BY RETA A. UNDERWOOD, ADC
Are you aware of these new survey requirements?
| In the past few months we have encountered much “to do” regarding the changes in F-tag 314 Pressure Ulcers; however, little has been said regarding the State Operations Manual (SOM) Appendix PP-Guidance to Surveyors for Long Term Care Facilities, Revision 5, which was issued, became effective, and was implemented on November 19, 2004. One might think that this is because there wasn’t much in it that was new, but such thinking is wrong. Not only was a tremendous amount changed, but serious ramifications await those facilities that do not review their own operational policies and procedures and take steps to update them to meet the new manual’s expectations. My goal in this article is to give you the framework to be successful in meeting these new expectations.|
What to Do First?
It never ceases to amaze me just how far behind facilities can be in obtaining current, necessary information on operating under government regulation. As late as four months after its release, I was still coming across facilities that not only did not have this new version, but had key department staff who hadn’t heard about the update. If you have not already downloaded your copy of the new SOM, visit www.cms.hhs.gov/manuals/107_som/som107ap_pp_guidelines_ltcf.pdf.
What Are the New Expectations?
Resident Rights 483.10(d)(2) F154.
Tip. The facility should review and revise its policies and procedures on resident information, as needed, and provide staff education relative to these. Documentation should minimally cover points found within the interpretive guidelines. Also, be aware that the guidelines’ revisions do not address what to do in cases in which the resident cannot comprehend the meaning of the care and treatment information. In long-term care, a general standard of practice is that the resident’s responsible party/legal guardian be informed on the resident’s behalf. Needless to say, the resident’s or responsible party’s feedback on the advanced care and treatment notice, carefully documented, will play an important part in determining facilities’ compliance.
Notice of Rights and Services 483.10 (b)(1) F156.
Tip. Resident rights materials can be purchased in alternate languages from a variety of resources or obtained free or for a minimal charge from your local state ombudsman. However, facility-specific policies or practices on residents’ rights cannot, and providers must devise their own. Now is the time to adopt or update your resident handbooks in the languages that residents commonly speak in your facility. You may have to hire a translator (possibly a good community service project for your local college or high school, provided their work is reviewed by a credible resource). Abuse policies need to be updated regarding noncompliance with the advance directives requirements found in 483.10(b)(7) of this tag. Reviewing changes in abuse policies during a resident and/or family council meeting and having the minutes reflect this communication provides an additional opportunity. The facility’s newsletter is also an avenue of positive marketing communication; take advantage of it. Regardless of the method of communication, make sure that resident rights and responsibilities and any changes made to them are governed by policies and procedures that staff understand and adhere to.
Privacy and Confidentiality 483.10(e) F164.
Tip. Review and revision of the facility’s medical record confidentiality policy and procedures should be completed.
Accommodation of Needs 483.15(e) F246.
Tip. You will need to take a close look at resident common and private areas, equipment, and supplies of all departments. Heavy emphasis is on activity and dining areas, resident furnishings, and their appropriate use and functionality given the space available. For example, delayed meals because activities materials have not been removed from the dining room, or therapy provided in hallways rather than therapy rooms, can be problems.
Personal Property 483.10(l) F252.
Tip. This is another area that can be addressed in a resident handbook and provided easily to residents and families upon admission. Include a statement that the facility has the right to limit the resident’s exercise of this right on grounds of space, health, or safety. Outline the expectations the facility places on the resident regarding compliance along these lines. Meanwhile, develop procedures that will assist your facility in determining safe use of personal possessions-for example, electric wheelchairs, scooters, and lift chairs. You may have a resident periodically demonstrate his or her appropriate use and skills in safely operating these devices.
Resident Assessment 483.20 F272.
Tip. Policies and procedures should have resident observation and communication added to the data-gathering process, if it’s not there already. For compliance purposes, staff should document resident observations and communication in a narrative format. Also, in the Resident Assessment Protocol (RAP) Summary documentation, indicate relevant facts provided by those staff and family members who participated in the assessment review. You also may have them sign the RAP, in addition to signing it yourself.
Comprehensive Care Plans 483.20(d) F279.
Tip. This is a small addition that has a mighty outcome. This will cause many interdisciplinary teams (IDTs) to change the way business is conducted. It means, at the very least, that the final assessment results must be reviewed by Quality Assurance to ensure that a comprehensive plan of care based on the assessment is developed and implemented. The development of care plans must be attributable directly to the final findings of the assessment.
It is recommended that the IDT (understood to include representatives from each clinical department) review the final MDS together and develop a problems, issues, needs, or concerns list, and then develop the care plan from this list. As always, those items that do not trigger a RAP, such as assessed pain, special care and treatment needs, and nursing rehabilitation and restorative care, should be included in the comprehensive plan of care.
Comprehensive Care Plans 483.10(d) (3)F280.
Tip. A policy and procedure revision may be necessary that includes the mandate that all residents are provided with notice of care plan meetings, time, and date, and allowed participation in the care plan process. Attach to the policy a copy of the forms to be used. Form letters and mailing practices should be outlined clearly for invited participants other than the residents themselves. For instance, return receipt request is a good idea for those who have state guardianship and other legal oversight.
Providing assistance to and from the care plan meeting and having the IDT go to the resident’s room to review the plan of care are practice options to ensure the resident is present. Obtaining the resident and/or responsible party’s signature is still paramount to show that they were afforded the opportunity and that the meeting was conducted.
A care plan summary/signature sheet should include a statement that the final care plan was reviewed and that those in attendance were provided the opportunity to ask questions or seek clarifications, and it summarizes all items that were discussed relating to the plan of care. When writing progress notes, staff should include the dates and times of resident observation and interviews that assisted them in developing the plan and whether care options or changes were discussed.
Coordination 483.20(e) F285.
Tip. Review and revision of admission policy relating to the PASRR process is the first step; the second is to copy this updated policy and procedure to your state office. In a cover letter, copy them the revised F285 language.
Medication Errors 483.25(m) F332 & 333.
Standard Menus and Nutritional Adequacy 483.35(c) F363.
Physician Visits 483.40(b) F386.
Tip. Your medical director should review physician signature policies. A good idea is to distribute a PDF copy of the new SOM to all the facility’s attending physicians.
Life Safety From Fire 483.70(a).
Also, be advised that on March 25, 2005, the Federal Register was updated to include the requirement for nursing homes that do not have sprinkler systems or hardwired smoke detectors to install battery-operated smoke detectors in patient rooms and public areas. In addition, nursing homes are on the list of healthcare providers allowed to install alcohol-based hand sanitizer dispensers in exit corridors as an encouragement to handwashing, but they must meet guidelines for safe location of these potential accelerants.
Tip. Get a copy of NFPA’s Life Safety Code by writing to the address in the SOM or go to www.nfpa.org. You will notice that they offer a copy on CD, which makes for easy distribution. You’ll want to get a copy to each department director. By addressing the Life Safety Code within the confines of the Quality Assurance program, facilities will be able to show that they are working toward compliance. Minutes should show the items identified and actions to be taken, along with time frames and staff responsibility in this area.
Resident-identifiable information 483.20(f)(5) F516.
Tip. If you have not already done so, you’ll want to obtain provider agreements/contracts of agents working in your facility who need access to resident records. Many have current policy and procedures because of HIPAA implementation.
For questions and concerns regarding CMS revisions, contact Karen Schoeneman at (410) 786-6855 or firstname.lastname@example.org.
Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky. For more information, call (877) 987-2001. To send comments to the author and editors, please e-mail email@example.com. To order reprints in quantities of 100 or more, call (866) 377-6454.
Topics: Articles , Risk Management