SMART Data Shows Year-to-Date Deficiency Trends
Analysis of data from 2567 reports through August 20 shows a significant increase in citations resulting in Substandard Quality of Care and Immediate Jeopardy.
This data has been entered into the VHCA Survey Management and Analysis Resource Tool (SMART).
The 2567 reports show that from January to August 20, 2016:
- There has been a significant increase in the average number of deficiencies cited statewide during a standard survey in 2016 compared to the same time frame in 2015 from 8.63 to 9.18.
- Focus on Accident and Safety and Pressure Ulcers at levels that will place nursing facility at risk for immediate imposition of sanctions.
- 15 percent of all surveys in 2016 have resulted in at least one Level 3 (actual harm) deficiency compared to 12.5 percent for the entire year of 2015.
Serious Citations – All Surveys
| Level 3 – Actual Harm | Substandard Quality of Care | Level 4 – Immediate Jeopardy | |
| 9/1/15 – 8/20/16 | 34 | 18 | 10 |
| 9/1/14 – 8/20/15 | 45 | 7 | 6 |
Over this time frame:
- F-Tag 323 Accident & Safety has contributed to most of the serious deficiencies:
- 11 of 34 G Levels tags
- 7 of the 18 substandard Quality of Care tag
- 7 of the 10 Immediate Jeopardy tags
- F-Tag 314 Pressure Ulcers was the second most frequently cited tag for serious deficiencies
- 6 of the 34 Level 3 tags for actual harm plus 4 of the 18 substandard quality of care (this means cited at Level of H or I)
Top 10 Deficiencies for 2016 Year-to-Date (8/20/2016) – All Survey Types
| F-Tag | Regulation | # times Cited | Most Frequent Reasons for Citation | |
| 1. | 309 | Quality of Care | 60 | Medication administration; diabetic management; not following physician orders, unnecessary medications |
| 2. | 514 | Clinical records – order | 48 | Inconsistency/accuracy; omissions; physician order sheet not updated |
| 3. | 323 | Accident prevention – environment | 38 | Hazardous materials not secured; supervision not provided; preventive devices not applied |
| 4. | 281 | Services meet professional standards | 36 | Orders not clarified, diabetic management; orders not followed; omissions/failed to document |
| 5. | 441 | Infection Control Program | 35 | Infection control tracking, infection control during treatment/wound care and medication administration |
| 6. | 329 | Unnecessary drugs | 35 | Did not follow parameters; about 2/3 were for meds other than antipsychotic including non-psychoactive meds; failed to document non-pharmacological interventions prior to administration of PRN medications |
| 7. | 280 | Care plan 7-days/team/periodic review | 34 | Care plan not revised after falls, change in condition such as pressure ulcers and when orders were discontinued |
| 8. | 278 | Accuracy of assessment | 32 | Interviews not done; section O for influenza vaccination; section G for ADLs; Section H for bladder; and CAA location/date in section V |
| 9. | 371 | Food storage/preparation/distribution | 32 | Hair restraint not used; items not covered/labeled/dated; expired foods, food temperature |
| 10. | 425 | Pharmacy Services | 31 | Over ¾ were related to medications not being available; others related to expired medications/biologicals; controlled medication management |