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F-Tag 309:. Are You Ready?. Joan Williams, MS, CRNP Director of Clinical Services. QUALITY OF CARE. 42 CFR 483.25 (F309) Effective Date: 3/31/09. 483.25 Quality of Care.

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F-Tag 309:

Are You Ready?

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Joan Williams, MS, CRNP

Director of Clinical Services

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42 CFR 483.25 (F309)

Effective Date: 3/31/09

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483.25 Quality of Care

  • 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.

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  • General Investigative Protocol

    covers care of residents where a

    more specific regulation or

    protocol does not apply

  • Pain Management Protocol

    covers all aspects of pain


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

  • F-309 now also includes hospice and

    ESRD services (formerly in

    Appendix P; moved, not changed).

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Nursing Process

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

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

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  • Will be observing and interviewing first hand.

  • Will be reviewing DOCUMENTATION of any kind related to the symptom, e.g. will review facility protocols if referenced in the treatment plan.

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

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Care/Treatment Plan Decisions

  • Appropriate?

  • All-inclusive based on resident assessment?

  • Achieved Outcomes?

  • Modified based on the resident’s abilities?

  • Evaluated regularly and on-going?

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Compliance Is:

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

    (actual and potential)

  • Defining and implementing interventions in accordance with resident needs, goals, and recognized standards of practice


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Compliance Is:

  • Monitoring and Evaluating care and the resident’s responses


  • Revising and Re-Planning

    (restarts the assessment circle)

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Investigation May Include:

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

    • Structure

    • Process

    • Outcome

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Deficiency Categorization

  • Key elements:

    • Presence/Potential of harm/negative outcomes

    • Degree of actual/potential harm R/T non-compliance

    • Immediacy of correction required

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

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    So the resident has a symptom…

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

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    • Complaint in the resident’s words

    • Time Frames—

      • Duration or history of the symptom

      • Onset (when)

      • Manner of initiation (how)

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    • Symptom Characteristics:

      • Quality (what feels like)

      • Location and/or radiation

      • Intensity or severity (rating scale, relate it to..)

      • Timing (continuous, intermittent)

      • Precipitating and Relieving Factors

      • Aggravating Factors (makes it worse)

      • Associated Symptoms (simultaneous, pre/post)

      • Progression

      • Effect of Treatment

      • What does the symptom keep you from doing?

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    • Assess the symptom

    • Make clinical judgment

    • Develop plan

    • Implement plan/treatments

    • Evaluate effectiveness of plan and expected outcomes

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    For every symptom…

    there is a plan, intervention, and evaluation.

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    Defining pain…

    Pain is-

    “an unpleasant sensory and emotional

    experience associated with actual or

    potential tissue damage, or described in

    terms of such damage”

    International Association for the Study of Pain (IASP)

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    Pain is…

    Acute-initially present due to the onset of

    symptoms or treatment of a disease

    Chronic-persistent beyond the usual of

    expected course of a disease or

    after a reasonable time for an

    injury to heal

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    Pain is…

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

    2008 American Conference on Pain

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    Pain is…

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

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

    substantial pain that is undertreated.

    American Geriatrics Society

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    So, what’s the problem?

    Pain is a major factor in




    each of our clients.

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

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    Assess Pain…

    • Regularly

    • Consistently

    • Methodically

    • Non-judgmentally

    • With the goal of control

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    Assess Pain…

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

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

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    Assess Pain…

    Methodically (with a method)…

    Analyze in order to communicate with

    the provider to get effective


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    Assess Pain…

    Symptom analysis is the simplest way.

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    Symptom Analysis…

    • Complaint in client’s words.

    • Onset (when, gradual or sudden?)

    • Precipitating/Relieving factors (what makes it better/worse?)

    • Quality (sharp, dull, aching?)

    • Radiation/Location (where and where go?)

    • Severity/Intensity (use scales)

    • Timing (when, continuous, intermittent)

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    Symptom Analysis…

    • Aggravating factors

    • Associated symptoms (N/V, numbness)

    • Progression of symptoms

    • Effect of treatment

    • Other: when did you last feel well?

      what does this keep you from


      what level of pain is tolerable?

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    Assess Pain…

    With consistency or uniformity….

    By using a format or scale which can be

    validly and reliably used by your


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    The trick is…

    Do what works in your facility.

    Do it regularly, consistently, and methodically.

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    Pain Relief Plans…

    • If pain is identified as a client problem,

      then the care plan must address it.

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

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    Pain Relief Plans…

    Should address physical, emotional,

    social, and spiritual aspects of pain.

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    Interventions for Pain Relief…

    • Non-pharmacologic interventions

    • Pharmacologic interventions

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    Evaluation of Pain Management

    Restarts the circle of pain control.

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

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    Evaluation of Pain Management

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

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    Evaluation of Pain Management

    • Freestyle Summary of Pain Episodes

    • Pain Assessment Tracking (with sample tracking form)

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    Evaluation of Pain Management

    Outcomes Desired


    Outcomes Achieved

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

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

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

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

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    Compliance Is…

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

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

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    Compliance Is…

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

    • Monitoring and modifying interventions

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

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    Investigation May Include:

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

      • Structure

      • Process

      • Outcome

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    Deficiency Categorization

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

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

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

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    Deficiency Categorization

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

    • The immediacy of correction required.

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    Severity Levels…

    • Level 4:

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

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    Severity Levels…

    • Level 3:

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

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    Severity Levels…

    Level 2:

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

    Level 1:


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