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Fundamentals of CMS Updates to Appendix PP of the State Operations Manual: Comprehensive Person-Centered Care Plans and Quality of Care

F689: Free of Accident Hazards/Supervision/Devices

The Requirements of Participation governing F689 mandate that the facility remove items and resolve situations over which the facility has control to protect residents from accidents. The facility must ensure that the resident environment remain as free of accident hazards as possible, and that each resident receive adequate supervision and assistive devices to prevent accidents. The scope and severity at which surveyors will cite a facility for noncompliance with this tag will vary depending on whether actual or potential physical or psychosocial harm is identified.

The SOM Revisions to F689 Provide Varied Guidance Regarding Residents Who Leave AMA, E-Cigarettes, and Accident Prevention

The SOM revisions under this tag offer additional guidance to assist facilities in distinguishing a resident's elopement from a resident leaving against medical device (AMA), especially as it relates to residents with a history of substance use disorder; to introduce the use of e-cigarettes as a potential accident hazard; and to advise facilities regarding assistance with bedrails and fall prevention.

The new guidance mandates that facilities cannot allow residents to leave the premises or safe area without facility knowledge, supervision, and an awareness of the resident's departure and/or whereabouts. The SOM distinguishes an elopement from a resident who leaves AMA, meaning the resident leaves before a planned discharge, but with facility knowledge of the departure and despite facility attempts to explain the risk. Facilities must document their explanation of the risks of leaving and the time the facility becomes aware of the resident leaving the facility to prevent an allegation of an elopement instead of the recognition of a leave AMA.

The new SOM further notes that residents with a history of substance use disorder may be at increased risk for leaving the facility without notification and/or for illegal or prescription drug overdose if the resident continues to use dangerous substances while residing in the nursing home. Facilities are directed to assess for these risks and to implement care plan interventions to ensure resident safety, and to assess residents for risks, signs, and symptoms of substance use disorder. Facilities must also be prepared to address relapses of substance abuse and overdoses.

Facilities are also directed to balance the rights of smoker, including smokers of e-cigarettes, and nonsmoker residents. Facilities are to recognize that the use of e-cigarettes indoors or where smoking is prohibited may expose others to potentially toxic chemicals from the e-cigarette use, and develop and implement policies for the safe use of both e-cigarettes and traditional cigarettes. In addition, residents who wish to use cigarettes of any kind should be assessed for their ability to safely handle the devices.

Lastly, the new guidance requires that facilities prevent entrapment by providing timely assistance to residents with bedrails when the resident needs to use the bathroom, re-position in bed, or execute other care-related activities. The SOM also notes that loose or improperly worn clothing is now a factor that may be found to result in residents' accidental falls.

Key Takeaways

The revisions to the SOM explicitly note the importance of entering documentation into the medical record to prevent an AMA from being adjudged an elopement. Documentation is similarly expected to demonstrate that the facility has undertaken the additional planning necessary to assist residents with substance use disorders.

The new guidance also places e-cigarette use on par with the use of traditional cigarettes regarding the types of safety precautions that a facility must arrange. The guidance further requires facilities to balance the rights of smokers, including smokers of e-cigarettes, and nonsmoker residents, without providing specific insight regarding how to achieve that balance. Lastly, the new revisions guide facilities of new expectations regarding entrapment and fall prevention.

F697: Pain Management

Noncompliance may be cited at F697 if a facility does not provide pain management to a resident who experiences pain, if the facility's pain management practice does not meet professional standards of practice, or if the facility does not provide pain management in accordance with the resident's comprehensive care plan, goals for care, and preferences.

The SOM Revisions at F697 Focus on the Use of Opioids in Pain Management

The revisions to the SOM provide substantial guidance regarding a facility's use of opioids for pain management. Under the new guidance, facilities are advised not to use long-acting forms of opioids in residents with dementia; immediate release forms are generally preferred. In addition, the guidance warns against combining opioids and benzodiazepines in treatment, unless clinically indicated for an individual resident.

The new guidance encourages facilities to use alternatives to opioids to manage pain, when appropriate. When used, the SOM guides facilities to prescribe opioids in the lowest effective dose for the shortest amount of time possible after considering medical needs. Facilities are also encouraged to use long-acting opioids to provide more consistent pain relief with less breakthrough pain. The new guidance also provides new definitions for Medication Assisted Treatment and Opioid Use Disorder.

Key Takeaways

Under the revisions, CMS addresses the provision of quality care by providing explicit guidance regarding the use of opioids for pain management, including discussing the types of opioids that should generally be used and under which circumstances. Surveyors may now review residents' medical records with this guidance front of mind.

F565 and F699: Comprehensive Person-Centered Care Plans

The SOM provides guidance about the process for creating appropriate care plans for residents. In addition to the existing requirements, the updates to tags F565 and F699 require an enhanced focus on person-centered care plans that are both "culturally-competent" and "trauma-informed."

Culturally Competent Care Plans

The revised guidance provides that a resident's care plan must reflect the resident's cultural needs and preferences, and align with the resident's cultural identity, to provide culturally competent care. Facility staff should be respectful of and responsive to the beliefs and practices of diverse population groups, including racial, religious, social, and ethnic groups. Cultural preferences may include food choices and preparation, clothing, physical contact, and etiquette.

Trauma-Informed Care Plans

Recognition of residents' traumatic experiences should be included in the care planning process. If a resident has a history of trauma, individualized interventions should be developed with the collaboration of the resident and their family and friends to understand the triggers and mitigate symptoms of trauma including substance abuse, depression, anxiety, aggression, and withdrawal or isolation from others. Facilities should use screening and resident assessment tools to identify a resident's history of trauma.

Key Takeaways

Facilities should make certain that their resident assessment and care planning process adequately identifies and responds to the cultural and trauma needs of residents and includes appropriate interventions to communicate and deliver care to residents. Facilities should provide activities that are culturally relevant to residents, provide a culturally diverse environment that respects and treats each resident with dignity, and monitor the effects of these interventions. Facilities must identify triggers that may re-traumatize residents and develop interventions that minimize or eliminate the effect of the trigger on the resident.

For specific guidance or more information about this alert, please contact Howard Sollins, Sandra Adams, Stefanie Doyle, or any other member of Baker Donelson's Long Term Care Team.

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