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Survey success depends on knowing recent SOM revisions

May 1, 2007
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Survey survival” within the January 2007 revisions of the State Operations Manual (SOM) will most often require substantial policy, procedural, and practice changes. Such is the case with F329 Unnecessary Drugs; historically this requirement has been problematic for providers. A quick statistical review of pertinent OSCAR data using the Kaiser Family Foundation's information ( finds that, during 2002 when survey enforcement leveled off, F329 ranked number 12 among the top 40 most frequently written deficiencies, representing 1,369 facilities and potentially affecting the 120,615 community members residing within.

Over the past five “softer” survey years, survey circumstances were not much better. In 2005, 16.9% of facilities were cited with actual harm or immediate jeopardy level deficiencies, along with 29% out of compliance in the area of Quality of Care (within which F-tag 329 falls), 28% in Professional Standards, and 23% in Accidents. All three areas are used as benchmarks of quality when assessing a facility's service capabilities.

The SOM's 504 pages included additional revisions such as F334 Influenza and Pneumococcal Immunizations, F356 Nurse Staffing Information, F369 Paid Feeding Assistants, F425 Pharmacy Services, F428 Drug Regimen Review, and F431 Labeling and Storage of Drugs and Biologicals.

The new revisions are accompanied by determination of compliance information, definition of terms along with reference materials, and endnotes, because these revisions require providers to review with a critical eye and possess knowledge of process needs when making system changes. One must also gain a clear understanding of the methodology used to determine citations. For example, Behavior and Mood Management systems and Alzheimer's and Related Dementia programs have the potential to be greatly affected by revisions found in F329 and F425–431.

For providers to remain in compliance with the comprehensive systems found in long-term care, the following items must be considered, or positive regulatory outcomes and service provisions will remain in jeopardy:

  • Set the standards of care based on regulation and professional practices.

  • Review, revise, and/or develop policies and procedures.

  • Assess and allocate adequate funds.

  • Acquire necessary equipment/tools/forms and supplies.

  • Develop staff education/competency modules and QA mechanisms.

  • Develop staffing system (includ-ing accountability, responsibility, job descriptions, chain of command, and wages).

  • Educate staff and designate system start date.

  • Implement system with ongoing QA review.

The SOM revisions are good and long overdue. They provide a host of information as a starting point, but do require providers to invest precious time and energy in process development by experts that have the gift of patience and an open mind. This is best summarized by Larry the Cable Guy: “GIT-R-DONE!”

Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky.

For more information, phone (877) 987-2001 or visit to download a free PDF copy of the recent 1-2007 SOM. To send your comments to the author and editors, e-mail