CMS Manual System - Louisiana Department of Health and Hospitals

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eceiving other medications with significant effects on the cardiovascular and central nervous systems. Therefore, careful titration of dosages based on monitoring/evaluating the effectiveness of the medication and the occurrence of adverse consequences is necessary. The clinical record should reflect the ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. Other interventions have been used for some residents with more advanced, complex, or poorly controlled pain. Examples include, but are not limited to: radiation therapy, neurostimulation, spinal delivery of analgesics (implanted catheters and pump systems), and neurolytic procedures (chemical or surgical) 25 that are administered under the close supervision of expert practitioners. Monitoring, Reassessment, and Care Plan Revision Monitoring the resident over time helps identify the extent to which pain is controlled, relative to the individual‘s goals and the availability of effective treatment. The ongoing evaluation of the status (presence, increase or reduction) of a resident‘s pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment. Adverse consequences related to analgesics can often be anticipated and to some extent prevented or reduced. For example, opioids routinely cause constipation, which may be minimized by an appropriate bowel regimen. Identifying target signs and symptoms (including verbal reports and non-verbal indicators from the resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident‘s pain and responses to interventions and determine whether the care plan should be revised, for example: • If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated; or • If pain has resolved or there is no longer an indication or need for pain medication, the facility works with the practitioner to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. Endnotes for Pain Management 1 Definitions Related to the Use of Opioids for the Treatment of Pain: Consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine, 2001. Document available at www.painmed.org, www.ampainsoc.org and www.asam.org. 2 Lussier, D., Huskey, A.G., & Portenoy, R.K. (2004). Adjuvant analgesics in cancer pain management. The Oncologist, 9, 571-591.
3 National Center for Complementary and Alternative Medicine. (2002). What is complementary and alternative medicine? NCCAM Publication, No. D156. Retrieved 3/06/06 from www.nccam.nih.gov. 4 American Medical Directors Association. (2003). Clinical Practice Guideline: Pain Management in the Long Term Care Setting. AMDA. Columbia: MD. Retrieved 3/06/06 from www.amda.com. 5 The Federation of State Medical Boards. (2004). Model Policy for the Use of Controlled Substances for the Treatment of Pain. Retrieved 3/06/06 from http://www.fsmb.org/pdf/2004_grpol_controlled_substances.pdf. 6 American Geriatrics Society: AGS Panel on Persistent Pain in Older Persons. (2002). Clinical Practice Guidelines: The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50, S205-S224. 7 Yong, H.H., Gibson, S.J., De L Home, D.J., & Hleme, R.D. (2001). Development of a pain attitudes questionnaire to assess stoicism and cautiousness for possible age differences [Electronic version]. The Journals of Gerontology, 56, 279-284. 8 Jones, K., Fink, R., Clark, L., Hutt, E., Vijor, C. & Mellis, K. (2005). Nursing Home Resident Barriers to Effective Pain Management: Why Nursing Home Residents May Not Seek Pain Medication. Journal of the American Medical Directors Association, 6(1): 10-17. 9 Cohen-Mansfield J. (2006). Pain Assessment in Noncommunicative Elderly Persons – PAINE. Clinical Journal of Pain. July/August; 22(6): 569-575. 10 Won, A.B., Lapane, K.L., Vallow, S., Schein, J., Morris, J.N., & Lipsitz L.A. (2004). Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. Journal of the American Geriatrics Society, 52, 867-876. 11 Teno, J.M., Weitzen, S., Wetle, T., & Mor, V. (2001). Persistent pain in nursing home residents. Journal of the American Medical Association, 285, 2081. 12 Cohen-Mansfield J. (2005). Self-report of pain in nursing home residents with dementia: a comparison of assessments. American Journal of Pain Management, 15, 128-139. 13 Pautex S., Michon A., Guedira M., Emond, H., Le Lous, P., Samaras, D., Michel, JP, Herrmann, F., Giannakopoulos, P., Gold, G. (2006). Pain in severe dementia: self-assessment of observational scales? Journal of American Geriatric Society, 54(7), 1040-5. 14 Ferrell BA, Ferrell BR, Rivera L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management, 10, 591-8. 15 Chibnall, J.T., Tait, R.C., Harman, B. (2005). Effect of acetaminophen on behavior,
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CMS Manual System Pub. 100-07 State
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State Operations Manual Appendix PP
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§483.25(n) Influenza and Pneumococ
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(including eligibility, coverage, c
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___________________________________
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Procedures §483.10(a)(3) and (4) D
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―Advance directive‖ means a wri
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§483.10(b)(5) -- The facility must
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Provide written information concern
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___________________________________
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§483.10(c)(3) Deposit of Funds (i)
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Were limits placed on amounts that
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___________________________________
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(B) Dietary services as required at
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medical service that is recognized
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satisfactorily resolved by discussi
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(i) Transfer to another health care
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Interpretive Guidelines §483.10(g)
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(ii) Any representative of the Stat
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___________________________________
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efore the resident may exercise tha
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§483.12(a) Transfer, and Discharge
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§483.10(o), Tag F177, addresses th
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Look for changes in source of payme
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How to notify the ombudsman (name,
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___________________________________
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Interpretive Guidelines §483.12(d)
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Interpretive Guidelines §483.12(d)
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―Convenience‖ is defined as any
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order reflecting the presence of a
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consistently implemented. Determine
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monitored separation from other Res
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to prevent occurrences, monitoring
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injurious behaviors, residents with
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A certified nurse aide found guilty
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o Day-to-day use of plastic cutlery
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for the resident‘s safety. For ex
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If a facility changes its policy to
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___________________________________
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Staff should strive to reasonably a
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egarding medical information. The f
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The report stated that, ―Resident
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If not contraindicated, modifying t
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o Visual interaction and to compens
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For residents from diverse ethnic o
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Encouraging volunteer-type work tha
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12 Christenson, M.A. (1996). Enviro
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selected this activity. The Nationa
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Interview the social services staff
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Identifies how the facility will pr
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o Determine if the facility has acc
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(ii) Has 2 years of experience in a
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Once the team has completed its inv
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___________________________________
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transportation services that are no
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F252 (Rev. 66, Issued: 10-01-10, Ef
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Although this Tag can be used for i
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Page 117 and 118: ___________________________________
Page 119 and 120: Intent §483.20 To provide the faci
Page 121 and 122: (vii) Psychosocial well-being ―Ps
Page 123 and 124: ___________________________________
Page 125 and 126: Resident‘s decision making change
Page 127 and 128: ___________________________________
Page 129 and 130: (i) Admission assessment. (ii) Annu
Page 131 and 132: Completing an assessment that is no
Page 133 and 134: Interpretive Guidelines §483.20(h)
Page 135 and 136: Submitting correction(s) to informa
Page 137 and 138: If the resident has refused treatme
Page 139 and 140: . Do the dietitian and speech thera
Page 141 and 142: Are physicians‘ orders carried ou
Page 143 and 144: What types of pre-discharge prepara
Page 145 and 146: If the resident‘s PAS report indi
Page 147 and 148: Briefly review the assessment, care
Page 149 and 150: and knowledge of the resident, shou
Page 151 and 152: Determine whether the facility had
Page 153 and 154: NOTE: Guidance regarding pressure u
Page 155 and 156: The resident has the right to refus
Page 157 and 158: others being hypersensitivity, idio
Page 159 and 160: Examples of clinical resources avai
Page 161 and 162: indicators which may represent pain
Page 163 and 164: • Impact of pain on quality of li
Page 165: National Center for Complementary a
Page 169 and 170: The objective of this protocol is t
Page 171 and 172: How effective the interventions hav
Page 173 and 174: Nurse Interview. Interview a nurse
Page 175 and 176: Communicated with the health care p
Page 177 and 178: qualified persons with input from t
Page 179 and 180: of pain. First, the team must rule
Page 181 and 182: The resident experienced daily or l
Page 183 and 184: Extensive Assistance - While reside
Page 185 and 186: Procedures: §483.25(a)(1)(ii) Dete
Page 187 and 188: Identify if resident triggers CAAs
Page 189 and 190: USE OF SPEECH, LANGUAGE, OR OTHER F
Page 191 and 192: ___________________________________
Page 193 and 194: Probes: §483.25(b) Identify if res
Page 195 and 196: ―Debridement‖- Debridement is t
Page 197 and 198: OVERVIEW A pressure ulcer can occur
Page 199 and 200: procedures, during prolonged ambula
Page 201 and 202: Assessment of a resident‘s skin c
Page 203 and 204: Both urine and feces contain substa
Page 205 and 206: use of lifting devices for repositi
Page 207 and 208: in accord with resident‘s overall
Page 209 and 210: Whether pain, if present, is being
Page 211 and 212: Some clinicians utilize validated i
Page 213 and 214: generally impairs wound healing, se
Page 215 and 216: 15 Fuhrer M., Garber S., Rintola D.
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of Localized Chronic Wound Infectio
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Previously unidentified open areas;
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complications including reassessmen
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If not, the development of the pres
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o Determine if the care plan was pe
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Examples of possible avoidable nega
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(Rev. 66, Issued: 10-01-10, Effecti
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later stages of dementia, diabetes,
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the resident‘s concerns and offer
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Functional and cognitive capabiliti
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toileting and response to specific
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cognitive deficit—provided that t
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the epidermis (comparable to a deep
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adequate. Based on the resident‘s
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Follow-Up of UTIs rectal temperatur
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9 Maki, D.G. & Tambyah, P.A. (2001)
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Whether the resident is on a schedu
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catheter/continence services. Reque
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Defines the catheter, tubing and ba
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If the attending physician is unava
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Assess, prevent (to the extent poss
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perform relevant activities of dail
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Requires immediate correction, as t
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The failures of the facility to pro
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Identify if resident triggers CAAs
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Probes: §483.25(f)(1) For sampled
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___________________________________
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Using universal precautions and cle
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Monitor the effectiveness of the
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Directs resources to address safety
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Monitoring is the process of evalua
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those (e.g., disease, environment)
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Addressing the factors for the fall
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155°F 148°F 140°F 133°F 127°F
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NOTE: The Safe Medical Devices Act
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ENDNOTES 1 Centers for Medicare & M
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Use To evaluate whether the facilit
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2. Interview The adequacy of the su
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Changes in condition such as the ab
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Noncompliance for F323 After comple
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Once the survey team has completed
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Unsafe wandering and/or elopement t
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Severity Level 1 Considerations: No
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―Qualified dietitian‖ refers to
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Current standards of practice recom
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dry mouth, and diseases of the orop
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Based on analysis of relevant infor
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For many residents (including overw
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In deciding whether and how to inte
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End-of-Life Resident choices and cl
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11 Chouinard, J. (2000). Dysphagia
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Objectives Use INVESTIGATIVE PROTOC
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Nutrition interventions, such as sn
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Whether the facility identified res
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Review of Facility Practices Relate
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42 CFR §483.20(b)(1), Tag F272, Co
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DEFICIENCY CATEGORIZATION (Part IV,
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If immediate jeopardy has been rule
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Intent §483.25(j) The intent of th
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Is proper administration technique
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§483.25(k)(5) Standard: Tracheal S
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(v) In the presence of adverse cons
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physical actions such as: pacing, c
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o Support decisions about modifying
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individual with dementia, to improv
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Medication management is based in t
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Whether the signs, symptoms, or rel
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o Pain; o Chronic psychiatric illne
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Common Conditions/ Symptoms Example
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Identifying the essential informati
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necessarily indicate a need for dos
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Sometimes, the decision about wheth
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The continued use is in accordance
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J., & Bates, D.W. (2005). Incidence
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(NSAIDs) Medication Issues and Conc
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Antibiotics Medication Issues and C
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Medication Issues and Concerns prim
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Medication Issues and Concerns Mono
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chlorpropamide glyburide Antifungal
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Medication Issues and Concerns MAO
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Medication Issues and Concerns days
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Medication Issues and Concerns Medi
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uspirone Medication Issues and Conc
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Medication Issues and Concerns amio
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Medication Issues and Concerns Angi
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Nitrates, e.g., Medication Issues a
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Medication Issues and Concerns Anti
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Medication Issues and Concerns esom
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Medication Issues and Concerns laxa
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Medication Issues and Concerns Resp
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Medication Issues and Concerns hygi
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Medication Issues and Concerns All
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iperiden trihexyphenidyl olanzapine
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NOTE: This review is not intended t
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If during the review, you identify
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How he/she approaches the MRR proce
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o Failure to monitor a medication c
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42 CFR 483.20(b), F272, Comprehensi
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Complications (such as diarrhea wit
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NOTE: If Severity Level 3 (actual h
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―Resident Condition‖ -- The res
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Medication Errors Due to Failure to
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Medications Administered with Enter
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if the facility uses the ―recap
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technique requires a comparison of
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eaction to the vaccine than would h
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o Persons who are 50 years of age o
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Sampling: To determine if education
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Processes to address issues that ar
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The facility failed to document tha
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Requires immediate correction as th
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(ii) other nursing personnel. §483
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(3) The State finds that, for any p
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(A) Has only patients whose physici
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For SNFs and SNF/NFs which may be w
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Assessing special nutritional needs
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Probes: §483.35(c)(1) Are resident
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___________________________________
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Interpretive Guidelines: §483.35(f
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―Food Preparation‖ refers to th
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for growth of harmful pathogens. Ba
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Source of Primary Agents of Primary
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Food Receiving and Storage When foo
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specified below will either kill da
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may consist of a combination of foo
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at the manifold, which is the area
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INVESTIGATIVE PROTOCOL SANITARY CON
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2. Interview Observe that foods are
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cooling, and ensure that PHF/TCS fo
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2. Degree of harm (actual or potent
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Severity Level 1 Considerations: No
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Intent: §483.35(h) The intent of t
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Whether they are assisting assigned
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and drink. If concerns are identifi
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Compliance with 42 CFR 483.35(h), F
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eligibility to eat and drink with a
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Examples of the facility‘s non-co
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delegating and supervising follow-u
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Probes: §483.40(b) Do services ord
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For what reasons are residents sent
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(2) Obtain the required services fr
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Probes: §483.45(a)(1)(2) 1. For ph
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a care plan must be developed, foll
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Are residents missing teeth and may
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Definitions are provided to clarify
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The National Coordinating Council f
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Establish procedures that address m
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How the receipt of medications from
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Documentation of actual disposition
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the pharmaceutical services. Fourth
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The facility‘s failure to involve
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The facility in collaboration with
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(2) The pharmacist must report any
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errors, or other irregularities, an
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NOTE: The surveyor‘s review of me
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o Seizure activity; o Spontaneous o
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Common Medication-Medication Intera
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The identification of any irregular
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aspects of pharmaceutical services.
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The pharmacist‘s MRR failed to id
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(3) Determines that drug records ar
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During a medication pass, medicatio
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This requirement has several aspect
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Determine whether the noncompliance
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§483.65 Infection Control The faci
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―Contact precautions‖ are measu
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Critical aspects of the infection p
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Conducting data analysis to help de
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observations of staff practices and
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Complications from invasive diagnos
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Airborne transmission can occur by
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After removing gloves or aprons; an
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Depending on the situation, options
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tears or holes be replaced. It is r
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ENDNOTES 68 Siegel, J.D., Rhinehart
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Guidelines for environmental infect
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INVESTIGATIVE PROTOCOL FOR INFECTIO
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Multiple use items (e.g., shower ch
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Interview the Designated Infection
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Utilize infection precautions to mi
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Properly implement transmission bas
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influenza in residents on another,
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§483.70(a)(6)(ii) The dispensers a
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Additional guidance is available in
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§483.70(d)(1)(i) Accommodate no mo
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Procedures: §483.70(d)(1)(iv) Ther
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Interpretive Guidelines: §483.70(d
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centralized nursing station, this c
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Are spaces adaptable for all intend
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defined as substandard quality of c
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(ii) Responsible for the management
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Probes: §483.75(e)(2 - 4) During a
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1919(e)(2)(A) of the Act the facili
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Interpretive Guidelines: §483.75(f
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The medical director helps the faci
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MEDICAL DIRECTION The facility is r
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The medical director is responsible
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REFERENCES 1 Pattee JJ, Otteson OJ.
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support with ventilators, intraveno
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The medical director provides input
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V. DEFICIENCY CATEGORIZATION (Part
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NOTE: If immediate jeopardy has bee
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Intent: §483.75(j)(1) The intent o
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Probes: §483.75(j)(1)(i) - (iv) Ar
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An inability to order radiological
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There is a written policy, at the h
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If there is a problem with confiden
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(i) Residents will be transferred f
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Preventing deviation from care proc
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Meetings of the QAA committee must
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INVESTIGATIVE PROTOCOL QUALITY ASSE
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The assigned surveyor should interv
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2. Degree of harm (actual or potent
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The facility‘s QAA committee meet
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R04SOM 11/12/2004 Guidance to Surve
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e. Special Care Fl19____ Receiving
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Form CMS-672 (10/10) ReSIDent CenSu
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Form CMS-672 (10/10) ReSIDent CenSu
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DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
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16. Weight Change/Nutrition/Swallow
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RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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