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Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

Federal Regulation F309

"Quality of Care: Provide Necessary Care for Highest Practicable Well-Being"

South Dakota long-term care facilities had 12 deficiencies cited for F309 in 2010. It ranks number 10 in the top twenty deficiencies for long-term care facilities in South Dakota. Receiving a deficiency for this regulation is not desirable because when it is cited, it means there are system problems and there may be additional deficiencies cited which overlap with F309. A positive message to take from this regulatory update is: F309 ranks 10th in the top twenty deficiencies and it was cited 12 times. When we look at the number of nursing homes in South Dakota, it could really be much worse than this, so it is something to be grateful for when looking at the whole picture.

The regulation F309 states,

"§483.25 Quality of Care

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care."


The intent of this requirement is to ensure the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process. F309 includes, but is not limited to, care such as end-of-life, diabetes, renal disease, fractures, congestive heart failure, non-pressure-related skin ulcers, pain or fecal impaction.

In any instance in which there has been a lack of improvement or a decline, the survey team must determine if the occurrence was unavoidable or avoidable. A determination of unavoidable decline or failure to reach the highest practicable well-being may be made only if all the following are present:

  • An accurate and complete assessment;
  • A care plan which is implemented consistently and based on information from the assessment;
  • Evaluation of the results of the interventions and revising the interventions as necessary.

There are 49 pages of Guidance to Surveyors for F309. If you haven't reviewed the content of the Guidance to Surveyors for F309, I strongly encourage you to do so. If it is determined a facility is non-compliant with F309, there are several other regulations which may or may not be cited as well, and they include:

  • 42 CFR 483.10(b)(11), F157, Notification of Changes - cited when it is determined staff have not notified the resident and consulted the physician regarding significant changes in the resident's condition or need to alter treatment significantly or notified the representative of a significant condition change.
  • 42 CFR 483.(20)(b), F272, Comprehensive Assessments
  • 42 CFR 483.20(k), F279, Comprehensive Care Plan
  • 42 CFR 483.20(K)(2)(iii), 483.10(d)(3), F280, Care Plan Revision
  • 42 CFR 483.20(k)(3)(i), F281, Services Provided Meets Professional Standards of Quality
  • 42 CFR 483.20(k)(3)(ii), F282, Care Provided by Qualified Persons in Accordance with Plan of Care
  • 42 CFR 483.30(a), F353, Sufficient Staff
  • 42 CFR 483.40(a)(1)&(1), F385, Physician Supervision
  • 42 CFR 483.75(f), F498, Proficiency of Nurse Aides
  • 42 CFR 483.75(i)(2), F501, Medical Director
  • 42 CFR 483.75(l), F514, Clinical Records

If F309 is cited, it is usually an indication of system problems relating to the above listed regulations, and thus, there is a high potential any and all of the above listed regulations could be cited when F309 is cited.

There are two factors I would like to address with this update. The first is for facilities to ask how they approach problems of (two examples of quality care concerns) pain management and skin issues other than pressure sores.

  • If there are residents on a pain management program but are still grimacing or having behavior problems, does the staff reassess the residents' responses to the pain management plan and look at other alternatives for pain management for these individuals?
  • If there are residents who have problems with sustaining skin tears, does the staff look at options for preventing the skin tears with resulting care plan revisions? Skin tears are significant issues in maintaining compliance with F309. Residents in nursing homes have compromised immune systems. When there is a break in their skin there is a break in their first line of defense against infections.

A facility which has excellent systems in place to counteract quality of care problems and a team consistently implementing the systems/processes, will find quality of care issues to be nonexistent or at a minimum.

If your facility would like to improve regulatory compliance and quality of care, contact AESS at (605) 668-8475 for solutions.


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.

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

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.