1 Psychosocial Outcomes Severity Guide Guidance Training By Rebecca L. Hall, M.Ed., Long Term Care Educator

2 Psychosocial? Article: “Social Work Services in Nursing Homes: Toward Quality Psychosocial Care” The term psychosocial describes a constellation of: Social Mental health and Emotional needs and the care given to meet them Quality of life focuses on the residents’ perspective on their total living experience in the home, not just medical care

3 Article Continued: A lack of professionally qualified social workers in nursing homes is one of several factors that potentially contribute to inadequate and inconsistent mental health and psychosocial care in nursing homes High rates of mental health disorders include 45 to 51 percent with dementia 35 percent with personality disorders 17 percent with behavior disorders

4 Are psychosocial needs adequately met? 39 percent of residents with psychosocial needs had care plans that were inadequate to meet those needs 41 percent of those with psychosocial needs addressed in their care plans did not receive all of their planned psychosocial services and 5 percent received none of the services

5 Psychosocial Psychosocial concerns include mental health disorders such as depression, anxiety, dementia, and delirium Also includes: Loss of relationships Loss of personal control Loss of identity Adjustment to the facility

6 What are some keys to promoting improvement in quality of life domains? Build on person directed values Implement environmental interventions Use knowledge of group processes to build resident, staff, and family involvement Address end-of-life issues Address discharge planning needs with a resident-centered perspective Be involved in quality improvement efforts

7 Process Indicators Is the psychosocial assessment timely? Is the psychosocial assessment comprehensive? Resident’s psychological and social circumstances are assessed adequately? Are residents involved in care planning? Decision making Are families involved in care planning? Cultural factors Lifestyle

8 Outcome Indicators Resident satisfaction with choice Are residents satisfied with the degree of choice available in everyday matters in the home? Are problems resolved? Are resident’s psychosocial problems relieved?

9 Other Psychosocial Issues and Relevant Domains: Comfort and security Enjoyment Relationships Meaningful activity Functional competence Individuality Privacy Autonomy Dignity Choices Spiritual well-being

10 Appendix P – Survey Procedures for Long Term Care Facilities Psychosocial injury or deterioration is referenced in Section E. Evidence Evaluation 1. Potential or Actual Physical, Mental or Psychosocial Injury or Deterioration to a Resident Including Violation of Residents’ Rights Review examples 2. Lack of (or the Potential for Lack of) Reaching the Highest Practicable Level of Physical, Mental or Psychosocial Well-Being Review examples

11 Possible F Tags Related to Psychosocial Care and Social Service Provisions – “Blueprint for Measuring Social Work’s Contribution to Psychosocial Care” F 243Residents have the right to organize and participate in resident groups F 246Nursing home policies accommodate residents’ needs and preferences F 248Meaningful activities for all residents F 250Nursing home provides medically- related social services

12 F Tags (continued) F 251Nursing home with more than 120 beds employs a qualifies social worker on a full-time basis F 319Nursing home provides resident with appropriate treatment for mental or psychosocial problems F 320 Nursing home ensures that residents do not have avoidable decline in their psychosocial functioning

13 Psychosocial Needs and Problems In the long term care facility, who is: Identifying residents’ psychosocial needs and problems? Assessing psychosocial needs and problems? Developing interventions based on identified psychosocial needs and problems? Implementing interventions? Monitoring psychosocial care for residents? How are interventions documented?

14 Purpose Overview Instructions Clarification of Terms Psychosocial Outcome Severity Guide Resources and Additional Information Psychosocial Outcome Guide Components

15 Psychosocial Outcome Guide Purpose The Guide is to help surveyors determine severity of psychosocial outcomes resulting from identified noncompliance at an F Tag. A deficiency has to be identified Negative psychosocial outcomes may result from a facility’s noncompliance with any regulatory requirement in any regulatory grouping. Quality of Care Quality of Life

16 Psychosocial Outcome Guide Purpose The Guide is used in conjunction with current scope and severity grid Used to determine the severity of outcome to each resident involved in a deficiency that has resulted in a psychosocial outcome

17 Psychosocial Outcome Guide Overview A resident may experience a negative physical outcome, psychosocial outcome or both resulting from the facility’s deficient practice. This severity guide will only be used for psychosocial outcomes resulting from the facility’s non-compliance.

18 Overview Psychosocial outcomes (i.e., mood and behavior) may result from a facility’s noncompliance with any regulatory requirement The presence of a given affect (i.e., behavioral manifestation of mood demonstrated by the resident) does not necessarily indicate a psychosocial outcome that is a direct result of noncompliance

19 Overview What could cause a resident’s reactions and responses (or lack there of) that may not be contributed to a facility’s noncompliance with a regulatory requirement?

20 Response to Question Pre-existing psychosocial issues Illnesses Medication side effects

21 Psychosocial Outcome Severity Guide Overview Psychosocial and physical outcomes must both be considered in determining severity. This Guide does not replace the current scope and severity grid; however, complements it The surveyor will address both physical and psychosocial outcomes The surveyor will determine which outcome is of greater impact on the resident

22 Psychosocial Outcome Guide Instructions If noncompliance has resulted in negative outcomes for more than one resident, the survey team will evaluate the severity for each resident. Each resident’s psychosocial response to the non- compliance is the basis for determining psychosocial severity of a deficiency. This is not new. The team bases severity on the highest level selected for any of the residents.

23 Psychosocial Outcome Guide Instructions (cont.) To determine severity, the team will use information gathered during the survey investigative process Information Gathering Tools Observations Interviews Record Reviews The team will compare the resident’s behavior (e.g., their routine, activity, and responses to staff or to everyday situations) and mood before and after the noncompliance.

24 Psychosocial Outcome Guide Instructions (cont.) The Guide may apply to four situations involving psychosocial outcomes resulting from a deficient practice: When a resident verbally or non-verbally communicates outcome When a resident exhibits a response When a resident has no discernable response When a resident’s response is incongruent with a response a reasonable person would have

25 Psychosocial Outcome Guide Instructions (cont.) The Guide can be used for: Residents who verbally or non-verbally communicate outcome What is the resident’s reaction or outcome to the practice? For example, a resident may report boredom, fear, anger, etc., in response to the deficient practice This may be communicated verbally, in writing, or using a communication board

26 Psychosocial Outcome Severity Guide Instructions (cont.) Residents who exhibits a response This resident is unable to communicate outcome The surveyor will be monitoring the resident’s non-verbal responses For example, the surveyor observes a staff member yelling at a resident and the resident responds by cowering, crying, etc.

27 Psychosocial Outcome Guide Instructions (cont.) The Guide can be used in conjunction with the Reasonable Person Concept How would a “reasonable person” react if he/she were in the resident’s situation? What degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance?

28 Psychosocial Outcome Severity Guide Instructions (cont.) The team will use this concept in two situations: First Situation: The resident’s psychosocial outcome may not be readily determined or there is no discernable response to the deficient practice

29 Psychosocial Outcome Severity Guide Instructions (cont.) Second Situation: The resident’s reactions are markedly incongruent with the deficient practice (i.e., the resident “does not mind” the deficient practice.)

30 Psychosocial Outcome Severity Guide Instructions (cont.) Why would this happen? When a resident has become institutionalized to expect this treatment by repetition of the deficient practice over time.

31 Psychosocial Outcome Guide Clarification of Terms Possible Psychosocial Outcomes Anger Apathy Anxiety Dehumanization Depressed mood Humiliation

32 Terms The expert panel that helped develop this new guidance provided definitions for these terms from the psychological research literature. These words are key terms in the determination of the level of psychosocial outcome.

33 Clarification of Terms Anger Refers to an emotion caused by the frustrated attempts to attain a goal, or in response to hostile or disturbing actions such as insults, injuries, or threats that do not come from a feared source

34 Terms Apathy Refers to a marked indifference to the environment; lack of a response to a situation; lack of interest in a concern for things that others find moving or exciting; absence or suppression of passion, emotion, or excitement

35 Terms Anxiety Refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic symptoms of tension (restlessness, irritability)

36 Terms What is dehumanization? Refers to the deprivation of human qualities or attributes such as individuality, compassion, or civility Is the outcome resulting from having been treated as an inanimate object or as having no emotions, feelings, or sensations

37 Terms Depressed mood Indicated by negative statements; self-deprecation; sad facial expressions; crying and tearfulness; withdrawal from activities of interest and/or reduced social interactions

38 Terms Humiliation Refers to a feeling of shame due to being embarrassed, disgraced, or depreciated Some individuals lose so much self-esteem through humiliation that they become depressed

39 Psychosocial Severity Guidance The guide is only to be used once the survey team has determined noncompliance at a regulatory requirement.

40 Psychosocial Outcome Severity Guide Remember that psychosocial outcomes of interest to surveyors are those caused by the facility’s noncompliance with any regulation This also includes psychosocial outcomes resulting from facility failure to assess and develop an adequate care plan to address a resident’s pre-existing psychosocial issues which brought about continuation or worsening of the condition

41 Failures Failure to: Assess Develop an adequate and workable care plan Address psychosocial issues Address pre-existing psychosocial issues As a result, the condition worsens Implement care planning interventions Assess progress or lack of progress Change interventions and/or approaches Communicate care planning approaches to direct care staff

42 Psychosocial Severity Guidance Severity Determination The key elements for severity determination are: Presence of harm or potential for negative outcomes Degree of harm or potential harm related to noncompliance Immediacy of correction required

43 Severity and Scope Grid. Immediate jeopardy to resident health & safety Level 4 JKL Actual harm that is not immediate jeopardy Level 3 GHI No actual harm, with potential for more than minimal harm Level 2 DEF No actual harm, with potential for minimal harm Level 1 ABC IsolatedPatternWidespread

44 Deficiency Categorization Severity Determination Levels Level 4 Level 4: Immediate Jeopardy to resident health or safety Level 3 Level 3: Actual harm that is not immediate jeopardy Level 2 Level 2: No actual harm with potential for more than minimal harm that is not immediate jeopardy Level 1 Level 1: No actual harm with potential for minimal harm

45 Deficiency Categorization Severity Level 4: Immediate Jeopardy Examples Of Outcomes To A Deficient Practice: Suicide attempt, suicidal thoughts, preoccupation, planning (e.g., refusing to eat or drink in order to kill oneself) Engaging in self-injurious behavior that is likely to cause serious injury, harm, impairment, or death to the resident

46 Deficiency Categorization Severity Level 4: Immediate Jeopardy Sustained & intense crying, moaning screaming Expression of severe, unrelenting, excruciating pain Pain that has become all-consuming and overwhelms the resident Recurrent debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior

47 Deficiency Categorization Severity Level 4: Immediate Jeopardy Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation that persists regardless of whether the precipitating event(s) has ceased and has resulted in a potentially life-threatening consequence Expressions of anger at an intense and sustained level that has caused or is likely to cause serious injury, harm, impairment, or death

48 Deficiency Categorization Severity Level 3: Actual Harm Examples Of Outcomes To A Deficient Practice: Significant decline in former social patterns that does not rise to the level of immediate jeopardy Depressed mood that may be manifested as: Social withdrawal: hopelessness, tearfulness Loss of interest or ability to feel pleasure

49 Deficiency Categorization Severity Level 3: Actual Harm Psychomotor agitation accompanied by sadness Inability to sit still Pacing Hand wringing Pulling or rubbing of the skin, clothing Sad expression Expressions of feelings of worthlessness Recurrent thoughts of death or statements such as, “I wish I were dead” or “my family would be better off without me”.

50 Deficiency Categorization Severity Level 3: Actual Harm Verbal agitation Repeated requests for help, groaning accompanied by sad facial expressions Markedly diminished ability to think or concentrate

51 Deficiency Categorization Severity Level 3: Actual Harm Examples Of Outcomes To A Deficient Practice (cont.): Expressions of persistent pain or physical distress that has compromised the resident’s functioning. Chronic or recurrent anxiety; sleeplessness due to fear. Expression of fear not to level of immobilization as in level 4. Ongoing expression of humiliation that persists after precipitating event has ceased. Aggression that could lead to injuring self or others.

52 Severity Level 3: Actual Harm These outcomes show that there has been compromise in the resident’s psychosocial functioning due to the deficient practice Severity Level 3 indicates noncompliance that results in actual harm, and can include but may not be limited to clinical compromise, decline, or the resident’s inability to maintain and/or reach his/her highest practicable well- being.

53 Deficiency Categorization Severity Level 2: Potential for Harm Examples Of Outcomes To A Deficient Practice: Intermittent sadness, as reflected in facial expression, tearfulness. Feelings or complaints of discomfort or moderate pain; irritability. Fear or anxiety manifested as signs of minimal discomfort that has the potential to compromise well-being.

54 Severity Level 2 This level indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his or her practical level of well being The potential exists for greater harm to occur if interventions are not provided

55 Deficiency Categorization Severity Level 2: Potential for Harm (cont.) Examples Of Outcomes To A Deficient Practice (cont.): Feeling of shame or embarrassment without loss of interest in the environment and self. Complaints of boredom accompanied by expressions of periodic distress, that do not result in maladaptive behaviors (e.g. verbal or physical aggression). Verbal or nonverbal expressions of anger that do not lead to harm.

56 Severity Level 2 These are a lesser level of outcome than the bullets that describe Level 3 At Level 2, the resident shows a reaction of discomfort that has not compromised functioning

57 Deficiency Categorization Severity Level 1: Potential for Minimal Harm Severity Level 1 is not an option because any facility practice that results in a reduction of psychosocial well-being diminishes the resident’s quality of life. The deficiency is, therefore, at least a Severity Level 2 because it has the potential for more than minimal harm.

58 Level 1 The Quality of Life tags and Quality of Care tags in general concern issues of key relevance to residents and will be cited at Level 2 or above Level 1 is intended for deficiencies such as the requirement at F 167 which mandates that the results of the survey must be made available for review

59 Task 6 – Information Analysis for Deficiency Determination Section E. Evidence Evaluation The survey team must evaluate the evidence documented during the survey to determine if a deficiency exists due to a failure to meet a requirement and if there are any negative resident outcomes due to the failure.

60 Evidence Evaluation Failure to meet requirements related to quality of care, resident rights, and quality of life generally fall into two categories: (1) Potential or Actual Physical, Mental or Psychosocial Injury or Deterioration to a Resident, including Violation of Residents’ Rights

61 Examples – Category 1 Development of, or worsening of, a pressure sore Loss of dignity due to lying in a urine- saturated bed for a prolonged period; and Social isolation caused by staff failure to assist the resident in participating in scheduled activities

62 (2) Category Lack of (or the Potential for Lack of) Reaching the Highest Practicable Level of Physical, Mental or Psychosocial Well- Being No deterioration occurred, but the facility failed to provide necessary care for resident improvement.

63 Examples - Category 2 The facility identified the resident’s desire to reach a higher level of ability, e.g., improvement in ambulation, and care was planned accordingly. However, the facility failed to implement, or failed to consistently implement the plan of care, and the resident failed to improve, i.e., did not reach his/her highest practicable well-being

64 Examples - Category 2 The facility identified a need in the comprehensive assessment, e.g., the resident was withdrawn/depressed, but the facility did not develop a care plan or prioritize this need of the resident, planning to address it at a later time. The resident received no care or treatment to address the need and did not improve, i.e., remained withdrawn/depressed. Therefore, the resident was not given the opportunity to reach his/her highest practicable well-being.

65 Examples - Category 2 The facility failed to identify the resident’s need/problem/ability to improve, e.g., the ability to eat independently if given assistive devices, and, therefore, did not plan care appropriately. As a result, the resident failed to reach his/her highest practicable well- being, i.e., eat independently.

66 Scenario During a resident interview on 7/16/06 at 2:15 pm in the room 212 B, the resident stated that she was slapped by a staff member on the night shift on 7/10/06. She stated that it was not a hard slap. She thinks that the CNA was frustrated and tired due to working a double shift. She complained about there not being enough staff to toilet the residents. The resident further stated that due to the side rails being up, she was unable to get to the bathroom in time and soiled herself. She had pressed her call bell repeatedly, but no one came to help.

67 Scenario continued: The resident further stated that she felt humiliated. The CNA stated to the resident, “what’s wrong with you; just use your diaper like the other residents and keep your mouth shut.” The resident stated that she is fearful of leaving her room. Observations of this resident: even though the resident enjoys singing, the resident did not attend the planned activity of singing. During the noon meal observation, the resident ate 25% and has lost 3 pounds since the incident.

68 Scenario continued: During the second interview with the resident, she tearfully stated, “I wish I were dead”. “I want to go home; this is not my home”. The surveyor asked the resident if she had reported the incident and her feelings. The resident stated that she had reported the incident to the DON.

69 Concerns What concerns do you have regarding what you have learned from the interviews and observations? List your concerns.

70 Concerns Do you think there is something wrong? If so, what regulatory requirements do you think best fits this situation?

71 Identification of the Regulatory Requirement What are the specific elements of the regulatory requirements? Write them down.

72 What’s Next? How do you think the surveyors would proceed in investigating this scenario?

73 Do you have a deficient practice? Resident experienced minor physical outcome from the slap However, suffered a greater, more severe psychosocial outcome In this case, the severity level on the psychosocial outcome would be used as the level of severity for the deficiency.

74 Psychosocial Outcome Severity Guide: Scenarios and Examples For each example developed by CMS, determine the level of severity you would select. For each example developed by CMS, determine the level of severity you would select. Why would you choose this level? Why would you choose this level? Please note that for each example, limited information is provided Please note that for each example, limited information is provided

75 Example 1 A comatose resident was raped by a staff member This would be Level 4 Rationale: Resident’s lack of discernable response makes it necessary for the team to decide based on the reasonable person concept

76 Example 2 Staff do not toilet residents at night. They tell residents to wet the bed and they will clean them up and the bed in the morning. Resident interview: “It’s just how things have to be” and he is “used to it.”

77 Example 2 With limited information, Level 2 Rationale: Reasonable person concept would be used since the reaction is incongruent with the deficient practice and shows that the resident is institutionalized to expect substandard treatment Level 3 would not be selected because actual harm has not been proven

78 Example 3 The team is citing a deficiency for activities. There are few activities and most residents are not included. One resident who is part of the deficiency is a cognitively impaired resident who does not verbalize. This resident was observed during all days of the survey sitting in the hall or in her room with nothing to do.

79 Example 3 Level 2 Rationale: Level 2 is selected because there is potential not yet realized for compromise Level 3 would not be selected since actual harm or compromise has not been proven

80 Example 4 A deficiency is being cited in incontinence. One resident included in this deficiency reports to the surveyor that she is so upset that she has become incontinent that she cries every day and refuses to leave her room.

81 Example 4 Level 3 Rationale: In this case, there is both physical and psychosocial outcome from a deficiency in Quality of Care. The physical outcome is that the resident has declined in functioning, which is Level 3, actual harm. The psychosocial outcome matches this, as the resident has become compromised in psychosocial functioning.

82 Example 5 A resident with severe depression when admitted, which was confirmed by appropriate medical and psychiatric evaluation, has not received any nonpharmacologic or medication interventions, despite appropriate indications and lack of contraindications for treatment. Resident continues to be severely depressed.

83 Example 5 Level 3 Rationale: This is a case in which the facility failed to help the resident with a serious medical condition with significant psychosocial implications. This should be cited at Level 3, actual harm, as the continuance of her severe depression is harm to the level of compromise.

84 Practical Example Surveyor observes a resident is crying. The resident is grieving the loss of her husband. The surveyor observed a psychosocial outcome. Would this result in a deficiency? Before the Psychosocial Outcome Severity guide is used, there must first be a deficient practice which results in a deficiency being cited

85 Example (continued) The survey team would utilize investigative skills of observation, interview and record review to determine if a deficient practice exists The survey team would assess if the facility had provided grief counseling and psychosocial support for the resident The survey team would observe staff interactions with the resident The survey team would interview the resident or resident’s family and staff

86 Example (continued) If the facility had identified, assessed, developed interventions, implemented interventions, and re-assessed for positive results, no deficiency would be cited If the facility failed to meet the psychosocial needs of the resident, a deficient practice would be identified. Appropriate F tag selected Psychosocial Outcome Severity Guide utilized

87 The End Rebecca L. Hall (334) (334)