CDPHE Regulatory Updates-January 2020

• F 689 IJ cited recently    Surveyors are digging deep into fall investigations. They are looking closely at any root cause analysis and  scrutinizing interventions to insure they are being implemented, care planned and staff education being provided related to individualized plans.
• The Department helped clarify a couple of long debated CNA tasks.  1. CNA’s can fill 02 tanks and can set the flow of 02 as long as it is a set number. They cannot titrate. The DON or RN has to provide training and can delegate to the CNA. The facility must have a policy detailing this. 2. CNAs can change colostomy bags as long as they have been properly trained.
• The Department is investigating FRIs of abuse and neglect within 3-45 day time frames, depending on the assessment of resident risk at the time facilities report. So, if you report any form of abuse or neglect understand that CDPHE will be coming out to investigate. When possible facilities should complete their own investigation, create a POC and review in QAPI prior to CDPHE coming on site to investigate. Completing the POC and QA review prior to the surveyor review could result in a past non-compliance citation which avoids submitting a POC and likely a revisit, both good things.
• A focus on weight loss from CDPHE is resulting in significant compliance outcome.  Weight loss has been cited at “H” level with fines.  All persons with probable weight loss due to diagnosis and poor food and fluid intake need to have RD review, care plan and regular checks on interventions.  If weight loss has occurred, regular RD and IDT review must be done with corresponding documentation. Medical providers must be notified of weight loss and documented of the notification.  A request for unavoidable weight loss status is suggested. If weights are refused, document in the progress note.