1. Long Term Care Provider
F314 – Pressure Ulcers
Long Term Care Provider
Associations Meeting
Sharon White
CMS – Region V
August 22, 2007

2. F314 483.25(c) Pressure Sores - Regulatory Requirement:
Based on the comprehensive Assessment of a resident, the facility must ensure that-
1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and
2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

3. Reasons to Prevent Pressure Ulcers
Increased morbidity and mortality
Increased infection rates
Debilitation
Pain
Increased cost
Additional medications
Increased staff time to provide appropriate care necessary to heal the ulcer

4. So what’s being done? National initiatives Individual facility efforts
Advancing Excellence Campaign
National Pressure Ulcer Advisory Panel
GPRA
Individual facility efforts
CMS Regional and State Survey Agency efforts

5. Provider Responsibility for Providing Adequate Care
Commitment to high quality pressure ulcer management that permeates all aspects of the facility’s operation
Instituting a prevention program based on accepted clinical guidelines for “at risk” residents
Use of Quality Measures to develop and implement systems for pressure ulcer reduction

6. Provider Responsibility for Providing Adequate Care
Thorough knowledge of the federal requirements in order to comply with the regulations and ultimately to provide for the health and safety of residents
Understanding of the survey process in helping providers evaluate the quality of care delivered and target quality improvement efforts

7. Role of RO V and the SSA in the Reduction of Pressure Ulcers
Investigate and evaluate the systems and processes for prevention and treatment of pressure ulcers in certified facilities
Consistent and strict enforcement of CMS policies and regulations

8. An Effective “System” would include:
Prevention
Assessment
Identification
Intervention
Monitoring
Evaluation
Treatment
“Ownership”

9. Assessment
Skin assessments are the first line of defense to prevent pressure ulcers from developing and to ensure effective treatment
It is important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers

10. Assessment
A comprehensive assessment should address factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers, which include:
Risk factors
Pressure points
Nutrition
Hydration
Skin moisture, and
Impact of moisture on skin

11. Assessment
A comprehensive assessment should include an evaluation of the skin integrity and tissue tolerance after pressure to the skin has been reduced or redistributed

12. Deficiency Determination in the Absence of Pressure Ulcers
A facility may have non-compliance with F314 without actual development of pressure ulcers by failing to:
Accurately or consistently assess a resident’s skin integrity
Identify a resident at risk of developing a pressure ulcer
Identify and address risk factors

13. Deficiency Determination in the Absence of Pressure Ulcers
Implement preventive interventions in accordance with the resident’s need and current standards of practice
Provide clinical justification for the unavoidable development or non-healing/delayed healing or deterioration of a pressure ulcer
Implement appropriate interventions for existing wounds to minimize infection and promote healing

14. Deficiency Determination in the Absence of Pressure Ulcers
Notify the physician of the resident’s condition or changes in the resident’s wound
Adequately implement pertinent infection management practices in relation to wound care
Identify and/or know how to apply relevant policies and procedures for pressure ulcer prevention and treatment

15. Deficiency Determination – “Avoidable vs. Unavoidable”
Was preventive care
-aggressive?
-consistent?
-appropriate?
-resident specific?
If not, the development of a pressure ulcer may have been “avoidable.”

16. Clarification - “Avoidable vs. Unavoidable”
The presence of any one, or even several, risk factors or conditions does NOT make a pressure ulcer “Unavoidable”

17. Scope and Severity Level 4 Level 3
Stage IV (development or non-healing)
Stage III (infected locally/systemically)
Extensive failure in multiple areas of care
Level 3
Stage III
Recurrent or multiple Stage II’s
Facility failure to consistently implement care plan -> increase size, failure to heal, untreated pain

18. Scope and Severity Level 2 Level 1 – Eliminated Stage I
Stage II receiving appropriate treatment
Failure to implement portion of care plan independent of healing
Level 1 – Eliminated

19. Region V’s Plan
Standard surveys: Federal and state surveyors review QM/QI Reports and CMS-672 with the facility to ensure that pressure ulcers have been reported accurately
FOSS surveys: Federal surveyors pay strict attention to how well SA surveyors evaluate the nursing home’s performance as it relates to pressure ulcers. When identified as a concern, specific mention will be recorded in Measures 1,2,3 and 6 of the FOSS report.

20. Region V’s Plan
Beginning calendar year 2007, Region V is warning facilities with non-compliance at F314, S/S level F or higher, that continuing non-compliance will result in the imposition of more severe remedies.
Future cycles of non-compliance will result in the imposition of more robust and possibly more diverse remedies

21. Region V’s Plan -
More severe remedies include: Optional Denial of Payment, higher Civil Money Penalty amounts, Directed Inservice Training, Discretionary Termination
Each case will be evaluated independently to determine which remedies will be most effective in promoting prompt and permanent correction of the deficiencies

22. Consistency is the key to effective prevention