How to address the top 10 F-tags in long term care & why compliance matters

After the comprehensive inspection, the facility receives a report detailing the areas the staff must address to remain compliant with federal regulations. The F-tag, or federal tag number, refers to the code’s section relating to a particular deficiency.^1,2

Patricia Howell, RN, BSN, WCC, CFCS and clinical support manager at McKesson Medical-Surgical, defines F-tags as patient-centered and the foundation of quality care – though they may carry a negative association for nursing home employees.

Howell has worked in various levels in nursing homes since 1991, so she’s well versed in the importance of F-tags in addressing quality of care issues effectively and efficiently. She’s also familiar with why F-tags for long term care show up on surveys, and what tools and resources are available to resolve them.

Here, with exclusive insights from Howell, we’ll outline the top ten most commonly cited F-tags and offer causes, challenges and solutions.

1. F-tag F884: Reporting – National Health Safety Network

This F-tag for reporting COVID cases joined the list in May 2020. Due to COVID’s prevalence among the nursing home population (staff included), many facilities have struggled with compliance around F884.

Because increased surveillance and documentation requirements are time-consuming, compliance around this F-tag remains challenging as the industry continues to become inundated with cases and personnel shortages due to the pandemic.

Even though COVID is no longer at its peak prevalence, how LTC facilities respond to and report its past, present and future occurrences is ever-evolving – leaving room for opportunity and growth alongside its challenges.

Howell believes we need to leverage technology to help track, capture and deliver the data. If long term care providers don’t have those tech tools, she highly recommends investing in finding and procuring a system that works – and training users in effective operation.

2. F-tag F880: Infection Prevention and Control

Howell says infection prevention (IP) practices and protocols have been “under the microscope” because of COVID. She adds that this F-tag was of particular concern pre-COVID because the improper handling of it can harm residents and staff.

“Everyone’s hands are in it – literally and figuratively,” she explains. “Whether they’re not washing their hands at all, or not washing them correctly.”

In addition to following proper hand-washing protocols, compliance around F880 for long-term care was challenging during COVID as it relates to personal protective equipment (PPE) and adherence to isolation guidelines.

3. F-tag F689: Free of Accident Hazards/Supervision/Devices

The primary reason this F-tag for long term care makes the top ten list? Patient falls. In fact, according to the Centers for Disease Control and Prevention (CDC) data, one in five falls causes serious injury and other negative outcomes for both the resident and nursing home provider.³

4. F-tag F686: Treatment/Services to Prevent/Heal Pressure Ulcers

Pressure ulcers are an unfortunately common occurrence in nursing homes, affecting 2.5+ million residents annually.⁴

According to Howell, it’s not just the treatment piece that’s problematic. It’s about preventing, knowing, treating and documenting these skin injuries.

Wound care requires time, focused attention and specialized clinical training – three things many nurses in understaffed nursing homes lack. Howell states that documentation (or a lack thereof) is a stumbling block in addition to the personnel issue. If wound care isn’t properly documented, there’s no proof it’s being done.

Also, different nurses have different treatment protocols and practices, says Howell. If a new treatment nurse comes in as a shift substitute or a new hire, she may have an entirely different wound care routine. Though it may be a good approach, she must communicate it to all team members involved and document it effectively.

5. F-tag F684: Quality of Care

This commonly cited F-tag encompasses a wide range of issues in nursing home care, and it’s also foundational concerning patient safety, quality of life and outcomes.

According to Howell, understanding the root cause is important in addressing quality care citations. “If people aren’t following procedures or practices, we need to understand why,” she explains.

For example, consider infection prevention related to the spread/containment of COVID. “If proper hand-washing practices weren’t followed, leaders need to ask why,” says Howell. “And if the response is ‘I was in a hurry,’ the leader needs to ask, ‘Why were you in a hurry?’ and so on until you get to the bottom line.”

In fact, Howell believes that root cause analysis requires asking “why” at least five times to drill down to the root of the problem.

“Were they not washing hands or wearing appropriate PPE because supplies hadn’t been refilled or because the gloves weren’t placed in an accessible, convenient location? These are the things leaders need to understand to correct and resolve the root cause, rather than just guessing,” she says.

6. F-tag F812: Food Procurement, Store/Prepare/Serve – Sanitary

Compliance around this F-tag for long term care isn’t limited to the kitchen, but includes anywhere in the facility where food preparation is happening or wherever food is stored.⁵

For example, this evaluation includes meals delivered to rooms on trays and carts – which frequently happened during isolation periods for COVID. Cross-contamination, food safety and temperature, product freshness and expired foods are all aspects of safe and sanitary food service in a long term care setting.⁶

7. F-tag F677: ADL Care Provided for Dependent Residents

Activities of daily living (ADLs) assistance is foundational for any LTC facility. But ADLs are comprehensive, including everything from bathing and grooming to dressing and eating, as well as incontinence care and toileting. Compliance around this F-tag is often related to grooming because these are time- and labor-intensive tasks that require hands-on care – and sometimes, more than one staffer.

With understaffed facilities, providing regular showers/baths – and even dressing residents in clean clothes – may prove challenging.

Howell recalls a community where the administrator invested in hiring additional (outside) personnel to help specifically with these tasks so his in-house staff could focus on all other care, including medication management and wound care.

8. F-tag F656: Develop/Implement Comprehensive Care Plan

Just as ADL care is one of the key building blocks of service in post-acute care and long term care settings, determining what each resident needs in terms of that support stems from the all-important care plan. Much is required in terms of human and time resources to standardize and streamline the development, tracking, updating and implementation of these plans, yet doing so is critical in terms of compliance.

9. F-tag F761: Label/Store Drugs and Biologicals

An essential component of medication safety includes properly storing and labeling the drugs, supplements and biologicals managed by care staff. Compliance around F761 is challenging for many of the same reasons as the above citations, particularly the time and hands-on attention of personnel required.

10. F-tag F609: Reporting of Alleged Violations

Reporting alleged violations is another area where compliance is difficult for many LTC facilities. Communication and documentation are non-negotiable when it comes to this F-tag. However, both can easily break down or get lost in the shuffle without leadership, accountability and enforcement.

Bonus: 8 tips for F-tag compliance resolution

Whether you’re reviewing a compliance issue among these commonly cited F-tags – or others not on this list – there are a few universal principles Howell recommends for bringing your community into compliance (and keeping it there).

1 | Investigate: Employ the root cause analysis strategy to drill down on a problem area instead of assuming you know the reason or guessing what it might be. Are outside visitors complying with your long-term care community’s policies and procedures? You might have 100% compliance from your staff on hand-washing, but you keep having infection control issues. Part of root-cause analysis includes considering every person who passes through your doors.

2 | Evaluate: Make regular risk assessments. Know your residents well to better understand the problems, hazards and risks unique to your community. For example, is an access door close to the locked memory care unit left open every time a vendor comes? “Look at the problems and trends in your community, check the pulse and always ask why”, says Howell.

3 | Educate: Take advantage of all available resources to learn best practices and new procedures and stay updated on changing regulatory requirements. And share this valuable information with everyone in your long-term care facility who would benefit from it.

4 | Notate: Write it down! Howell can’t emphasize this enough. There’s no proof that something happened without written records that include essential details such as dates, times, persons involved, protocols initiated, care delivered and so on. Leaders must develop (and put in writing ) their plans to resolve issues revealed by their risk assessments, their plans to address citations and any/all care plans for the resident population.

5 | Communicate: Howell says that when you’ve done the hard work of documentation, plan creation and implementation, make sure everyone knows about it. Hold team huddles with the entire staff covering every shift. What good is a new hand-washing protocol if the housekeeping staff, who visit resident rooms in a hands-on way daily, don’t know to comply with it – or if no one is even checking on their compliance?

6 | Advocate: “Find your champions and lean on them,” says Howell. “It doesn’t always have to be the director of nursing.” By encouraging all staff to spearhead initiatives, conduct risk assessments or encourage new ideas for compliance resolution, you give them a voice – improving staff morale, which then helps improve resident care.

7 | Integrate: Reporting requirements and regulatory changes are happening all the time and you can’t hit pause on daily care and services when you need to catch up. What you can do – even at an additional cost – is take advantage of tech tools or hire additional personnel to lighten the load for frontline staff.

8 | Update: Keep an eye on your progress rather than waiting until the next survey and make changes accordingly. Howell also endorses a “check the checkers” policy for accountability. For example, if you’ve delegated the oversight of a new safety plan to your maintenance director, don’t just assume the work is getting done. Check-in to verify and check any documentation indicating it’s been done.

Improving outcomes through F-tags for long term care

Managing compliance and addressing citations in a constantly changing regulatory landscape is daunting, especially in the face of industry shortages.

A recent American Health Care Association (AHCA) study estimates that more than 400 nursing homes will likely close this year and 300 already closed during the pandemic. Another AHCA study claims that 94% of nursing homes reported staffing shortages, which limited admissions for 58% of these facilities.^7,8

In light of these challenges, it’s vital for long-term care industry leaders to work with supporting organizations and engage all available resources for the continued provision of – and improvements to – quality care and outcomes.