Nursing homes must demonstrate substantial compliance with certain key processes of care related to pain management or risk being cited with an F309 deficiency statement. The following is a step-by-step guide used to point out the key processes and goals related to pain management.
Plan of Correction for F309 Deficiency
Annual Inspection: Questions and Answers about the Annual Inspection
Plan of Correction: Questions and Answers about the Plan of Correction
Overview of the Process for responding to an F309 Survey Deficiency
An Overview of each step needed in order to best respond to an F309 Survey Deficiency:
What is the purpose of the Annual Survey?
Nursing homes participating in the Medicare and Medicaid programs are required by federal law to undergo an annual survey. The purpose of the survey is to assess whether the quality of care, as intended by the law and regulations, and as needed by the resident, is being provided in the nursing home. Homes must be in substantial compliance with Medicare and Medicaid requirements as well as state law to be certified by the Centers for Medicare and Medicaid Services (CMS). As a result of the survey process a deficiency statement may be formulated indicating that the nursing home failed to meet a requirement specified in the federal regulations.
What is the federal regulation residents' pain in nursing homes?
Pain management is now an essential component of the regulation governing quality care for nursing home residents. The quality of care regulation (F309 483.25) reads: "Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care."
The regulation doesn't say anything about pain. In fact, isn't the regulation rather vague?
You're right. The regulation doesn't specifically talk about pain. However, while it may be short on details it isn't vague about expectations. Remember, the nursing home is to assure that, "each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being." In order to meet the expectations your residents need to be comfortable and free of distressing pain and other symptoms.
What are the surveyors looking for regarding pain?
Surveyors use interpretive guidelines that prompt them through the survey process regarding all areas of compliance, including compliance with the quality of life regulation. The surveyors are looking for evidence that the nursing home has appropriate policies and procedures in place to assure that all residents' pain is routinely assessed and adequately managed using key processes of care.
What do you mean by Key Processes of Care?
There are four key processes of care related to pain that are essential components of compliance with the quality of life regulation. The four key process of care are:
1. Screening for and assessment of pain.
2. Communication of the pain assessment to others involved with the resident's care.
3. Formulation and implementation of plan of care related to pain.
4. Individualized monitoring, including reassessment, of the resident's response to the interventions outlined in the plan of care.
Goal Screening and Assessment All Nursing Home residents are screened and appropriate persons receive an in-depth assessment. Communication of Assessment to Health Care Providers " Registered Nurse communicates with health care providers in timely manner with the needed information for a plan of care to be formulated regarding pain management.
" Resident/family receive the desired information about pain assessment and management.
Formulation and Implementation of Plan of Care To provide Nursing Home resident with the desired level of pain relief with minimization of adverse reactions. Individualized Monitoring To ensure that once a plan of care is formulated, there is ongoing assessment of whether pain is achieving the resident's specific goals.
Is there a process to disagree with a Surveyor's findings?
Federal regulations require each state to implement an informal dispute resolution (IDR) process that allows facilities to contest deficiencies without initiating a formal administrative appeal. The regulations do not prescribe how the process must be established or implemented. Check with your state officials regarding their procedures for IDR.
When will we get the Statement of Deficiency CMS-2567?
The surveyor will complete their part of the Statement of Deficiency CMS-2567 and return to you with instructions on how to complete the Plan of Correction. You should receive this form within a few days following the survey. Remember, you need to return your completed Plan of Correction within ten (10) days of receipt of the Statement of Deficiency CMS-2567. Take a closer look at the Survey Report Form CMS 2567. This report form is where the results and findings of your survey are recorded. You will use this form to document your response to the deficiency and completion dates for your Plan of Correction.
What does ID Prefix Tag mean?
The column on the far left marked "ID PREFIX TAG" indicates the identifying number associated with the regulation being cited. The ID prefix tag related to pain is F309. If the survey team determines that F309 deficiency exists, they consider whether the F309 deficiency constitutes immediate jeopardy or actual harm to residents; and whether the F309 deficiency is isolated, constitutes a pattern, or is widespread. A Nursing Home can be cited on one or more F309 deficiency related to specific key processes of pain management.
How about the next column?
The next column is marked "SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION). The surveyor's first entry in this column is the actual regulation being referenced. If your nursing home was cited on a F309 deficiency you will see the full language from the regulation 483.25 Quality of Care.
Next, the surveyor documents the evidence found to support the deficiency. The evidence may be from medical records, interviews and/or based on the surveyor's observations. Finally, the surveyor documents in detail the findings that support the evidence of non-compliance. The other columns are to be used to document the nursing home's plan of correction.
Example of a Survey Report Form CMS-2567
What is the overall purpose of the Plan of Correction?
Nursing Homes are expected to remain in substantial compliance with Medicare and Medicaid program requirements as well as state law. Emphasis is placed on continued, rather than cyclical compliance. Therefore, your policies and procedures must be able to promptly remedy deficient practices and to ensure that correction is sustainable. This means that your facility must take the initiative and responsibility to continuously monitor performance.
What information must be included in the content of the Plan of Correction?
1 - All deficiencies cited in the CMS-2567 must be individually addressed in your Plan of Correction.
2 - Your Plan of Correction is a public document and must not include resident or facility staff names, allude to another supplier, or malign an individual. Use only the resident and staff identifiers used by the surveyor in CMS-2567.
3 - You and your team must complete an in-depth analysis to ascertain why the problems exist and why they occurred so you can include in your Plan of Correction specific interventions necessary to achieve resolution and sustain compliance.
4 - The required content of the Plan of Correction for each deficiency depends on whether the deficiency is resident-centered or facility-centered.
a. Resident-Centered Deficiencies are violations of requirements that must be met for each resident. Examples of resident-centered deficiencies include failure to prevent pressure sores, protect the dignity of residents, provide notice prior to transfer, and adequately assess residents.
b. Facility-Centered Deficiencies are violations of requirements that must be met for the facility overall. In general, these are "system" deficiencies such as lack of an infection control program, inadequate staffing, or an inoperative fire alarm.
Overall, what elements must the Plan of Correction include for each deficiency?
1. How corrective action has been or will be accomplished for those residents found to have been affected by the deficient practice;
2. How the facility has identified or will identify other residents having the potential to be affected by the same deficient practice;
3. What measures have been or will be put into place or systemic changes made to ensure that the deficient practice will not recur facility wide; and,
4. How your facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.
What about completion dates?
A single date of completion (month, date, year) must be entered in the right hand column of the CMS-2567 for each deficiency. The overall completion date for all the items within that cited deficiency should be the one that appears in the right-hand column opposite the tag number.
Some corrective actions will have intermediate steps towards full completion and it is appropriate to show separate dates for correction of specific items.
The earliest allowable correction date is one day after the survey completion date shown at the top of the report.
How does the surveyor follow-up on the Plan of Correction?
Your completed CMS-2567 with the plan of correction must be returned to the survey agency within ten (10) days of receiving the Statement of Deficiency CMS-2567. If your plan of correction is not acceptable your facility will be contacted for clarifications and modifications. You will be notified if your Plan of Correction is acceptable.
A revisit survey is required for certain levels of non-compliance. The purpose of the revisit is to confirm that your facility is in substantial compliance and has the ability to remain in substantial compliance.
STEP 1 - Post Exit Conference Meeting
Immediately following the Exit Conference, your Survey Response Team should meet to discuss the findings. Expected outcomes from the meeting should include agreement upon four key issues:
1 - Statement of the problem.
An example of a specific resident-centered problem is: "Pain management not consistently provided as ordered for Resident 1." An example of a more systematic facility-centered problem is: "Physician's order for pain management not followed."
2 - Identification of processes to be improved.
An example of a specific resident-centered process is: "All residents requiring wound care are assessed for pain management needs." An example of a facility-centered process is: "Staffing is adequate to assure that medication orders are followed for all residents."
3 - Distribute specific tasks to analyze problems and processes.
For example, "Charge Nurses from each unit will review all charts of residents with would care to determine adherence to pain assessment and medication administration policies."
4 - Commit to calendar for follow up meetings.
For example, "The Survey Response Team will meet daily from 8:00-9:00 AM until PoC is submitted."
Example Case Study for Step 1:
Post Exit Conference Meeting
The Survey Response Team must identify all possible underlying issues responsible for each F309 deficiency cited related to the key processes of care for pain assessment and management. There may be various reasons for deficiencies and the may not always be apparent. There are four areas that need to be examined in order to determine the infrastructural issues that may be leading to each F309 deficiency. You must:
1 - Examine the policies and procedures related to the key process of care for pain, specifically related to assessment and intervention. You must address:
a - Are you policies and procedures clear, specific, and based on current professional standards and guidelines of practice?
b - Are they readily available to staff members?
c - Are all staff members familiar with them?
d - Do staff members need in-services on them?
e - Do they need to rewritten or updated?
2 - Evaluate forms and tools used for pain screening, assessment, and management. You must address:
a - Do the forms contain all of the essential information?
b - Are the forms logically organized and easy to use?
c - Are there forms for assessment, monitoring, tracking, evaluating, and auditing forms?
3 - Evaluate the staff practices, knowledge and skills related to the key process of care for pain across the entire facility. You must address:
a - Are staff members receiving adequate orientation and ongoing education to assess pain?
b - Are staff members following policies and procedures?
c - Do they need training regarding pharmacological and non-pharmacological options to treat and manage pain?
d - Is management providing appropriate guidelines to staff members related to the key processes of care for pain?
4 - Review your Quality Improvement program's role in the F309 deficiency. You must address:
a - Are regular audits performed to monitor facility practices?
b - Are the audits specific enough to identify problem areas?
c - Do staff members participate in the audit process?
d - Are audit results examined by management, and acted upon in a timely manner?
e - How is feedback provided to staff members and senior leadership regarding audit results?
Evaluating Policies and Procedures
Evaluating Staff Practices, Knowledge and Skills
Review Quality Improvement Program's role in F309 Deficiency
Once the team identifies the underlying issues responsible for the deficiency, you must determine the resources needed to effectively address them if you are to complete an acceptable plan of correction. You must look at the following 3 areas of resource use:
1 - Human Resources. You must address:
a - Does you facility need to hire more licensed staff to assure compliance with the key process of care for pain?
b - Do job descriptions for licensed and non-licensed staff members list their role and responsibilities for the quality of life of residents in their care?
c - Is the staff evaluation process tied to performance related to the specifics of their specific job description?
d - Are management positions filled with qualified and effective employees?
2 - Financial Resources. You must address:
a - Does the facility's budget allow for additional hiring if needed?
b - Are there funds available to support education and training if needed?
c - Does technology and/or equipment require upgrading?
d - Is Quality Improvement adequately budgeted?
3 - Pain Management Resources. You must address:
a - Does the facility have education and training materials related to pain management for elders in the nursing home setting?
b - Is the person responsible for staff education up to the task?
Example Case Study for Step 3:
Pain Management Resources
Now that the team has moved through steps 1-3, the task of writing a solid plan of correction can begin. There are three facets to this step:
1 - Assign Task
Assign appropriate team members specific tasks and activities for creating, implementing and monitoring the plan of correction.
2 - Write the Statement
Write a facility policy statement in reference to the cited deficiency and thoroughly outline the corrective action.
3 - Determine Quality Indicators
Determine the Quality Indicators your team will audit and monitor. Be sure the indicators chosen provide meaningful information regarding the nature of the deficiency cited for the specific resident, for other residents at risk and for systemic change.
Example Case Study for Step 4:
Assign appropriate team members
Write a facility policy statement
Determine the Quality Indicators
Each journey begins with the first step, let's start with The Introduction to an Audit.
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© 2005 The Center for Gerontology
& Health Care Research.
Last edited March 30, 2005. Send questions or comments to