This week’s Ftag of the Week on the CMSCG Blog is the final Ftag that is part of the Physical Environment Regulatory group, F921 Safe/Functional/Sanitary/Comfortable Environment. The Centers for Medicare & Medicaid Services (CMS) must have felt that the title of the Ftag was sufficient to explain the regulatory requirement to providers, as the regulation is only one sentence long and is void of any Interpretive Guidance. The regulation for “other” environmental conditions states that the facility must provide an environment for residents, staff and the public that is safe, functional, sanitary and comfortable. F921 is referenced under the Interpretive Guidance at F584 Safe/Clean/Comfortable/Homelike Environment (which has a very similar name) as a potential Ftag for surveyors to consider as well. Specifically, the IG states that surveyors should consider citing F912 for issues related to cleanliness of staff-only areas of the facility or areas only used by the public. This includes areas such as break rooms, the kitchen (despite there being an Ftag for that as well at F812), and facility parking lots that may be used by visitors or others.
F921 has been cited infrequently, and mostly on Complaint Surveys, however, when it has been cited, it has been predominantly at an Immediate Jeopardy level. Areas where issues with compliance were identified include:
- Ceilings on hallways and resident rooms with water damage and mold (Recertification Survey S/S: L)
- Fire alarm system did not notify fire department or law enforcement if activated and water was leaking from the ceiling into the therapy hallway (Complaint S/S: L)
- Water in excess of 120F observed running during survey, and residents were queried about why the water was on everywhere, they told the surveyor that it was to keep the pipes from freezing (Complaint S/S: K)
- Dirty, stained grout in shower stalls with stained, worn shower chairs and worn shower curtains observed on survey (S/S: F)
As you can see from these actual citations, there is a bit of variation as to what is cited under F921, and all of it is not necessarily related to staff/public use areas. These citations could have been easily avoided through routine Environmental Rounds by the Housekeeping and Maintenance staff and follow-up with any third-party vendors, such as the fire alarm company, to ensure that maintenance and repairs were completed as required. CMSCG is hoping that looking at all of the Physical Environment Ftags through the microscope that a surveyor can use makes you realize that the expectation is that residents who live in your facility have an environment that you would like to live in.