F498 Below you will find F-tag language excerpted from the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev 66, 10-01-10). F498 483.75(f) Proficiency of Nurse Aides The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents needs, as identified through resident assessments, and described in the plan of care. Interpretive Guidelines: 483.75(f) Competency in skills and techniques necessary to care for residents needs includes competencies in areas such as communication and personal skills, basic nursing skills, personal care skills, mental health and social service needs, basic restorative services and resident rights. Procedures: 483.75(f) During the Resident Review, observe nurse aides. Probes: 483.75(f) Do nurse aides show competency in skills necessary to: Maintain or improve the resident s independent functioning, e.g.: o Performing range of motion exercises, o Assisting the resident to transfer from the bed to a wheelchair, o Reinforcing appropriate developmental behavior for persons with MR, or o Psychotherapeutic behavior for persons with MI; Observe and describe resident behavior and status and report to charge nurse; Follow instructions; and Carry out appropriate infection control precautions and safety procedures. The following Mandatory Task Form has questions pertaining for F498 and must be completed during every survey. Stage II Critical Elements for Activities of Daily Living (ADL) and/or Range of Motion (ROM) Status (Includes Cleanliness/Grooming and Positioning) (CMS-20066) Use To determine whether the facility is providing services to:
Meet ADL and positioning needs for those residents unable to carry out these activities; Prevent decline in positioning, ADLs or ROM; or Maintain or improve positioning, ADLs or ROM abilities. Procedure If resident is still in facility: Briefly review the assessment, care plan and orders to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review. Observations Observe whether staff consistently implement the care plan over time and across various shifts. Staff are expected to assess and provide appropriate care from the day of admission. During observations of the interventions, note and/or follow up on deviations from the care plan as well as potential negative outcomes. Resident/Representative Interview Interview the resident, family or responsible party to the degree possible to identify: Resident's/Representative's involvement in the development of the care plan, defining the approaches and goals, and if interventions reflect choices and preferences; Resident's/Representative's awareness of the interventions in use and how to use devices or equipment; Whether timely assistance is provided as needed for positioning, toileting, eating, bathing, hygiene, grooming, dressing and ambulating according to the care plan; If the resident comprehends and applies information and instructions to help improve or maintain ADL performance (where cognition permits); Presence of pain that affects ADL performance including the location, cause, if any and how it is managed; and If interventions were refused, whether alternatives and/or other alternative approaches were offered. For the resident who has limitations in range of motion and/or contractures, interview the resident, family member or responsible party to determine: When the range of motion and/or contracture(s) developed; Resident's/Representative's involvement in care plan development including defining the approaches and goals, and if interventions reflect preferences and choices; Resident's/Representative's awareness of the interventions in use and how to use devices or equipment; 2
Whether assistance is provided as needed for the provision of either AROM, PROM, and according to the care plan; Whether the resident comprehends and applies information and instructions to help improve or maintain range of motion (where cognition permits); Presence of pain that affects range of motion including the location, cause, if any and how it is managed; and If interventions were refused, whether alternatives and/or other alternative approaches were offered. Staff Interviews Interview staff on various shifts to determine: How much assistance is needed with ADLs (including oral hygiene), positioning or ROM; Whether there are any rehabilitation and/or restorative care schedules and instructions to be followed; The resident s level of comfort related to positioning, contractures and ADL care; Whether there is any resistance to care provided, and if so, when does the resistance occur (for example, during certain types of care, certain times of the day, certain staff, etc.); How the nurse monitors for the implementation of the care plan; If interventions were refused, whether alternatives and/or other alternative approaches were offered; and If the resident is not on a restorative program, how the determination was made that the resident could not benefit from a program. Concerns with Structure, Process, and/or Outcome Requirements Related to Process of Care During the investigation of bowel and bladder function, the surveyor may have identified concerns with related structure, process, and/or outcome requirements. The surveyor is cautioned to investigate these related requirements before determining whether noncompliance may be present. Some examples of requirements that should be considered include the following (not all inclusive): F498, Proficiency of Nurse Aides Determine whether nurse aides demonstrate competency in the provision of restorative nursing, range of motion, care of contractures, and positioning. If the surveyor determines that the facility is not in compliance with any of these related requirements, the appropriate F tag should be surveyor initiated. 3
Stage II Critical Elements for Bowel or Bladder Function/Use of an Indwelling Catheter (CMS-20068) Use Use this protocol for a sampled resident who is incontinent of urine, has a symptomatic UTI or has an indwelling catheter. NOTE: If concerns with cleanliness and grooming are identified then the ADL CE will also be completed. Procedure Briefly review the assessment, care plan and orders to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review. Observations (if the resident is still in the facility) Observe whether staff consistently implement the care plan over time and across various shifts. For residents with urinary incontinence or a condition, which may contribute to incontinence or the presence of an indwelling urinary catheter (including newly admitted residents), the staff are expected to assess and provide appropriate care from the day of admission. During observations of the interventions, note and/or follow up on deviations from the care plan, deviations from current standards of practice, as well as potential negative outcomes. Observe whether accommodation of need has been provided in accord with the assessment, such as: o The call bell within reach and timely staff response to the call bell; o Unobstructed pathway and access to facilities; o Elevated toilet seats, grab bars, adequate lighting; and o The availability of, and the assistance needed for, the use of the devices, such as urinals, bedpans and commodes. If assistance (e.g. prompting, transfer, stand-by assist to ambulate) is required for toileting and/or the resident is on a program to restore continence, a scheduled toileting program, or is generally continent, observe whether assistance has been provided to prevent incontinence episodes. Note the frequency of breakthrough incontinence, the staff response to the incontinence episodes, and the provision of care in accord with standards of practice (including infection control practices) and with respect and dignity for the resident. 4
For a resident who has been determined by clinical assessment to be unable to participate in a program to restore continence or a scheduled toileting program and who requires care due to incontinence of urine, observe: Whether the resident is on a scheduled check and change program; and Staff timely check and change the resident. For the resident who has experienced an incontinent episode, observe: The condition of the pads/sheets/clothing (brown rings/circles, saturated linens/clothing, odors, etc.); The resident's physical condition (such as skin clarity or maceration, erythema, erosion); The resident's psychosocial outcomes (such as embarrassment for involuntary micturation or expressions of humiliation); Whether staff implemented appropriate hygiene measures, (e.g. cleansing, rinsing, drying and applying protective moisture barriers or barrier films as indicated) to prevent skin breakdown from prolonged exposure of the skin to urine; and The staff response to incontinence episodes, and the provision of care in accord with standards of practice (including infection control practices) and with respect and dignity for the resident. For the resident with an indwelling catheter, observe the delivery of care to evaluate: Whether staff use appropriate infection control practices, with regard to hand washing; care for the catheter, tubing, and the collection bag; Whether staff recognize and assess potential signs and symptoms of symptomatic UTI or other changes in urine condition (such as onset of bloody urine, cloudiness, oliguria, deepening/concentrating urine color, if present); How staff manage and assess urinary leakage from the point of catheter insertion to the bag, if present; If the resident has catheter related pain, how staff assess and manage the pain; and What interventions, (such as anchoring the catheter; avoiding tugging on the catheter during transfer and care delivery) are being used to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. For each resident who is incontinent or has an indwelling or intermittent catheter, observe: Whether the resident is provided and encouraged to consume sufficient hydration to meet the resident's needs and to address, e.g., risks of UTI and constipation 5
(approximately 30ml/kg/day or as indicated based on the resident s clinical condition). If the resident consumes less fluid than is indicated, note whether staff implement alternative approaches to encourage fluid intake (such as frozen products, gelatins, soups, etc.). Resident/Representative Interview Interview the resident, family or responsible party to the degree possible to identify: The resident's/representative's involvement in the development of the care plan, defining the approaches and goals, and if interventions reflect choices and preferences; The resident's/representative's awareness of the continence program in use and how to use devices or equipment; Whether timely assistance is provided as needed for toileting needs, hydration and personal hygiene and whether continence care and/or catheter care is provided according to the care plan; Whether the resident comprehends and applies information and instructions to help improve or maintain continence (where cognition permits); Presence of pain, location, cause, if any and how it is managed; If interventions were refused, whether counseling on alternatives, consequences, and/or other alternative approaches to address the incontinence was offered; and Awareness of any current UTI, history of UTIs, or perineal skin problems. Staff Interviews Interview staff on various shifts to determine: How the nurse monitors for the implementation of the care plan, changes in continence, skin condition, and the status of UTIs; If the resident resists toileting, how staff have been taught to respond; Types of interventions that have been attempted to promote continence (i.e. special clothing, devices, types and frequency of assistance, change in toileting schedule, change in diet/hydration, environmental modifications); and If the resident is not on a restorative program, how the determination was made that the resident could not benefit from a program or scheduled toileting program. For the resident on a program of toileting, determine whether the nurse is familiar with: The type of incontinence; The interventions to address that specific type; How the determination is made that the schedule and program is effective, i.e. how continence is maintained or if there have been declines or improvement in continence how the program is revised to address the changes; and 6
Whether the resident has any physical or cognitive limitations present that impact improvement of the resident s continence. For residents with urinary catheters, determine whether the nurse has knowledge of: The justification for the use of the catheter; Attempts made to remove a catheter; and History of UTIs, whether present, recurring, persistent or chronic, and interventions to prevent UTIs. If the resident has a skin problem that may be related to incontinence or staff are not following the resident's care plan (continence or catheter care program), interview the nursing assistants to determine, if they: Are aware of and understand the interventions specific to this resident such as the bladder or bowel restorative/management programs; Have been trained and know how to handle catheters, tubing and drainage bags and other devices used during the provision of care; and Know what, when, and to whom to report changes in status regarding constipation, hydration/concentrated urine, impaction, and complaints of potential UTI symptoms. Concerns with Structure, Process, and/or Outcome Requirements Related to Process of Care During the investigation of bowel and bladder function, the surveyor may have identified concerns with related structure, process, and/or outcome requirements. The surveyor is cautioned to investigate these related requirements before determining whether noncompliance may be present. Some examples of requirements that should be considered include the following (not all inclusive): F498, Proficiency of Nurse Aides Determine whether nurse aides demonstrate competency in the delivery of continence and catheter car to minimize skin breakdown, UTIs, catheter-related injuries, and dislodgment. If the surveyor determines that the facility is not in compliance with any of these related requirements, the appropriate F tag should be surveyor initiated. Stage II Critical Elements for the Use of Physical Restraints (CMS-20077) Use Use this protocol for: A sampled resident who has MDS data that indicates a physical restraint is used; or 7
Surveyor observation of a device or practice that may be physically restraining the resident. The goal of using this CE is to determine, for a resident the surveyor has determined to be restrained, whether the restraint is in compliance with the regulations. To be in compliance, the restraint: Must be necessary to treat a medical symptom; Must not be used to discipline a resident or for staff convenience in the absence of a medical symptom; Must not be used because of family request in the absence of a medical symptom; and Must be the least restrictive device possible, in use for the least amount of time per day possible; and the facility must have an active plan in place to decrease usage or for eventual removal of the restraint. NOTE: Physical restraint includes all devices and practices used by the facility that restrict freedom of movement or normal access to one's body. This includes side rails as well as facility practices such as tucking in bed sheets so tightly that the resident is unable to leave the bed. NOTE: Do not rely on facility documentation alone to determine whether the device or practice is a restraint. It is a surveyor's determination whether the device or practice is restraining the resident, despite facility documentation to the contrary. If facility records state that the device (or practice) is not a restraint, but your investigation finds otherwise, the device or practice is a restraint. NOTE: If the device does not meet the definition of a physical restraint, discontinue completion of this CE. Procedure Briefly review the assessment, care plan and orders to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review. Observations (if the resident is still in the facility) Observe whether staff consistently implement the care plan over time and across various shifts. Staff are expected to assess and provide appropriate care from the day of admission. During observations of the interventions, note and/or follow up on deviations from the care plan as well as potential negative outcomes. Determine: The type of restraint in place; The resident s reaction to the restraint; 8
Whether the restraint is applied correctly; The services that are provided to meet resident needs while the restraint is not in place; and If the restraint affects position and body alignment, the resident is positioned appropriately. NOTE: A resident may have a device in place that the facility has stated can be removed by the resident. For safety reasons, do not ask the resident to release the device unless there is facility staff supervision. Resident/Representative Interview Interview the resident, family or responsible party to the degree possible to identify: The resident's/representative's involvement in the development of the care plan, goals, and if interventions reflect choices and preferences; The resident's/representative's awareness of care plan approaches; and Whether counseling on alternatives, consequences, and/or other interventions were offered prior to, or in addition to physical restraint use. Staff Interviews Interview staff on various shifts to determine: Knowledge of specific interventions for the resident, including: o The restraint(s) being used (and when use was initiated); o How often and under what circumstances the restraint(s) is used; o When, and for how long, the restraint is released; o The potential risks of using the restraint; o How the resident is monitored when the restraint is in use; and o Interventions that are in place to minimize or eliminate the medical symptom or underlying problems causing the medical symptom. Knowledge of facility-specific guidelines/protocols; and Whether the nurse monitors for the implementation of the care plan, and the frequency of review and evaluation of changes in the effectiveness or resident response to the restraint. o What the resident s functional ability is such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet; and o Any changes over the past year such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression. Concerns with Structure, Process, and/or Outcome Requirements Related to Process of Care 9
During the investigation, the surveyor may have identified concerns with related outcome, process and/or structure requirements. The surveyor is cautioned to investigate these related requirements before determining whether non-compliance may be present. Some examples of requirements that should be considered include the following (not all inclusive): F498, Proficiency of Nurse Aides Determine whether nurse aides demonstrate competency in the application of the restraint. If the surveyor determines that the facility is not in compliance with any of these related requirements, the appropriate F tag should be surveyor initiated. Stage II Critical Elements for Rehabilitation and Community Discharge (CMS-20080) Use For a resident: Admitted for rehabilitation, received PT, OT or ST services but was not discharged back to the community (may have been discharged to another long-term care facility/skilled nursing facility); or Whose most recent MDS (5 and 14 day comparison) assessments indicates the resident received PT or OT but did not improve in transferring ability. NOTE: Although this review is triggered by lack of improvement in transfer ability, all areas of functional ability should be reviewed, as pertinent to the individual. Use to determine whether the facility provided care to ensure that (a) the resident received necessary rehabilitative services and, (b) based on discharge potential, discharge planning was provided. Procedure Briefly review the assessment, care plan and orders to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review. Observations Observe whether staff consistently implement the care plan over time and across various shifts. Staff are expected to assess and provide appropriate care from the day of admission. During observations of interventions, note and/or follow up on deviations from the care plan, deviations from current standards of practice, as well as potential negative outcomes. 10
Determine whether: The resident received encouragement and needed assistance to perform therapy tasks (while in therapy sessions); Nursing staff provided restorative nursing services to foster improvement in functioning in accordance with the treatment plan such as assisting the resident to walk with a gait belt as planned assisting the resident to button rather than doing it for them, assisting the resident to use communication devices; The resident was provided supportive and assistive devices/equipment as assessed, received encouragement and assistance to use the device(s) on a regular basis and that devices fit properly; The resident exhibits signs of pain during treatment sessions, and whether staff intervene or address the pain; and The resident is afforded privacy during treatments that expose the body. Resident/Representative Interview Interview the resident, family or responsible party as appropriate to identify: The resident's/representative's involvement in the development of the care plan, defining the approaches and goals, and whether interventions reflect choice and preferences; The resident's/representative's awareness of the interventions in use and how to use devices or equipment; Whether the resident comprehends and applies information and instructions to help improve functioning; Whether staff allows the resident sufficient time to perform rehabilitative and restorative tasks; The presence of pain that affects ability to make rehabilitative progress; including location, cause, and how it is managed; If interventions are refused, whether alternatives were offered; and (If resident is due for discharge in the near future) the resident's/representative's involvement in discharge planning. Staff Interviews Interview staff on various shifts to determine: How much assistance is needed to complete ADL tasks, including transfer and ambulation; Whether the resident receives therapy or restorative services and what is the schedule; Whether the resident is using any supportive and/or assistive devices; What restorative interventions staff are following, according to the care plan; Whether the resident displays any resistance to care, resistance to using any assistive devices, or refusal to attend therapy, and how staff respond; and 11
Whether they are aware of a plan to discharge the resident to a lesser level of care or to home in the near future (if there is such a plan). Concerns with Structure, Process, and/or Outcome Requirements Related to Process of Care F498, Proficiency of Nurse Aides Determine whether nurse aides demonstrate competency in the provision of restorative nursing. If the surveyor determines that the facility is not in compliance with any of these related requirements, the appropriate F tag should be surveyor initiated. 12