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New anti-retaliation regulations now in effect

Doug Beardsley
By Doug Beardsley  |  September 6, 2019  |  SNF/NF providers




Immediate jeopardy (IJ) deficiencies at skilled nursing facilities/nursing facilities (SNFs/NFs) continue to be issued at a record pace by the Minnesota Department of Health (MDH). Data provided to Care Providers of Minnesota by MDH on September 3, 2019, indicates 42 IJs have been issued to-date in 2019.
  • 28 IJs issued as a result of free-standing complaint investigations (48%)
  • 10 IJs issued as a result of previously received complaints investigated during the annual certification survey (24%)
  • 3 IJs issued as a result of observations during the annual certification survey (no previous complaint) (7%)
  • 1 IJ issued as a result of a dementia focused survey

For comparison, 37 total IJs were issued during the entire 2018 calendar year, 27 IJs were issued in the 2017 calendar year, and 11 were issued in calendar year 2016. The IJs issued to-date in 2019 include:
  • F600—Freedom from abuse or neglect: 15 (36%)
  • F689—Accidents and supervision: 11 (26%)
  • F678—CPR related findings: 6 (14%)
  • F684—Quality of care: 5 (12%)
  • F686—Pressure ulcers: 2 (5%)
  • F578—Advance directives: 1 (2%)
  • F760—Medication error(s): 1 (2%)
  • F880—Infection control: 1 (2%)

With almost 50% of IJs resulting from investigation of complaints or facility reported incidents, providers need to focus on what they include in their immediate suspected maltreatment reports to OHFC. MDH surveyors need to make an initial determination of potential immediate jeopardy based exclusively on information provided in the initial immediate report, they cannot wait for additional information or details submitted in the 5-day investigation.

When possible, facilities should include the following information in your initial immediate report:
  1. What did you see the suspect do or what has caused this suspicion of maltreatment?
  2. What immediate actions have you taken to:
    1. protect the individual that was potentially maltreated?
    2. provide medical care to the individual (when appropriate)?
    3. protect other residents who may be exposed to similar potential maltreatment?
  3. If the situation or suspicion supports it, did you contact 911?

By providing this information, the triaging surveyor may be able to rule out the need to conduct an on-site investigation within two days to determine if an immediate jeopardy situation existed or continues to exist. The subsequent five-day report may then give additional data to determine if a 10-day onsite investigation is needed, or if the incident can be investigated later or not at all.

If the report does not include these critical elements, it is more likely to be triaged as a possible immediate jeopardy situation requiring an onsite investigation within two days. 

Facilities should verify that staff who submit maltreatment reports understand how important it is to include information on these critical elements in the initial maltreatment report.



Doug Beardsley  |  Vice President of Member Services  |   dbeardsl@careproviders.org  |  952-851-2489

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