Savvy on the SOM’s Blog Roll

05.21.2019

Depression and PDPM

Maximizing reimbursement under PDPM requires a new, more careful understanding of the MDS assessment. This is not, nor has it ever been, a “fluff” tool. It is not just another PIA from CMS!

Under PDPM, a complete and accurate MDS assessment – done by the specific disciplines whose expertise will result in the most accurate assessments – will make the difference in a facilities financial survival.

Consider this quote from Vintage Voices: Depression in Nursing Homes, an article by Richard Juman, PsyD, and Robert Figlerski, PhD:

Admission to a nursing home is one of the most significant challenges an individual can face. Coming to terms with the circumstances that created the need for long term care while simultaneously creating the best possible adjustment to one’s next chapter, a new resident must be fully engaged and resilient to achieve a successful outcome. Unfortunately, many are burdened by depression at exactly this moment. Ideally, depression would be quickly identified and treated so that the resident has a “fighting chance” to create an optimal adjustment, but unfortunately, that is often not the case. Untreated depression may be the single most deleterious shortfall in skilled nursing facility (SNF) care, causing countless residents to decline when they otherwise could thrive.”

Or this McKnight’s article on the Clinical and Financial Ramifications of Undiagnosed Depression in SNFs by Robert W. Figlerski, PhD.

The following is taken from a CMS draft worksheet on calculating the PDPM score. This is one of the easiest worksheets to help understand how scoring will be done under PDPM. This is the evaluation for depression.

Signs and symptoms of depression are used as a third-level split for the Special Care High category. Residents with signs and symptoms of depression are identified by the Resident Mood Interview (PHQ-9 ©) or the Staff Assessment of Resident Mood (PHQ-9-OV©). Instructions for completing the PHQ-9 © are in Chapter 3, Section D. Refer to Appendix E for cases in which the PHQ-9 © or (PHQ-9-OV©) is complete but all questions are not answered.

The following items comprise the PHQ-9 ©:

  • Resident /Staff Description.
  • D0200A/ D0500A – Little interest or pleasure in doing things.
  • D0200B /D0500Bm – Feeling down, depressed, or hopeless.
  • D0200C /D0500C – Trouble falling or staying asleep, sleeping too much.
  • D0200D /D0500D – Feeling tired or having little energy.
  • D0200E /D0500E – Poor appetite or overeating.
  • D0200F /D0500F – Feeling bad about yourself; that you are a failure or have let yourself down or your family down.
  • D0200G /D0500G – Trouble concentrating on things such as reading the newspaper or watching television.
  • D0200H D0500H – Moving or speaking noticeably slowly; or being fidgety or restless.
  • D0200I /D0500I – Thoughts about being better off dead, or of hurting yourself in some way.
  • D0500J – Being short-tempered, easily annoyed.

These items are used to calculate a Total Severity Score for the resident interview at Item D0300 and for the staff assessment at Item D0600. The resident qualifies as depressed for PDPM classification in either of the two following cases: the D0300 Total Severity Score is greater than or equal to 10 but not 99, or the D0600 Total Severity Score is greater than or equal to 10.

As you plan for PDPM, bringing together all clinical disciplines and tasking each of them to become experts in their sections of the MDS assessment is paramount to your success under this new payment system.

05.07.2019

Family, Food and LTC

Infection Control and Food and Nutrition Services are the #1 and #2 most frequently cited deficiencies – still!

One simple deficiency to avoid is staying in compliance with regard to facility responsibilities for food brought into a resident from outside. These requirements are specifically covered in F-813; but don’t ignore all of the food safety tips found in F-812 as you develop your facility policy and procedures.

General Guidelines:

First and foremost – never allow personal food that enters the facility from the outside to enter the regulated kitchen. Period.

Perishable food may be stored in a personal refrigerator or in a community refrigerator, but a community refrigerator cannot be located in the facilities kitchen or the facilities dining area. And, of course, the community refrigerator/freezer temperature must be monitored once per day. Refrigerators should hold food at 41°F or below; freezers at approximately 0°F.

Foods from outside of the facility must be labeled with the resident name and room number, the date the food was brought to the facility, and the discard date. Because many foods brought to a resident are “leftovers” and have been cooked elsewhere, reheating to a specific temperature may not be needed. If there are questions about the food, reheat to a temperature of 165 degrees.

A vulnerable population:

Residents in nursing homes are considered to be Highly Susceptible Populations (HSPs) whose immune systems may be compromised due to age, illness, medications and/or medical treatments. Elderly or immune-compromised individuals are more likely to become ill from contaminated food. Food borne illnesses can be much more severe and can even cause death in this population. Food safety should always be taken seriously especially when dealing with such a vulnerable population.

Foods commonly associated with food borne illnesses include:

  • Raw animal foods – foods prepared with uncooked eggs (home-made eggnog, Caesar salad), steak tartare.
  • Raw marinated fish or shellfish.
  • Foods not cooked to the minimum required temperatures, such as lightly-cooked fish, rare meat, soft-cooked shell eggs, and meringue.
  • Raw seed sprouts.
  • Unpasteurized juices.

F-813 Requirements

The facility must have a policy regarding the use and storage of foods brought to residents …to ensure safe and sanitary storage, handling, and consumption. Since surveyors will interview residents, family/friends, and the facility staff about the food brought in from home, ensure the facility procedures and policies cover the following items:

  • How and when will the facility educate the resident and family/friends about food safety? We suggest this information NOT be included in your admission packet. It won’t be read or remembered.
  • Food safety education should be in several languages (identified in the Facility Annual Assessment).
  • Food safety and the facility policy should be discussed with the resident and family to insure understanding. How will this be documented?
  • Who will check the outside food to insure it is in compliance with any ordered dietary or food restrictions?
  • How will foods brought in for a resident “potluck” be stored, reheated, served, or saved?
  • Who will label and date the food item. Discard date should be included. How long will food remain in the facility before being discarded?
  • Who will be responsible for checking and recording the temperature of resident or community refrigerators?
  • Who will be responsible for checking the resident or community refrigerator for outdated food?
  • If food needs to be reheated, where will this be done and by whom? If reheating to a specific temperature, how will this be done?
  • How will non-perishable foods not requiring refrigeration be stored?
  • Who is responsible for cleaning all areas used for storing, preparing, and heating foods brought into residents from outside of the facility?
  • How will the facility staff be educated on safe food practices and the facility policy on food brought in from the outside?

Remember Resident Focused Care may allow a resident to make a poor food choice but the facility is maintains responsibility for food safety. SAVVY on the SOM covers Food and Nutrition Services in depth in Volumes 19, 20, and 21.

4.22.2019

The Dental part of Care in LTC

Several weeks ago, a friend fell and fractured her hip. She was admitted to the hospital on Saturday evening and had surgery on Sunday. By Monday evening she was transferred to a skilled nursing facility.

When I visited on Tuesday, I was amazed at how well she was doing. She had minimal pain, was tolerating physical therapy twice a day and, by using a walker, was able to walk to the outside patio with me.

I noticed that her speech was somewhat funny – slightly slurred and she appeared to be talking out of one side of her mouth. When I asked her about her speech she said when she fell, she hit the side of her face and cracked a tooth. Part of the cracked tooth was digging into her tongue and causing quite a bit of irritation. She said her tongue was quite sore from rubbing against the sharp edge of the broken tooth. When I asked her how she was able to eat, she said she had met with the dietary person, had explained about her tooth and requested very soft foods that did not require any chewing and liquids.

I asked her if she had told the nurse or the social worker about her tooth, the pain it was causing, or the fact that she was unable to chew. She had not.

I then told her that the facility could and would get her dental help; either a dentist could come to the facility or make arrangements for her to go to see a dentist. She said that would really help her and she would be willing to pay for the service. I told her to tell her nurse so the process could be started.

On Friday morning when I checked in on my friend, I asked about her tooth and what dental arrangements had been made. She informed me that the nurse case manager told her the facility did not offer dental services and she would have to make her own arrangements after discharge.

The Regulations

Both F-790 and 791 use the same language:

The facility must assist residents in obtaining routine and 24 hour emergency dental care…to meet the needs of each resident.

NOTE: F-791 does add the proviso – routine dental services (to the extent covered by the state plan) and emergency dental services.

For a Medicare resident, F-790 shows the facility may charge an additional amount for routine and emergency dental services.

Both regulations require a facility to assist a resident in making appointments and by arranging for transportation to and from the dental service location – if necessary or if requested.

Let’s revisit the survey process

Surveyors will spend most of the first day speaking with and observing residents. A reasonably skilled surveyor would note my friend’s speech pattern and ask more questions. The answers – fall, cracked tooth, notification of dietary, mouth pain and a request for dental care – would lead to an in depth clinical record review including the MDS (especially sections G, K and L), the baseline care plan, the physician’s dietary orders, the dietary note and any nurses or social service notes related to the request for dental services. A review of the MAR would show the frequency of administration of pain medication related to mouth pain.

Once the clinical record review was completed, the surveyor would use the Critical Element Pathways for Dental Status and Services (Form CMS 20070), Pain (Form CMS 20076), and Nutrition (Form CMS 20075) as guides when interviewing the resident and facility staff.

Is there any doubt that this facility would – and should – receive a minimum of two or more deficiencies?

04.02.2019

Immediate Jeopardy 3/2019

According to CMS “Immediate jeopardy is a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider’s, supplier’s, or laboratory’s noncompliance with one or more health and safety requirements. Immediate jeopardy represents the most severe and egregious threat to the health and safety of recipients, as well as carries the most serious sanctions for providers, suppliers, and/or laboratories.”

There are several key changes to Appendix Q that you should know about. Perhaps the most significant is a change of verbiage from potential to likelihood – a pretty big deal since that in essence removes culpability.

Here’s the memo to all survey agencies:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-09-ALL.pdf

and the updates themselves:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf

03.19.2019

Cannabis, LTC and CA

Several months ago, SAVVY on the SOM published two blogs on the use of medical marijuana. We did this, not as a moral or political issue but because a) the largest population of new users are seniors, and b) as a reminder that federal law prevails over state law – which prohibits the use of a schedule 1 drug where prohibited by the Controlled Substances Act.

This AFL is the newest information on the use of CBD for a very specific diagnosis. Additionally, CBD of no more than 0.1 percent THC has been moved from a schedule I to a schedule V drug – meaning it can lawfully be prescribed under federal and California law.If your facility is not in California, please check with your state office.

February 14, 2019

AFL 19-06

TO: All Facilities

SUBJECT: Transfer of Epidiolex ® (Cannabidiol or CBD) from Schedule I to Schedule V of the Controlled Substances Act

AUTHORITY: Health and Safety Code section 11150.2 Title 21 Code of Federal Regulations section 1308.15

All Facilities Letter (AFL) Summary

This AFL notifies health facilities that the Drug Enforcement Administration (DEA) has moved the cannabidiol (CBD) drug Epidiolex ® from federal Schedule I to Schedule V.

Only drugs approved by the Food and Drug Administration (FDA) that contain CBD derived from cannabis and no more than 0.1 percent residual tetrahydrocannabinols (THC) have been moved to Schedule V.

Epidiolex ®, and any subsequent CBD drug that meets the criteria of FDA approval and THC content, may be lawfully prescribed and dispensed under federal and California law.

On September 28, 2018, the Federal Register issued the final rule Schedules of Controlled Substances: Placement in Schedule V of Certain FDA-Approved Drugs Containing Cannabidiol; Corresponding Change to Permit Requirements. The final rule places FDA-approved drugs containing CBD with no more than 0.1 percent THC in Schedule V of the Controlled Substances Act.

Epidiolex ®, an oral solution that contains CBD extracted from the cannabis plant, is the only drug currently included in Schedule V. The FDA approved Epidiolex ® on June 25, 2018, for treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients two years of age and older.

With the enactment of Assembly Bill 710 (Chapter 62, Statutes of 2018), Epidiolex ® and any subsequent CBD drug that meets the criteria of FDA approval and THC content, may be lawfully prescribed and dispensed under federal and California law.

The FDA has not yet approved any other CBD products or products that contain CBD; therefore, the vast majority of cannabis and/or CBD products remain as Schedule I under federal and California law. Drugs containing cannabis/marijuana, or any of its component parts or derivatives, that do not meet criteria of FDA approval and THC content may not be prescribed or dispensed. Health facilities must continue to comply with state and federal law for pharmaceutical services.

If you have questions about this AFL, please contact the L&C Pharmaceutical Consultants Unit at at [email protected]

03.05.2019

Nursing Services in LTC

I was asked to speak at the Wisconsin SNF DON conference held at Lake Geneva in February.

One of the other speakers was a nurse from CMS who spoke about F725 – Nursing Services.

F725 reads: The facility must have sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psycho social well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility resident population in accordance with the facility assessment.

What struck me as extraordinary in this presentation was staffing data collection from SNF sub-acute units.

Sub-Acute staffing

Respiratory Therapists are not counted in the staffing hours for sub-acute units. This is not an oversight – this is deliberate on the part of CMS.

Why would CMS choose not to count RTs in the staffing mix for a sub-acute? Management of a ventilator, ventilator rounds, ventilator setting adjustments, suctioning and responding to alarms are vital to the care of residents on such a unit. RNs and LVNs in these units simply do not have the ventilator knowledge or the time to handle the complexities of ventilator management. But when these areas of concern were raised, the CMS nurse said RTs might be added in the future!

PBJ is submitted electronically. Staffing reports are electronically sent to providers. This is a simple line item addition which would take an IT person 10 minutes of time.

Perhaps CMS is unaware of the Scope of Practice for RTs.

We would encourage Sub-Acute Administrators and DONs to write to CMS and to the AHCA to express their concerns and ask for assistance in correcting this deficient practice on the part of CMS.

We also encourage writing to the American Association of Respiratory Care attn.: Anne Marie Hummel, Associate Director for Government Affairs and ask for AARC support to correct this deficiency on the part of CMS.

For CMS to ignore this issue leaves SNF Sub-Acute units with the very real possibility of earning a one star for staffing without any recourse.

02.12.2019
ACTIVITIES. AGAIN.

We know we have written a newsletter and blogged extensively on the Activity Program but with the number of questions and observations we have made lately – this information bears repeating.

Our Observations

We continue to see Activity Assessment forms which have not been updated in the last 5 to 10 years; forms which may ask about interests such as music but are not completed with specifics such as types of music or artists, or worse yet, forms which contain a list of various nonspecific interest categories and the documentation is just the word “yes.” These answers are not resident specific and do not meet the intent of Resident Focused Care or provide for meaningful life activities.

We recently reviewed such a form which showed the resident loved classical music without a mention of any specifics (Big Band? Baroque? Mozart? Opera?). The care plan had no notation related to any type of music. The documented activities showed that music was provided four times in three months. This is a deficiency waiting to happen!

These examples do not meet the requirements at F-656 for a Resident Focused Comprehensive Care Plan OR the requirements at F-675 for Quality of Life OR F-679 Activities Meet the Interests and Needs of Each Resident.

If one reviews F-656, under the heading “Potential Tags for Additional Investigation,” one finds “If the surveyor identifies concerns about the resident’s care plan being individualized and person-centered, the surveyor should also review requirements at:

Resident Assessment

Activities …

The verbiage at F-675 references the 1986 Institute of Medicine report which identified “that a sense of well-being, self-esteem, and self-worth was enhanced by personal control over choices, such as mealtimes, activities, clothing…”

F-679 clearly states “The facility must provide…an ongoing program to support residents in their choice of activities…”

This regulation also provides some wonderful activity approaches to residents with Dementia and references non-CMS websites which the facility may find useful in developing a meaningful activity program for residents with Dementia.

Don’t give surveyors a reason to use a non-resident focused activity tool, the activity care plan, or documentation of activities provided as a reason for a deeper look at your facilities ability to provide Resident Focused Care.

01.29.2019

Privacy in LTC

F-583 addresses Privacy and Confidentiality in EVERY way possible. Let’s take a look at some of the types of privacy covered by this regulation.

Written communication

Any written communication to or from the resident must be safeguarded by the facility. The facility must not leave notices to the resident taped to the resident’s door or lying on the bedside table. Examples would include ABNs or Trust Account summaries.

Oral Communication

There are many situations within the facility setting when a resident is asked to divulge deeply personal information. Does the admission assessment take place in a shared bedroom with a roommate present? Is the resident’s medical history discussed in this setting? Are medications reviewed in a shared bedroom?

Electronic Communication

Electronic communication includes privacy when making or receiving phone calls and safeguarding information on a shared computer. If asked by a surveyor, do residents know they can make private phone calls? If asked, does the staff know how personal information is safeguarded on a shared computer?

Accommodation

This includes all aspects of care given to a resident and requires more than pulling the curtains. Who is present when personal care is given to a resident? Does a second person need to be present when catheter care is given or a diaper is checked or changed?

Records

All types of records are covered by HIPPA such as medical, social, financial, etc. Any records showing a resident’s name and personal information would also come under HIPPA – such as the dietary listing of residents, diagnoses and their diets, a listing of daily lab draws which includes resident names, DOB and lab tests, a clipboard of residents with surgery or diagnoses requiring PT treatments, or a MAR left open on a med cart. Any of these incidents would be a HIPPA violation.

Meetings

When requested, is there a space where private meetings can take place? Do residents know they can request a private space for a meeting? Do staff know where this private space is located?

Other examples of failure to provide privacy might include:

  • Posting a resident’s weight on a public whiteboard next to the bed.
  • Asking personal questions in the presence or hearing of another person (think admission assessment).
  • Allowing a physician to examine or discuss medical care in a public setting (dining room).
  • An unattended nurses station which contains any resident information.
  • A staff member having a telephone discussion of personal resident information which can be overheard by other residents or visitors.

The bottom line is it is the facility’s and the facility’s staff responsibility to safeguard the resident’s privacy IN EVERY POSSIBLE WAY.

01.15.2019

Data Elements for Post Acute

So here is some information that apparently not a lot of providers know about.

There has been a collaboration between CMS and RAND Corporation to develop standardized data elements for Post Acute Care. The goal is to develop, implement and maintain standardized PAC patient assessment data.

This might be quite useful as you develop your own assessment data.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/IMPACT-Act-SODF-March-28-2018.pdf

01.08.2019

Survey Entrance Conference

Are you preparing for a survey in the near future?

You know what paperwork will be requested immediately during the Entrance Conference. Will you find yourself scrambling to assemble it? What’s due in that first hour, four hours, and 24 hours?

No sweat! We can help!

Let’s go back to school and get a large 3 ring binder. Fill it with 28 tabbed dividers. Make divider labels that correspond to the number on the Entrance Conference Worksheet that require hard copy data. Are we having fun yet? Just like your high school Trapper Keeper.

Behind door (tab) #1 is your current actual census number. No hard copy data is needed, but keep it updated.

Entrance conference item #2 is a completed matrix on admissions in the last 30 days. This goes behind tab #2. Keep it updated. And so on and so forth.

Why would you do this?

CMS wants more surveys to start during off hours or on weekends. If the survey team shows up on Saturday or at 6 am, how will your staff give the team coordinator the paperwork required immediately?

A survey binder with all of the required paperwork will save someone a lot of unnecessary stress! Make sure your staff knows what the Survey Binder is and where it is kept.

Words of Wisdom

Items #2 and #18 – Completion of the Matrix (CMS 802) was updated 1/2018. Make sure you have the latest copy. The matrix forms should be updated weekly. It may need a tweak or two when the survey starts but nothing major. The latest matrix can be found at:

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS802.pdf

We advise giving the matrix from item #18 (or at least offering it) to the survey coordinator during the Entrance Conference. The survey team will be grateful. We hope by having an up to date survey binder you and your staff will be ready for the first hour of your next survey.

No Sweat!

12.27.2018

Critical Element Pathways Part 1

During the new survey process, the survey team will utilize questions from several Critical Element Pathways when interviewing residents. The Critical Element Pathways were developed to assist surveyors in gathering information about the facility from the residents perspective and to standardize the questions asked of both residents and families.

The structure of the Critical Element Pathways encourages the use of multiple pathways and will form a network of linkages to potential deficiencies.

The staff at SAVVY on the SOM is recommending that the questions on these Critical Element Pathways be reviewed by the Administrative and clinical staff. Perhaps more importantly, these questions should be used to solicit input from residents and families prior to your next survey.

If residents or families have voiced dissatisfaction with aspects of care or the services at the facility, these should be resolved before your survey.

Care Planning Pathway

Ask your residents –

How did the facility involve you in your care plan and goals?

What are your goals for care? Is the facility helping you to meet your goals? How?

Ask your new admits – Did you receive a copy of your baseline care plan? Did you understand it?

For Pain Management Pathway

Ask your residents –

How were you involved in developing pain management strategies?

What treatment options (pharmacological and non-pharmacological) have been discussed with you? Were possible outcomes of different options discussed with you?

Sufficient and Competent Staff Pathway

Ask your residents –

Do you feel there is enough staff to care for you and answer your call light promptly? Are there any problems at shift change or on the weekends?

Are you able to wake, rise, eat at times you prefer?

Do you think the nursing staff are knowledgeable when caring for you?

Have you had to return to the hospital for any reason?

Behavioral Emotional Status Pathway

How are the resident’s needs being met through a person centered care approach? Can you give examples?

Urinary Catheter Pathway

Why is a urinary catheter being used? How long has the urinary catheter been in place?

Ask your resident –

Were the risks and benefits of the catheter discussed with you?

Do you have any pain or discomfort from the catheter?

Hearing and or Vision Pathway

Ask your resident –

Do you need or have you requested device(s) to assist with hearing or communication? How has the facility helped you?

If you have refused devices, what alternatives have been discussed with you??

Dental Pathway

Ask your residents –

Do you have any dental concerns which have not been addressed by the facility staff?

Are you experiencing any pain or difficulty eating because of a dental problem?

Have you had any missing or damaged partials or dentures? If so, did the facility make a referral within 3 business days?

How did the facility ensure you would be able to continue to eat and drink while waiting for dental services?

Dialysis Pathway

Ask your residents –

If you refuse a fluid and or dietary restriction, has the staff attempted to find alternatives and explained the potential consequences?

Nutrition/Diet Pathway

Ask your residents –

How does the staff involve you in decisions about your diet, food preferences, and where to eat?

Does the staff give you the correct diet, snacks, and supplements, and honor your preferences?

Therapy

Ask your residents –

How were you informed about your need for therapy? Were alternatives discussed with you?

Did anyone talk to you about possible consequences if you refused therapy?

Are the services helping you to improve? How?

If you have assistive devices, were you shown how to use the device correctly?

This is just a sampling of the types of questions contained in the Critical Element Pathways. Perhaps you’ve gathered that you should ASK YOUR RESIDENTS. All the Critical Element Pathways were updated 8/3/18, and are available at:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

12.11.2018

The Cost of Pressure Injury

According to the Agency for Healthcare Research & Quality (AHRQ), pressure ulcers cost the US healthcare system an estimated $9.1-$11.6 billion annually.

According to the National Database of Nursing Quality Indicators, the average cost of a pressure injury is $38,700.00!

Much of the following information was received by subscribers of SAVVY on the SOM in Volumes 3 and 4. It bears repeating because of recent survey deficiencies for the development and worsening of pressure injuries.

Remember that prior to a facility survey, the survey team will review the facility’s history including the deficiencies from the last survey, the facility’s CASPER report, and any complaints with deficiencies. The Resident Level Report will identify any residents with a new or worsening pressure injury. These residents will be targeted for interview and review during the initial tour rounds.

Since pressure injury is such a high cost item and will always be a focus area during surveys, Administration and the QAA committee must make an ongoing commitment to monitor and analyze pressure injury outcome measures.

Do you have a problem? Analyze what you’ve got!

The Quality Assurance Committee can begin by reviewing the Facility Characteristic Report and the Facility Quality Measure/Indicator Report to understand how your facility compares to other facilities in your state. Do you have a higher incidence of pressure injuries? How many of these pressure injuries were present on admit vs pressure injuries which developed after admission? If a pressure injury developed after admission, did the facility do a root cause analysis to determine why the pressure ulcer developed? Was the root cause analysis completed by a multidisciplinary team? How did the care plan change after the development of the facility acquired pressure injury? Can you prove that the care changed? If the facility received a deficiency at F 686 during your last survey, was your Plan of Correction (POC) implemented? Was your Plan of Correction effective? How do you know your POC was effective?

Note: During the Quality Assurance interview, the facility Administrator will be asked for proof that the POC was implemented and was effective.

Chart reviews may or may not tell you if the POC was implemented but direct observation of care may give you the information you need. Correlate the observations with the actions found in the resident care plan and assess the care plan. Is it specific to this resident and the identified risk factors or is the care plan canned text?

From a surveyor’s perspective, facilities receive deficiencies at F686 due to a lack of staff knowledge about preventing pressure injuries, understanding severity/staging of pressure injuries, lack of ongoing assessments, care plans which are not resident specific, care plans which do not address risk factors, care plans which are not consistently implemented, lack of root cause analysis of pressure injuries, and lack of a multidisciplinary input into care planning.

These are process problems and process problems belong to the Administrative team and the Quality Assurance Committee.

A word of caution

While implementation of the facility QAPI plan is not required until Phase 3 – November 28, 2019 – the facility must be prepared to present its QAPI Plan to the State Survey Agency beginning November 28, 2018 (see F865).

11.27.2018

Person Centered Care Plan & the Resident with Dementia

The initial assessment for the newly admitted resident with a diagnosis of dementia will contain many of the same elements as any other assessment but for the care plan to be an effective tool, the nurse will need additional time and assessment skills.

The data gathered will be a more personal history of who this person was in the past, who this person is now and what happened in between.

The goal of any care plan is to assist caregivers at all levels to understand who this resident is and how to approach and provide care to this person. If the resident is non-verbal then information may be obtained from a family member or previous caregivers.

The care plan for the resident with Dementia should include as much information as possible about the following areas:

  • Social functioning

  • Cognitive Ability

  • Family Structure

  • Emotions

  • High risk/safety issues

  • Sleep/wake

  • Showering/bathing

  • Grooming

  • Dressing

  • Toileting needs

  • Meal Times/food

As each discipline gathers data, the goals for this resident should focus on ways to help this person find meaning, comfort, pleasure, security and self worth. Interventions should focus on meaningful activities which are specific to this resident.

This is where involvement of the family may be vital. Knowing what activities gave this resident pleasure in the past may be the key to meaningful activities now. Most activities can be adapted to the resident’s current abilities from listening to concerts, watching a ballet or listening to talking books. Finding ways to keep a resident engaged in meaningful activities prevents social isolation and may prevent behavioral problems. Volume 15 of SAVVY on the SOM covers person centered care in depth for more information.

Archives

11.13.2018 – Cultural Competence 101

11.06.2018 – Guidelines for Determining Immediate Jeopardy

10.29.2018 – Value Based Purchasing

10.23.2018 – Tips for the Medication Pass

10.09.2018 – Animals in SNF

10.02.2018 – Person Centered Care

09.25.2018 – Baseline Care Plan

09.18.2018 – Hospice and the SNF – Deficiencies

09.11.2018 – Hospice and the SNF

08.28.2018 – Staff Competency & the Patient Driven Payment Model

08.21.2018 – Food and Nutrition in LTC – Part II

08.14.2018 – The SNF Readmission Reduction Program

08.07.2018 – Sexual Harassment in LTC

07.31.2018 – Death with Dignity Laws and LTC

07.24.2018 – The New Pharmacy F-Tags

07.17.2018 – Summer Sizzle

07.12.2018 – Food and Nutrition in LTC 

07.05.2018 – Abuse in LTC – Part 2 

06.26.2018 –  Where in the world shall we live? 

06.19.2018 – Abuse in LTC– Part 1

06.12.2018 – On Smoking in LTC 

06.05.2018 – Let’s Talk About Teeth 

05.29.2018 – Leadership

05.22.2018 – Are Baseline Care Plans a Big Deal?

05.15.2018 – LGBTQ Rights and Long Term Care 

05.08.2018 – Cannabis in LTC – Part 2

05.01-2018 – Cannabis

04.24.18 – Cultural Competence

04.17.18 – Active Shooter

04.10.18 – LTC Water Requirements in a Disaster

04.03.18 – Resident Trust Accounts – Part 4

03.27.18 – New Five Star Quality Rating System

03.20.18 – On Falls – Again

03.13.18 – A Word About Money – Resident Trust Accounts Pt.3

03.06.18 – A Word About Money – Resident Trust Accounts Pt.2

02.27.18 – A Word About Money – Resident Trust Accounts

02.20.18 – Quality Improvement Culture

02.13.18 – Are You 5 Star Quality?

02.06.18 – Phase 2 Implementation

01.30.18 – F 838 SNF Administrative Roles

01.23.18 – Flu Season Prep

01.16.18 – LTC Lacks Geriatric Training

01.09.18 – QA + PI

01.02.18 – Revised CMS Survey Requirements

12.19.17 – Epic Tool for LTC Survey Preparation

12.12.17 – Smoking Regulations and LTC

12.05.17 – LTC – the elephant in the room?

11.28.17 – Abuse reporting in LTC

11.21.17 – Emergency Preparedness and LTC

11.14.17 – Abuse Reporting in LTC

11.07.17 – Finding the Base of Baseline Care Plans

10.31.17 – Fight the Flu in LTC

10.24.17 – LTC needs a new image – Part II

10.17.17 – Restraint with Restraints – Alternatives

10.10.17 – Show Restraint with (Chemical) Restraints

10.03.17 – Show Restraint with Restraints

09.26.17 – LTC needs a new image…

09.19.17 – SNF’s, Surveys and Pressure Injury

09.12.17 – F tag changes – Infection Control

09.05.17 – Well-Being and the SNF

08.29.17 – Infection Protection in SNFs

08.22.17 – Don’t Panic – Be Savvy

08.15.17 – Newest Tool for Medicare Compliance

08.08.17- Tools for Cultural Competence in SNFs

08.01.17 – Never Non-Compliant

07.25.17 – New Regs from CMS – Phase 2

07.18.17 – Phase II & the SNF DON

07.11.17 – What is Clinical Competency?

07.06.17 – The Terrible, No Good, Rising Cost of Pressure Injury Part III

06.27.17 – Are you SAVVY on the SOM?

06.20.17 – The Terrible, No Good, Rising Cost of Pressure Injury Part II

06.13.17 – Phase II – Facility Annual Assessment

06.06.17 – Restraint or Enabler?

05.30.17 – Quality of Life Interviews and YOU

05.23.17 – The terrible, no good, rising cost of Pressure Injury

05.16.17 – Let’s Talk about Eggs

05.09.17 – Don’t Slip on Fall Prevention

05.02.17 – Hospice in Skilled Nursing

04.25.17 – Let’s Talk About McGeer’s

04.18.17 – Survey Ready – Initial Tour Rounds

04.11.17 – “Person Centered Care”

04.04.17 – On Antibiotic Stewardship

03.28.17 – Kitchen Catastrophe?

03.21.17 – Suffer from Survey Anxiety?

03.14.17 – Activities Program 2.0

03.07.17 – Worried about Functional Outcomes?

02.28.17 – on referrals

02.16.17 – Care Plan Woes?

01.17.17 – Brand New Day