07/03/2025
Survey Tip of the Week: CPR Immediate Jeopardy
Immediate jeopardy (IJ) citations related to F-tag 678, Cardiopulmonary Resuscitation (CPR), continue to occur in Ohio. Already in 2025, IJ citations have been issued in both the first and second quarters. One of the situations involved a resident on hospice with a full code status. In another, the staff had difficulty obtaining the advance directive status in the EMR. F678 was the fourth most frequently cited IJ F-tag in 2024.
According to the CMS State Operations Manual Appendix PP, CMS F678 guidance emphasizes that facilities must ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident’s advance directives, and physician orders.
Additional past citation examples include:
- No staff onsite trained in CPR
- Nurses without current CPR certification
- Lack of competency with CPR procedures
- Medical records inconsistent with advance directives
- Full code not initiated as per wishes
- Crash carts without supplies or unable to be unlocked
LeadingAge Ohio encourages providers to review current CPR policies. Human resources should review current systems for monitoring compliance with CPR certifications. Providers should review current training and drills to determine if frequency needs to be increased and identify how the CPR policy and advance directives are educated upon hire. Providers should also identify frequency for random auditing of the clinical record for system breaks, EMR alerts, code status icons/identifiers, complete records uploaded into the EMR, care plan consistency with advance directives, and staff competency in following the policy. Incorporate the Long-Term Care Survey Process (LTCSP) by conducting record reviews using the survey pathways and interviewing. Ask the staff how they know the code status of the residents. Ask residents if their advance directives are reviewed with them quarterly, as outlined in the CMS State Operations Manual Appendix PP.
LeadingAge Ohio encourages facilities to monitor compliance using the surveyor guidance found in the State Operations Manual Appendix PP . Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo. The previously provided survey tips can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.
For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the July 7 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.
