F-Tag 309: Are You Ready? Are You Ready?. Joan Williams, MS, CRNP Joan Williams, MS, CRNP Director of Clinical Services Director of Clinical Services

F-Tag 309:F-Tag 309:

Are You Ready?Are You Ready?

Joan Williams, MS, CRNP Joan Williams, MS, CRNP

Director of Clinical ServicesDirector of Clinical Services

QUALITY OF CAREQUALITY OF CARE

42 CFR 483.25 (F309)42 CFR 483.25 (F309)

Effective Date: 3/31/09Effective Date: 3/31/09

483.25 Quality of Care483.25 Quality of Care

Each resident must receive and the facility Each resident must receive and the facility must provide the necessary care and must provide the necessary care and services to attain or maintain the highest services to attain or maintain the highest practicable physical, mental, and practicable physical, mental, and psychosocial well-being, in accordance psychosocial well-being, in accordance with the comprehensive assessment and with the comprehensive assessment and plan of care.plan of care.

Includes:Includes:

General Investigative ProtocolGeneral Investigative Protocol

covers care of residents where acovers care of residents where a

more specific regulation or more specific regulation or

protocol does not applyprotocol does not apply Pain Management ProtocolPain Management Protocol

covers all aspects of pain covers all aspects of pain

managementmanagement

Additions to Non Pressure-Related Skin Additions to Non Pressure-Related Skin Ulcer/Wound Quality of CareUlcer/Wound Quality of Care

F-309 now also includes hospice and F-309 now also includes hospice and

ESRD services (formerly in ESRD services (formerly in

Appendix P; moved, not changed).Appendix P; moved, not changed).

Nursing ProcessNursing Process

Both protocols—General Investigative and Both protocols—General Investigative and Pain Management—are based in the Pain Management—are based in the Nursing Process. Nursing Process.

For any symptom the resident has: are For any symptom the resident has: are you assessing, care planning with you assessing, care planning with outcomes, implementing care outcomes, implementing care management strategies, evaluating the management strategies, evaluating the outcomes, and revising the plan/care outcomes, and revising the plan/care given?given?

DOCUMENTDOCUMENT

Will be observing and interviewing first hand.Will be observing and interviewing first hand. Will be reviewing DOCUMENTATION of any Will be reviewing DOCUMENTATION of any

kind related to the symptom, e.g. will review kind related to the symptom, e.g. will review facility protocols if referenced in the treatment facility protocols if referenced in the treatment plan.plan.

All documents used for the resident must be All documents used for the resident must be available to staff and caregiversavailable to staff and caregivers

Care/Treatment Plan DecisionsCare/Treatment Plan Decisions

Appropriate?Appropriate? All-inclusive based on resident All-inclusive based on resident

assessment?assessment? Achieved Outcomes?Achieved Outcomes? Modified based on the resident’s abilities?Modified based on the resident’s abilities? Evaluated regularly and on-going?Evaluated regularly and on-going?

GENERAL GENERAL

INVESTIGATIVEINVESTIGATIVE

PROTOCOLPROTOCOL

Compliance Is:Compliance Is:

Recognition and assessment of factors placing Recognition and assessment of factors placing the resident at risk for specific conditions, the resident at risk for specific conditions, causes, and/or problems.causes, and/or problems.

(actual and potential)(actual and potential) Defining and implementing interventions in Defining and implementing interventions in

accordance with resident needs, goals, and accordance with resident needs, goals, and recognized standards of practicerecognized standards of practice

(justified)(justified)

Compliance Is:Compliance Is:

Monitoring and Evaluating care and the Monitoring and Evaluating care and the resident’s responsesresident’s responses

(document) (document)

Revising and Re-PlanningRevising and Re-Planning

(restarts the assessment circle)(restarts the assessment circle)

Investigation May Include:Investigation May Include:

An investigation into Quality of Care may An investigation into Quality of Care may include any additional concern related to include any additional concern related to care provisioncare provision

• StructureStructure• ProcessProcess• OutcomeOutcome

Deficiency CategorizationDeficiency Categorization

Key elements:Key elements:• Presence/Potential of harm/negative outcomesPresence/Potential of harm/negative outcomes• Degree of actual/potential harm R/T non-Degree of actual/potential harm R/T non-

compliancecompliance• Immediacy of correction requiredImmediacy of correction required

Utilizes determination of Immediate Jeopardy Utilizes determination of Immediate Jeopardy first (Appendix Q), then the general guidance first (Appendix Q), then the general guidance (Appendix P) if no other guidance available (Appendix P) if no other guidance available

So the resident has a symptom…So the resident has a symptom…

What is the standard of care for the What is the standard of care for the assessment of that symptom?assessment of that symptom?

Complaint in the resident’s wordsComplaint in the resident’s words

Time Frames—Time Frames—• Duration or history of the symptomDuration or history of the symptom• Onset (when)Onset (when)• Manner of initiation (how)Manner of initiation (how)

Symptom Characteristics:Symptom Characteristics:• Quality (what feels like)Quality (what feels like)• Location and/or radiationLocation and/or radiation• Intensity or severity (rating scale, relate it to..)Intensity or severity (rating scale, relate it to..)• Timing (continuous, intermittent)Timing (continuous, intermittent)• Precipitating and Relieving FactorsPrecipitating and Relieving Factors• Aggravating Factors (makes it worse)Aggravating Factors (makes it worse)• Associated Symptoms (simultaneous, pre/post)Associated Symptoms (simultaneous, pre/post)• ProgressionProgression• Effect of TreatmentEffect of Treatment• What does the symptom keep you from doing?What does the symptom keep you from doing?

Assess the symptomAssess the symptom Make clinical judgmentMake clinical judgment Develop planDevelop plan Implement plan/treatmentsImplement plan/treatments Evaluate effectiveness of plan and Evaluate effectiveness of plan and

expected outcomesexpected outcomes

For every symptom…For every symptom…

there is a plan, intervention, and evaluation.there is a plan, intervention, and evaluation.

Pain Pain

ManagementManagement

ProtocolProtocol

Defining pain…Defining pain…

Pain is-Pain is- “ “an unpleasant sensory and emotionalan unpleasant sensory and emotionalexperience associated with actual orexperience associated with actual orpotential tissue damage, or described in potential tissue damage, or described in terms of such damage”terms of such damage” International Association for the Study International Association for the Study

of Pain of Pain (IASP)(IASP)

Pain is…Pain is…

Acute-initially present due to the onset of Acute-initially present due to the onset of

symptoms or treatment of a diseasesymptoms or treatment of a disease

Chronic-persistent beyond the usual ofChronic-persistent beyond the usual of

expected course of a disease orexpected course of a disease or

after a reasonable time for an after a reasonable time for an

injury to heal injury to heal


known to be present in approximately 80% known to be present in approximately 80% of institutionalized elderly clients.of institutionalized elderly clients.

2008 American Conference on Pain2008 American Conference on Pain


Often chronic in the elderly; in point of fact Often chronic in the elderly; in point of fact the elderly are believed to have twice the the elderly are believed to have twice the prevalence of chronic pain as the general prevalence of chronic pain as the general population.population.

Most importantly– approximately 45-80% of Most importantly– approximately 45-80% of LTC residents are estimated to have LTC residents are estimated to have

substantial pain that is undertreated.substantial pain that is undertreated.

American Geriatrics SocietyAmerican Geriatrics Society

So, what’s the problem?So, what’s the problem?

Pain is a major factor inPain is a major factor in

the the

QUALITY OF LIFEQUALITY OF LIFE

ofof

each of our clients.each of our clients.

In order to effectively manage pain, we In order to effectively manage pain, we must believe that it is possible to control must believe that it is possible to control and manage this symptom on an ongoing and manage this symptom on an ongoing basis with positive outcomes for our basis with positive outcomes for our residents.residents.

Assess Pain…Assess Pain…

RegularlyRegularly ConsistentlyConsistently MethodicallyMethodically Non-judgmentallyNon-judgmentally With the goal of controlWith the goal of control


…….regularly…..according to your policy and .regularly…..according to your policy and procedure. This may be daily, every shift, procedure. This may be daily, every shift, every x-number of hours, or however every x-number of hours, or however frequently your policy states. frequently your policy states.

…….regularly is not once a month (MDS)..regularly is not once a month (MDS).


Methodically (with a method)…Methodically (with a method)…

AnalyzeAnalyze in order to communicate with in order to communicate with

the provider to get effective the provider to get effective

treatments.treatments.


Symptom analysis is the simplest way.Symptom analysis is the simplest way.

Symptom Analysis…Symptom Analysis…

Complaint in client’s words.Complaint in client’s words. Onset (when, gradual or sudden?)Onset (when, gradual or sudden?) Precipitating/Relieving factors (what Precipitating/Relieving factors (what

makes it better/worse?) makes it better/worse?) Quality (sharp, dull, aching?)Quality (sharp, dull, aching?) Radiation/Location (where and where go?)Radiation/Location (where and where go?) Severity/Intensity (use scales)Severity/Intensity (use scales) Timing (when, continuous, intermittent)Timing (when, continuous, intermittent)

Symptom Analysis…Symptom Analysis…

Aggravating factorsAggravating factors Associated symptoms (N/V, numbness)Associated symptoms (N/V, numbness) Progression of symptomsProgression of symptoms Effect of treatmentEffect of treatment Other: when did you last feel well?Other: when did you last feel well? what does this keep you from what does this keep you from doing?doing? what level of pain is tolerable?what level of pain is tolerable?


With consistency or uniformity….With consistency or uniformity….

By using a format or scale which can be By using a format or scale which can be

validly and reliably used by your validly and reliably used by your

personnel.personnel.

The trick is…The trick is…

Do what works in your facility.Do what works in your facility.

Do it regularly, consistently, and Do it regularly, consistently, and methodically.methodically.

Pain Relief Plans…Pain Relief Plans…

If pain is identified as a client problem,If pain is identified as a client problem,

then the care plan must address it.then the care plan must address it.

The RAP does not have a specific place The RAP does not have a specific place labeled ‘pain’ right now. However pain labeled ‘pain’ right now. However pain may come out in a number of areas. If may come out in a number of areas. If you have a number of these noted, look you have a number of these noted, look for pain.for pain.

Pain Relief Plans…Pain Relief Plans…

Should address physical, emotional, Should address physical, emotional,

social, and spiritual aspects of pain.social, and spiritual aspects of pain.

Interventions for Pain Relief…Interventions for Pain Relief…

Non-pharmacologic interventionsNon-pharmacologic interventions

Pharmacologic interventionsPharmacologic interventions

Evaluation of Pain ManagementEvaluation of Pain Management

Restarts the circle of pain control.Restarts the circle of pain control.

We really keep assessing/working and We really keep assessing/working and reworking the plan/evaluating its reworking the plan/evaluating its effectiveness and re-assessing the client’s effectiveness and re-assessing the client’s needs.needs.


Analysis of Pain Control may use different Analysis of Pain Control may use different types of documentation, but the net goal is types of documentation, but the net goal is to try to see what works, how long it to try to see what works, how long it worked, what factors affected it working, worked, what factors affected it working, and what the client thought of the pain and what the client thought of the pain relief.relief.


Freestyle Summary of Pain EpisodesFreestyle Summary of Pain Episodes

Pain Assessment Tracking (with sample Pain Assessment Tracking (with sample tracking form)tracking form)


Outcomes Desired Outcomes Desired

vs. vs.

Outcomes AchievedOutcomes Achieved

KEY POINTS---KEY POINTS---

One key point in the pain management One key point in the pain management protocol is the emphasis placed not only protocol is the emphasis placed not only on current, known pain symptoms, but on current, known pain symptoms, but also on also on POTENTIAL POTENTIAL pain symptoms.pain symptoms.

KEY POINTS---KEY POINTS---

Another key point is the specific definitions Another key point is the specific definitions included in the section regarding included in the section regarding recognition and management of pain—in recognition and management of pain—in order for your staff to manage pain order for your staff to manage pain effectively, they will need to understand effectively, they will need to understand these definitions (especially the ones these definitions (especially the ones regarding types of pain like acute and regarding types of pain like acute and incident pain types)incident pain types)

KEY POINTS--KEY POINTS--

The reference sections included in the The reference sections included in the CMS 1/23/09 guidance section related to CMS 1/23/09 guidance section related to the pain management protocol are the pain management protocol are excellent and provide many varied excellent and provide many varied approaches to supplement your personal approaches to supplement your personal and staff education.and staff education.

KEY POINTS--KEY POINTS--

Timing-Timing-

If the problem occurs, you assess If the problem occurs, you assess and care plan a strategy according to your and care plan a strategy according to your policy and procedure. Make sure you policy and procedure. Make sure you communicate the plan as well.communicate the plan as well.

Compliance Is…Compliance Is…

Recognition and evaluation of all aspects Recognition and evaluation of all aspects of pain management for residents who of pain management for residents who experience painexperience pain

Development and implementation of a Development and implementation of a pain management plan for/with the pain management plan for/with the resident (or a rationale for why not)resident (or a rationale for why not)

Compliance Is…Compliance Is…

Anticipatory recognition and prevention of Anticipatory recognition and prevention of pain where it can be anticipatedpain where it can be anticipated

Monitoring and modifying interventionsMonitoring and modifying interventions

Further investigation and communication Further investigation and communication regarding inadequately managed pain or regarding inadequately managed pain or adverse consequences of pain adverse consequences of pain managementmanagement

Investigation May Include:Investigation May Include:

An investigation into Quality of Care may An investigation into Quality of Care may include any additional concern related to include any additional concern related to care provisioncare provision

• StructureStructure• ProcessProcess• OutcomeOutcome


Presence of harm or actual/potential Presence of harm or actual/potential negative outcome because of lack of negative outcome because of lack of appropriate treatment and careappropriate treatment and care

• Persistent/recurring pain and discomfort R/T failure Persistent/recurring pain and discomfort R/T failure to recognize, assess, or implement interventionsto recognize, assess, or implement interventions

• Decline in function from failure to assess after Decline in function from failure to assess after awareness of new onset of moderate to severe awareness of new onset of moderate to severe painpain


Degree of actual or potential harm related Degree of actual or potential harm related to the non-compliance.to the non-compliance.

The immediacy of correction required.The immediacy of correction required.

Severity Levels…Severity Levels…

Level 4: Level 4:

facility allowed, caused, or situation facility allowed, caused, or situation resulted in serious injury, harm, resulted in serious injury, harm, impairment, or death to a resident and impairment, or death to a resident and requires immediate correction. ‘severe, requires immediate correction. ‘severe, unrelenting, excruciating, and unrelieved unrelenting, excruciating, and unrelieved pain’pain’


Level 3:Level 3: indicated non-compliance resulting in indicated non-compliance resulting in

actual harm related to clinical compromise, actual harm related to clinical compromise, decline, or inability to maintain and/or decline, or inability to maintain and/or reach his/her highest practicable well-reach his/her highest practicable well-being ‘compromise of function with being ‘compromise of function with subsequent additional symptoms, or subsequent additional symptoms, or episodic pain related to treatments or episodic pain related to treatments or interventions’interventions’


Level 2:Level 2: Noncompliance resulting in resident outcomes Noncompliance resulting in resident outcomes

of minimal discomfort, potential inability to of minimal discomfort, potential inability to reach/maintain highest level of well-being, or reach/maintain highest level of well-being, or complaints of moderate discomfort/ pain. complaints of moderate discomfort/ pain. Potential for greater discomfort.Potential for greater discomfort.

Level 1:Level 1: NoneNone

Questions?Questions?

Documents

F-Tag 309: Are You Ready? Are You Ready?. Joan Williams, MS, CRNP Joan Williams, MS, CRNP Director of Clinical Services Director of Clinical Services