Attachment N_Scope and Severity Ratings.pdf

Scope and Severity Rating Descriptions (Scope and severity rating descriptions A-L are described below.

Ratings are listed in order from least serious to most serious ratings.)

Ratings with Potential for Minimal Harm

A Isolated/Potential for minimal harm – Least serious rating and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor impact on the resident(s).

B Pattern/Potential for minimal harm – Least serious deficiency but affects more than a limited number of residents, staff or occurrences. This deficiency has the potential for causing no more than minor negative impact on the resident(s) and was not found to be throughout the facility.

C Widespread/Potential for minimal harm – Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents, but has the potential for causing no more than a minor negative impact on the resident(s).

Ratings with Minimal Harm or Potential for Actual Harm

D Isolated/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency and is isolated to the fewest number of residents, staff or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential to negatively affect the resident’s ability to achieve his/her highest functional status.

E Pattern/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency and affects more than a limited number of residents, staff or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status.

This deficiency was not found to be throughout the facility.

F Widespread/Minimal harm or potential for actual harm – This is a less serious (but not the lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status.

Ratings with Actual Harm

G Isolated/Actual harm – This is a more serious deficiency but is isolated to the fewest number of residents, staff or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status.

H Pattern/Actual harm – This is a more serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status. This deficiency was not found to be throughout the facility.

I Widespread/Actual harm – This is a more serious deficiency that was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency results in a negative outcome that has negatively affected the residents’ ability to achieve his/her highest functional status.

Ratings with Immediate Jeopardy

J Isolated Immediate Jeopardy – This is the most serious deficiency although it is isolated to the fewest number of residents, staff or occurrences.

This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

K Pattern/Immediate Jeopardy - This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout the facility.

L Widespread/Immediate Jeopardy - This is the most serious deficiency and was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

Definitions of Scope

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 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 practice. The effect of the deficient practice is not found to be pervasive throughout the nursing home.

Widespread: When the problem(s) causing the deficiency is pervasive in the nursing home and/or represents a systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents.

Scope and Severity Grid

Immediate Jeopardy to the residents health and safety Level 4 J K L

Actual Harm that is not immediate jeopardy

Level 3 G H I

No Actual Harm, with potential for more than minimal harm Level 2 D E F

No Actual Harm, with potential for minimal harm Level 1 A B C

Isolated Pattern Widespread

Corrective Action Plans

The Scope and Severity Grid is utilized as part of the unannounced survey process. Facilities will receive their final report which will address TJC standard, the Federal Tag, and a letter rating (A-L) that denotes the scope and severity of the deficiency.

Letter ratings J-L constitute immediate jeopardy. Immediate jeopardy is a situation where the facility’s failure to meet a requirement has caused or is likely to cause serious injury, harm, impairment, or death of a resident. If at any time a member of the unannounced survey team identifies possible immediate jeopardy, the team will alert the Office of Geriatrics and Extended Care Operations immediately and will remain at the facility until the immediate jeopardy is abated.

Letter ratings H and above require an action plan to be submitted to the Office of Geriatrics and Extended Care Operations within 7 days of completion a conference call to discuss the immediate actions taken. Immediate jeopardy deficiencies must still be included in the final corrective action plan.

Letter ratings G and below require an action plan to be submitted to the Office of Geriatrics and Extended Care within 30 days of receipt of the final report.

The Office of Geriatrics and Extended Care will initiate a follow-up process with the facility to ensure that action plans are appropriate and that deficiencies are corrected.

Dispute Resolution

If a facility disagrees with any of the survey findings, the facility must submit a written statement to the Office of Geriatrics and Extended Care Operations within:

7 business days of the end of the conference call to discuss the immediate actions for H and above letter ratings

10 business days of receipt of the final report for all other scope and severity ratings.

A dispute resolution team will be convened to review the dispute documents.

The Office of Geriatrics and Extended Care Operations will make the final determination regarding the dispute. If the Office of Geriatrics and Extended Care Operations concurs with the facility, the report will be amended and returned to the facility.

Please address your statement to Lisa Minor, Rhonda Toms, and Amy Erlandson. The statement must include the Federal Tag, letter rating, and an explanation of how the facility meets the standard. Any additional, substantive information should be included (facility policies, procedures, directives, etc.)