Survey changes coming - Frontlines - long term care survey process of Health Care Financing Administration

Nursing Homes, April, 1999 by Beth A. Klitch

In mid-February, the Health Care Financing Administration (HCFA) released a draft of revisions to the State Operations Manual (SOM), including Appendices P and PP, the Long Term Care Survey Process and Interpretive Guidelines. These revisions were proposed in response to the President's initiatives to improve the quality of nursing home care and, following a comment period, are expected to be implemented quickly. The key changes include the following:

* Addition of new investigative protocols for weight loss, dehydration and pressure sores;

* An enhanced dining observation protocol;

* Addition of a new task (5G) that assesses how facilities prevent abuse, neglect and misappropriation;

* Addition of a new tag, F226, that describes the necessary components of abuse prevention;

* New guidance and procedures that assess residents over age 65 who are receiving certain drugs; and

* Incorporation of Quality Indicators (QIs) into the survey process.

To explain each a little more fully:

New Investigative Protocols

The Pressure Sore Investigative Protocol's objectives are twofold. The first is to determine if the identified pressure sore(s) was avoidable or not. The second is to determine the adequacy of the facility's pressure sore treatment interventions. The survey team is instructed to interview staff and determine if the RAPs were used and if the resident has a documented clinical condition that constitutes a high risk for pressure sore development; if the care plan was developed, evaluated and revised based upon the resident's needs; if the resident refused treatment; and if the interventions were implemented in accordance with professional standards of practice.

The Dehydration Investigative Protocol's objectives include: (1) to determine if the facility identified risk factors that lead to dehydration and developed an appropriate preventive care plan; and (2) to determine if the facility provided the resident with sufficient fluid intake to maintain proper hydration and health. The survey team is instructed to follow the procedures as identified above - i.e., interview staff, review the use of RAPs, identify risk factors leading to dehydration, evaluate the care plan, and observe care delivery.

The Unintended Weight Loss Protocol's objectives specify: (1) to determine if the identified weight loss was avoidable or not; and (2) to determine the adequacy of the facility's response to the weight loss. The survey team will follow the same procedures as noted in both of the preceding protocols.

Enhanced Dining Observation

The purpose of enhanced Dining Observation Procedures is threefold. First, the survey team is directed to investigate residents with weight loss and dehydration protocols to determine if the interventions specified in the resident's written care plan were implemented. Second, the survey team will assess the quality of the food, food service and staff support during dining. Third, the survey team will assess the quality of life during dining for all residents. The survey team will observe the residents, verify that they are properly positioned, and check that tables and chairs are properly adjusted and that assistive devices are used. Most importantly, the survey team will calculate staff minutes per resident who might be partially or totally dependent for dining assistance, using a formula specified in the procedures.

Task 5G - Abuse Prevention Review

The general objective of this new task is that "The facility must develop and operationalize policies and procedures that prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all residents...." The survey team is directed to determine if the facility is in compliance with F225 and F226 by following these procedures:

* Obtain and review the facility's abuse prevention policies and procedures to determine that they include the key components: i.e., screening, training, prevention, identification, investigation, protection and reporting/response.

* Interview the individual identified by the facility as responsible for managing the policies and procedures.... Request written evidence of how the facility has handled actual occurrences.

* Select two or three occurrences. Review and determine if the facility's response met the requirements....

* Interview at least three direct care staff, including activities and nursing assistants, to determine if they are trained and know how to appropriately intervene in situations with residents who exhibit aggressive or catastrophic behavior.

* Interview at least three frontline supervisors of staff who interact with residents (Nursing, Dietary, Housekeeping, Activities, Social Services). Determine how they monitor their staff to prevent abuse.

* Obtain a list of all employees hired within the previous four months. From the list, select five and review their files to determine if the facility screened them according to its policies prior to employment.

Addition of F226

F226 states that "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property." The guidelines specify that facilities should develop and implement policies and procedures that meet their own needs and situations and include the following elements I - VII: