behavioral health needs going forward, and even not having an agreement for services in place for residents that require certain services that can only be provided by an outside resource can point to a lack of a system to appropriately meet your residents’ needs.

The CMS Compliance Group Team wishes you and yours a happy holiday and all the best in 2020! This is our last Ftag of the Week post for 2019 – see you next year!

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