f314 – pressure ulcers
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Long Term Care Provider Associations Meeting
Sharon WhiteCMS – Region VAugust 22, 2007
F314 – Pressure Ulcers
F314 483.25(c) Pressure Sores - Regulatory Requirement: Based on the comprehensive Assessment of a
resident, the facility must ensure that-
1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and
2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
Reasons to Prevent Pressure Ulcers Increased morbidity and mortality Increased infection rates Debilitation Pain Increased cost Additional medications Increased staff time to provide
appropriate care necessary to heal the ulcer
So what’s being done? National initiatives
Advancing Excellence Campaign National Pressure Ulcer Advisory Panel GPRA
Individual facility efforts
CMS Regional and State Survey Agency efforts
Provider Responsibility for Providing Adequate Care
Commitment to high quality pressure ulcer management that permeates all aspects of the facility’s operation
Instituting a prevention program based on accepted clinical guidelines for “at risk” residents
Use of Quality Measures to develop and implement systems for pressure ulcer reduction
Provider Responsibility for Providing Adequate Care
Thorough knowledge of the federal requirements in order to comply with the regulations and ultimately to provide for the health and safety of residents
Understanding of the survey process in helping providers evaluate the quality of care delivered and target quality improvement efforts
Role of RO V and the SSA in the Reduction of Pressure Ulcers
Investigate and evaluate the systems and processes for prevention and treatment of pressure ulcers in certified facilities
Consistent and strict enforcement of CMS policies and regulations
An Effective “System” would include:
Prevention Assessment Identification Intervention Monitoring Evaluation Treatment “Ownership”
Assessment Skin assessments are the first line of
defense to prevent pressure ulcers from developing and to ensure effective treatment
It is important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers
Assessment A comprehensive assessment should
address factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers, which include: Risk factors Pressure points Nutrition Hydration Skin moisture, and Impact of moisture on skin
Assessment
A comprehensive assessment should include an evaluation of the skin integrity and tissue tolerance after pressure to the skin has been reduced or redistributed
Deficiency Determination in the Absence of Pressure Ulcers
A facility may have non-compliance with F314 without actual development of pressure ulcers by failing to:
Accurately or consistently assess a resident’s skin integrity
Identify a resident at risk of developing a pressure ulcer
Identify and address risk factors
Deficiency Determination in the Absence of Pressure Ulcers
Implement preventive interventions in accordance with the resident’s need and current standards of practice
Provide clinical justification for the unavoidable development or non-healing/delayed healing or deterioration of a pressure ulcer
Implement appropriate interventions for existing wounds to minimize infection and promote healing
Deficiency Determination in the Absence of Pressure Ulcers
Notify the physician of the resident’s condition or changes in the resident’s wound
Adequately implement pertinent infection management practices in relation to wound care
Identify and/or know how to apply relevant policies and procedures for pressure ulcer prevention and treatment
Deficiency Determination – “Avoidable vs. Unavoidable”
Was preventive care -aggressive?-consistent?-appropriate?-resident specific?
If not, the development of a pressure ulcer may have been “avoidable.”
Clarification - “Avoidable vs. Unavoidable”
The presence of any one, or even several, risk factors or
conditions does NOT make a pressure ulcer “Unavoidable”
Scope and Severity Level 4
Stage IV (development or non-healing) Stage III (infected locally/systemically) Extensive failure in multiple areas of care
Level 3 Stage III Recurrent or multiple Stage II’s Facility failure to consistently implement care
plan -> increase size, failure to heal, untreated pain
Scope and Severity
Level 2 Stage I Stage II receiving appropriate treatment Failure to implement portion of care plan
independent of healing
Level 1 – Eliminated
Region V’s Plan
Standard surveys: Federal and state surveyors review QM/QI Reports and CMS-672 with the facility to ensure that pressure ulcers have been reported accurately
FOSS surveys: Federal surveyors pay strict attention to how well SA surveyors evaluate the nursing home’s performance as it relates to pressure ulcers. When identified as a concern, specific mention will be recorded in Measures 1,2,3 and 6 of the FOSS report.
Region V’s Plan
Beginning calendar year 2007, Region V is warning facilities with non-compliance at F314, S/S level F or higher, that continuing non-compliance will result in the imposition of more severe remedies.
Future cycles of non-compliance will result in the imposition of more robust and possibly more diverse remedies
Region V’s Plan - More severe remedies include: Optional
Denial of Payment, higher Civil Money Penalty amounts, Directed Inservice Training, Discretionary Termination
Each case will be evaluated independently to determine which remedies will be most effective in promoting prompt and permanent correction of the deficiencies
Consistency is the key to effective prevention
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