F-309 Revised Guidance to Surveyors How does this impact your Documentation

1. F-309 Revised Guidance to SurveyorsHow does this impact your Documentation Joan Redden VP Regulatory Affairs Skilled Healthcare, LLC

2. F-309 • Although the regulation does not specifically mention a particular condition, it does require that the necessary care and services to provide for each resident to attain or maintain his or her highest practicable level of well-being, the facilityis expected to provide the necessary care and services necessary to improve, maintain or prevent decline, to the extent possible.

3. New Guidance F-309Effective March 31, 2009 The F-309 guidance is utilized for the review of quality of care including, but not limited to, such areas as end of life, diabetes, renal failure, fractures, congestive heart failure, non-pressure related skin ulcers, pain or fecal impactions.

4. Additional Changes to the F-309 • The guidance now removed hospice and dialysis survey protocol language from Appendix P and placed it into F 309 • Additional revisions that were published along with the changes to F 309 included: • Guidance to the storage of MDS F286 • Removed demand billing process to task 5C • Removed weight loss investigations protocol to F 325 from Appendix P

5. Interpretive Guidelines 483.25 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. This determination requires that 3 areas in documentation are not present!

6. Determination of Avoidable Decline • An accurate and complete assessment is not found • A care plan is not implemented consistently or based on information form the assessment • Evaluation of the results of the interventions and revising interventions are not present

7. Determination of Quality of Care “Determine if the facility is providing the necessary care and services based on the findings of the comprehensive assessment and plan of care!”

8. Review of The Non-pressure Ulcer • At the time of assessment and diagnosis of a skin ulcer/wound, the clinician is expected to document the clinical basis e.g. underlying conditions contributing to the ulcerations, ulcer edges, wound bed, locations, surrounding tissues, which permit differentiating the ulcer type, especially if the ulcer characteristics are consistent with pressure ulcers, but it is determined not to be one.

9. Investigative Protocols, IP • Observe whether the staff implemented the care consistently across the various shifts. • Interview C.N.A’s, residents, and /or responsible party as to their awareness of the care plan • Review the MAR, IDT, RAI, MDS and CP to determine the accuracy of the assessment • Determine if the staff have monitored the effectiveness of the care plan interventions, reviewing and revising with the directions of the resident or responsible party.

10. IP of the Dialysis Resident • Review the MAR to assure that medications are administered before and after dialysis as ordered by the physician. This should account for optimal timing to maximize effectiveness and avoid adverse effects of medication • Interview staff as to their knowledge of how to mange emergencies and complications of bleeding, septic shock, and other infection control concerns • Are the staff aware of the emotional and psycho-social needs of the resident. Are these areas documented

11. Hospice If the resident is receiving hospice services, it is important that the care of the resident is appropriately coordinated among all the providers. The nursing staff remain the resident’s primary care giver under the regulatory requirements. Hospice assumes the full responsibility for the professional management of the resident. There must be evidence of collaborative documentation between the providers for the care of the resident.

12. Pain Management • recognize, identify, manage, and prevent are all actions words! • Unrelieved pain is not an inevitable consequence of aging, but leads to decreased function and diminished quality of life. • Misconceptions can negatively affect the ability to adequately recognize, assess, prevent , or manage a resident’s pain.

13. Acceptable Documentation • Identifies the pain indicators and characteristics, causes and contributing factors • identities a history of pain and related interventions • identifies the impact of the pain of the resident's function and quality of life • Identifies the resident response to interventions including the efficacy and adverse consequences and modifies according to standards of good clinical practice.