01/26/2023

ODH and Ombudsman office update on citation trends: ODH citations, satisfaction survey, and emergency preparedness updates

Today, LeadingAge Ohio staff held its monthly meeting with representatives from the Ohio Department of Health (ODH) and Office of the State Ombudsman, covering survey trends, family satisfaction surveys, and other updates. 

Survey & enforcement

The Ohio Department of Health (ODH) reported there are 370 nursing homes (NH) and 369 residential care facilities (RCF) with overdue standard annual surveys. According to the Centers for Medicare & Medicaid Services’ (CMS) QCOR data, 216 nursing home surveys are 32 months or more overdue for Ohio. ODH’s challenge to get overdue annual surveys completed is partly due to the amount of complaint surveys they are having to conduct which has increased 40% since 2018. ODH conducted 3,755 complaint surveys in 2022 and only 493 annual surveys. The top ten complaint citations in 2022 were:

• F0880  Infection Prevention & Control
• F0684  Quality of Care
• F0689  Free of Accident Hazards/Supervision/Devices
• F0686  Treatment/Services to Prevent/Heal Pressure Ulcer
• F0677  ADL Care Provided for Dependent Residents
• F0755  Pharmacy Services/Procedures/Pharmacist/Records
• F0580  Notify of Changes (Injury/Decline/Room, etc.)
• F0609  Reporting of Alleged Violations
• F0610  Investigate/Prevent/Correct Alleged Violation
• F0760  Residents are Free of Significant Med Errors

ODH along with the Ombudsman’s office shared that a portion of these complaints could have been prevented with increased communication to residents and/or resident representatives. Complaints called into the Ombudsman’s office increased by 2% for NH’s and 6% for RCF compared to the prior federal fiscal year data. Common ombudsman’s office complaints were for concerns related to discharges, cold food, housekeeping, call light response and care needs not being met such as personal hygiene and timely medication. ODH reported dealing with staffing challenges and although ODH has hired six new surveyors ODH still has over thirty vacant positions. The field manager position for the eastern region vacated by Kathy Mitchell has been filled by Kelly Sites.

Family satisfaction survey reports

Deputy State Long-Term Care Ombudsman Erin Pettigrew provided an update on the satisfaction surveys. The detailed reports for the family satisfaction survey were delayed due to IT turnover but should be posted any day. The resident satisfaction surveys are underway and facilities that had their visits before February will get a preliminary report since there has been a delay in getting them all completed. The rest of the facilities will get their report in the summer when all have been completed.

Self-reported incidents

The self-reported incident module is slated to be completed with technical edits in February. The system will then allow providers more space within the online version to include the additional data elements now being required in the paper format.  ODH encourages providers to include as much detail as possible in the initial report which will allows ODH to triage the incident appropriately. This potentially prevents ODH from having to do the onsite visit sooner than necessary and allows the facility time to complete their investigation.

Life Safety Code surveys

Life Safety Code (LSC) surveys have not seen a significant change in common citations. The top ten LSC citations for 2022 are:

• K0345  Fire Alarm System - Testing and Maintenance
• K0353  Sprinkler System - Maintenance and Testing
• K0918  Electrical Systems
• K0222  Egress Doors
• K0712  Fire Drills
• K0372  Subdivision of Building Spaces - Smoke Barrier
• K0511  Utilities - Gas and Electric
• K0521  HVAC
• K0324  Cooking Facilities
• K0741  Smoking Regulations

ODH stated that when they conduct onsite visits following an emergency event they are looking to see if it was avoidable and if the facility is following their emergency plan such as notifying the fire marshal and ODH when their sprinkler system is down and they are in fire watch such as during the recent weather at the end of December when frozen pipes might have burst but were likely unavoidable. ODH will evaluate if routine maintenance had been completed during these visits. If a building is needing to evacuate and needs to notify ODH, they can call 614-752-9524 and the email is BLTCQ@odh.ohio.gov.

ODH will be virtually hosting the quarterly LSC and emergency preparedness meeting and individuals interested in attending should reach out to Stephanie DeWees at sdewees@leadingageohio.org.

LeadingAge Ohio will be sharing additional information shared during this call on the next STAT: Survey Tips and Tactics call. Register now for the February 8 call at 11:00AM.