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Casting a Wide Regulatory Net: Professional Standards of Quality - Remedi SeniorCare

By: William M. Vaughan, BSN, RN, Vice President, Education and Clinical Affairs, Remedi SeniorCare

Reviewing the 2019 update to the American Geriatrics Society’s Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, I reflected on the role of such publications in the nursing home survey process. The Beers Criteria is referenced in the CMS Guidance to Surveyors under F758 (Unnecessary Drugs) and F759 (Psychotropic Drugs). CMS notes that the Beers Criteria “provides information on safely prescribing medications for older adults,” along with a standard disclaimer that “references to non-CMS sources do not constitute or imply endorsement of these organizations or their programs.” Despite this, CMS clearly believes the value of providing the Beers Criteria to surveyors, presumably for use in determining compliance with federal regulations.

So how do standards, published by organizations outside of CMS, gain traction in the survey process? The answer can be found at F658 (Comprehensive Care Plans), which reads in part, “The services provided or arranged by the facility ... must meet professional standards of quality.” Professional standards of quality are then broadly defined in the associated Guidance to Surveyors: “Professional standards of quality” means that care and services are provided according to accepted standards of clinical practice. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency.

A review of recently cited deficiencies under F658 provides insight into how surveyors are interpreting this regulation.

  • A resident’s knee was twisted during a one person transfer resulting in immediate complaints of pain. The resident’s leg was not assessed for 24 hours, at which time she was sent to the hospital and diagnosed with multiple fractures. In the deficiency, the surveyor referenced a chapter on pain management from the textbook, Fundamentals of Nursing Practice as the unmet professional standard.
  • While observing a medication pass, the surveyor noted that the nursing staff did not wash their hands or use an alcohol-based hand sanitizer in between contact with multiple residents. The surveyor referenced the CDC Guidelines for Hand Hygiene in Healthcare Settings as the unmet professional standard.
  • A facility was cited for failure to provide CPR to a resident who orally and in his advance directive requested the intervention. The unmet professional standard was referenced in the American Heart Association’s guideline for CPR.
  • Promoting person-centered care, a nursing facility liberalized their medication pass times which allowed for four-hour blocks in which to administer selected medications. The surveyors then cited the facility for this practice, erroneously noting that “.... professional standards only allow one hour before or one hour after the scheduled time for the medication administration ... if the medication was administered outside of the two-hour window … then a medication error was made.” To support the surveyors’ conclusions, the deficiency contained a reference to a 2011 Institute for Safe Medication Practices (ISMP) document, “Guidelines for Timely Administration of Scheduled Medications (Acute)*.” This document addressed medication management in the acute care setting and was written five years before the person-centered “mega rule” was implemented. The surveyors were also unaware of the admonition in the Guidance to Surveyors under F759 (Medication Error Rate) to, “Count a wrong time error if the medication is administered 60 or more minutes earlier or later than its scheduled time of administration, but only if that wrong time error can cause the resident discomfort or jeopardize the resident’s health and safety.” Although unclear if the facility disputed this deficiency, it would have been our strong recommendation to challenge the citation. 

Nursing facilities should care for their residents using evidence- based practices, many of which can be found in publications referenced in the Guidance to Surveyors under F658. As evidenced by the above deficiencies, in practice, these publications ultimately have the force of regulations.


This content is brought to you by William M. Vaughan, Vice President, Education and Clinical Affairs at Remedi SeniorCare. William was a surveyor with the Maryland State Survey Agency from 1988 until 2001. He became Chief Nurse of the agency in 2001 and remained in that position until joining Remedi SeniorCare in 2013.

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