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Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

F281 Professional Standards of Quality

This regulation was the second most cited regulation in 2010 with 42 deficiencies for long term care facilities in South Dakota. The number of deficiencies cited for this regulation is less than the number cited in 2009 by two deficiencies which makes it a 4% decrease. The regulatory language for this regulation is, “The services provided or arranged by the facility must—(i) Meet professional standards of quality”. When does this regulation get cited? The Guidance to Surveyors says, “When a negative resident outcome is determined to be related to the facility’s failure to meet professional standards, and the survey team determines a deficiency has occurred, it should be cited under the appropriate quality of care or other relevant requirement. The surveyors should question only those practices which have a negative outcome or have a potential negative outcome.

Last year I included several resources for standards of practice for facilities to use when questions arise regarding standards of practice. As I write this article today in the dead of winter when the pace is slower and we have less sunlight, I am led to look deeper into the question of how to achieve compliance with the professional standards regulation. If only achieving compliance with professional standards of quality in your facility would be as simple as telling your staff to accomplish tasks like the ones included in this list –

  • Administer medications according to policy and procedure and manufacturers’ recommendation
  • Complete procedures correctly
  • Make sure all patients/residents have an individualized care plan based on their comprehensive assessment
  • Treat all residents/patients with dignity and respect
  • Maintain the residents/patients’ right to confidentiality
  • Make sure the water temperatures are safe
  • Store, prepare, and serve food in a way to prevent food borne illness
  • Notify families when there is a change in the resident/patient’s condition.

If only it could be that simple, but it is not. We cannot assume that just because an individual has a nurse’s license, or has completed training for a nurse aide certification, they will consistently provide resident/patient care according to professional standards of care.

What are the solutions? How can our healthcare facilities develop their teams in such a way that will ensure compliance with professional standards of quality?

Sometimes we have to go to the very core of why we are providers of healthcare. Most facilities have a mission statement, and if your facility does not, I would recommend developing such a statement. There is no regulation requiring healthcare facilities to have a mission statement, but this may be one part of a solution to becoming a place where professional standards of quality thrives.

Having a mission statement does not magically make the healthcare facility compliant with professional standards of quality requirements, but it is part of it. What does your facility’s mission statement state? What does it mean to you in your own words? Too often we get caught up in all of the details and tasks and we forget why we chose to work in healthcare. How awesome it is when we discover our employer has a mission statement that we can take pride in every work day, a mission statement that focuses on the highest good for the residents/patients and employees. If your facility does not have a mission statement, what can you do to bring about a change in this area?

Recently I reviewed an article in the December 2010 issue of the Hospitals and Health Networks magazine. The article was titled “How to Hire Employees Who Live the Mission”. It was a brief article that spoke volumes. The article spoke about interview questions which were used at Scottsdale (Arizona) Healthcare during their hiring process with the intent of supporting the facility’s vision for setting a standard of excellence for personalized care. The facility has a set of nine guiding principles and interview questions to support their standards of excellence. The principle, “We deliver exceptional service as an integrated team,” was assessed by asking the applicants to define teamwork and to identify at least two expectations they would have of their colleagues while working together during a shift. The applicants’ answers to these questions provided valuable information to assist in hiring decisions. In 2010 their turnover rate was 5 percent and patient satisfaction was in the 90th percentile.

In this same article Randall Carr, Vice President of Learning and Leadership Development at Covenant Health in Knoxville, Tennessee was quoted as saying, “The most important thing a leader can do is hire the right people.” This facility uses a 20 minute video which shows subtle signs of patient satisfaction and dissatisfaction. For example, a lost patient/resident looks around the lobby to see chatting employees walk past unaware. Interview questions are used that are designed to determine if the applicant picks up on the clues. How the applicants respond to the video assists the facility in hiring people who are patient/resident-centered.

In conclusion, there are many ways to achieve compliance with F 281 Professional Standards of Quality. One of the ways to achieve compliance involves a facility developing a way to choose the right people for its team – a team that shares the same values and goals, understands the facility’s mission and their role in that mission, and then participates completely for the highest good of the residents/patients and employees.

Contact me at mapederson@avera.org for all of your Regulatory Compliance and Survey Preparation needs.

Do the math! The facility bottom line improves when resident care continually improves.

As a former health facilities senior surveyor, Marci worked at the Department of Health Office of Licensure and Certification for eight years. Marci provides Survey Preparedness Consulting designed to create a culture of constant survey preparedness by helping staff understand regulatory requirements, not just comply with them.

Read more Regulations Updates.The Avera Solutions’ Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.


Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.

Have a question for Marci? A topic idea for her next column? Need more information on having a mock survey at your facility? Send her an email at mapederson@avera.org.