When the Department of Health, Office of Health Care Facilities Licensure and Certification surveys a nursing facility and finds it is not in compliance with the regulation, it cites the deficient practice. Each health and Life Safe Code deficiency is assigned a Scope and Severity (SS=__), which can be found in the left-side column of the survey report, in the column marked (X4) ID Prefix Tag. For example, a deficiency noted as SS= L means the deficient practice is widespread in the facility and presents an immediate threat to the health or safety of residents. Conversely, a deficiency noted as SS=A, indicates the practice is isolated and has the potential for a minor negative impact on residents. Just above the SS=__ is the survey tag reference number.
Scope
Has three levels:
-
Isolated — when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.
-
Pattern —when more than a very limited number of residents are affected and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.
-
Widespread — When the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents.
Severity
Has four levels:
Level 1 — has the potential for causing no more than a minor negative impact on the resident(s).
Level 2 — has the potential for no more than minimal physical, mental, and/or psychosocial discomfort to the resident and/or has the potential to compromise the resident(s) ability to maintain and/or reach his/her highest practicable physical, mental, and/or psychosocial well-being.
Level 3 — results in a negative outcome that has compromised the resident(s) ability to maintain and/or reach his/her highest practicable physical, mental, and psychosocial well-being.
Level 4 — is immediate jeopardy, a situation in which immediate corrective action is necessary because the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death.
Bold letters within the grid denote deficiency ratings that constitute Substandard Quality of Care if the requirement that is not met is one that falls under the following regulations:
-
42 CFR 483.13 Resident behavior and facility practices.
-
42 CFR 483.15 Quality of life.
-
42 CFR 483.25 Quality of care.
Any deficiency rating in the top row of the grid, for any regulation constitutes Immediate Jeopardy.
Substandard Quality of Care is a technical regulatory term which means that one or more requirements under the federal regulations were not met. A finding of substandard quality of care indicates that the nursing home was found to have had a significant deficiency / deficiencies, which the home must address and correct quickly to protect the health and safety of residents.