Jeannine LeCompte, Publishing and Research Coordinator
The Centers for Medicare & Medicaid Services (CMS)’s State Operations Manual (SOM) states that all long-term care facilities must ensure that they have an “active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility.”
F-tag 837 (F837), “Governing Body,” is based upon the SOM’s section 483.70(d)(1)–(3), which includes the requirement that a process be developed for the “frequency by which the administrator reports to the governing body, the method of communication between the administrator and the governing body, including how the governing body responds back to the administrator and what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the governing body.”
A review of some citations issued by CMS under F837 serves as a valuable illustration of the types of communication lapses which can result in punitive measures against a facility.
– In Connecticut, a facility was cited for failure to ensure that medical staff bylaws were established, and a process for the initial appointment and/or reappointment of medical practitioners was implemented and reviewed by the governing body. This would have fallen under the reporting requirement of Administration, and that department’s failure to report this issue was the primary cause of the citation.
– In Massachusetts, a facility was cited for a failure to ensure that the appointed nursing home administrator, who was responsible for the management of the facility, held a current and unencumbered license to practice. This was a failing of the reporting process by the human resources department who was responsible for screenings and license review, resulting in failure by the governing body to appoint an administrator who is appropriately licensed.
– In New York, a facility was cited for failure to establish and implement policies regarding the management and operation of the facility, which should have included establishment of a two-way communication system with the governing body. This was a failing on the part of the governing body, in that they did not appoint and maintain an individual who was responsible for the management of the facility to ensure regulatory compliance.
– In Georgia, a facility was cited for failure to ensure that a process was in place to identify risk and exposures, and to guarantee that there was effective communication between the governing body, the facility administrator, and the staff. This failure can be laid directly at the door of the governing body itself, which in this particular case, consisted of individuals who were heavily involved in the administration of several different facilities, and were thus negligent in maintaining compliance across a number of those organizations.
– In Washington DC, a facility was cited for failure to ensure that an action plan was developed and implemented to ensure that facility staff thoroughly investigated an accident which resulted in a resident sustaining a serious fracture and multiple bruises. This incident should have automatically been flagged for the attention of the governing body through a risk-based reporting system.
– Also in Washington DC, a facility was cited for failure to ensure that action plans were developed and implemented to prevent residents from smoking in their rooms and to record investigations of resident-to-resident altercations as a potential for abuse. This should have been flagged by the internal audit system for reporting purposes to keep the governing body informed.
– A Georgia facility was cited for failing to produce evidence that demonstrated the active involvement of a governing body for establishment and implementation of the Quality Assurance Performance Improvement (QAPI) program. This function should have been fulfilled by administration and should have been a priority with the governing body—who most likely were not even informed about the requirement.
These examples, which span almost all areas of operations, highlight the need for a facility to develop an appropriate, timely, two-way communication program with their governing body.
