Additions & Changes to Quality of Care FTags

Moving into 2023, it is important to note the changes the Centers for Medicare & Medicaid Services (CMS) made to the State Operations Manual (SOM) guidance and F-tags related to the Quality of Care requirements. As you all know, these changes became effective in October of 2022 and review of current citation data reveals that Quality of Care citations remain in the top ten citations both in Washington and nationally. The following article provides an overview of some the CMS expectations outlined in Appendix PP.

CMS clarified in F686, Skin Integrity (Pressure Sores) that when determining whether damage to the skin and underlying tissue is a pressure injury/pressure ulcer it depends on the staging of the damaged tissue. They also added wording that the facility must provide treatment “and services” to heal a pressure injury, “to prevent infection” and development of additional pressure injuries. They also changed expectations regarding risk assessments. Risk assessments related to skin breakdown should occur upon admission, weekly for the first four weeks after admission, and then “quarterly” (rather than monthly), or whenever there is a change in condition.

CMS added new language in F687, Foot Care related to infection prevention practices for foot care equipment (nail clippers, scalers, files). Facilities are expected to ensure that the following measures are in place related to foot care:

In F689 Accidents, CMS added specific language and clarification regarding resident use of electronic cigarettes. The guidance identifies risks associated with the use of electronic cigarettes/vaping to include health effects to the user as well as second-hand exposure, potential nicotine overdose by ingestion or skin contact, and explosion or fire caused by the battery. CMS expects facilities to oversee the use of these devices and address the use of such in their smoking policies. Specifically, facility policies should cover the unique characteristics and risks of electronic cigarettes/vaping, how staff will supervise a resident that needs supervision, how it identified which residents use e‐cigs and how to manage the batteries and refill cartridges. Facilities must ensure resident safety while honoring a resident’s right to use the device and how they protect other residents that do not want to be exposed.

Also, under F689, CMS added information to clarify resident elopements. A resident that leaves the premises or a safe area without the knowledge or supervision of staff is considered an elopement. CMS clarified information related to residents leaving “against medical advice” (AMA). CMS states the facility is responsible for knowing if a resident leaves the building. A resident who leaves the facility without facility knowledge of the departure, despite efforts to explain the risks, would likely be an AMA discharge. Facility documentation should show attempts to provide the resident with other options and risks associated with leaving AMA and the time the facility became aware of the resident leaving.

Due to a resident with SUD potentially being at increased risk for leaving the facility to satisfy an addiction, additional guidance to address the safety of residents with substance use disorder (SUD) was also included under F689. The resident should be assessed for the risk of elopement and interventions should be care planned to address this risk.

Facilities should also assess the resident for the risk of drug use in the facility. Staff should have knowledge of the signs of drug use and be prepared to address emergencies related to substance use such as opioid reversal agents, CPR, and contacting emergency services. It is important to note that CMS acknowledges that if a resident overdoses, it does not necessarily mean that facility noncompliance exists. If evidence shows that a facility took steps to increase monitoring, and despite this effort, the resident overdosed between monitoring checks, then noncompliance may not be present.

Minor changes were made to Incontinence, F690 to clarify the regulatory language is specific to bowel incontinence, not bowel management.

Requirements outlined in Parenteral Fluids, F694 added guidance related to the frequency of assessments. An exact timeframe is not specified but the guidance provides factors which could affect how the frequency of assessments is determined, such as the resident’s ability to report symptoms (pain or redness), the type of infusion a resident is receiving (irritant or vesicant), and the location of the IV (placed in an area of flexion such as the antecubital space where more likely to dislodge). New language was added on proper infection control practices when accessing or using IVs. CMS also clarified that facilities should document the reason for keeping an IV when it is no longer being used for fluid or medication.

There are no new requirements in Respiratory Care, F695. However, CMS did clarify that specific guidance related to the care of residents receiving mechanical ventilation only applies to facilities choosing to provide this type of care.

Additions and clarifications were made to Pain Management, F697, specifically related to the use of opioids to address the treatment of resident pain within the context of the current opioid crisis. CMS added definitions for medication assisted treatment (MAT) and opioid use disorder (OUD). MAT is defined as the use of medications, in combination with counseling /behavioral therapies, to treat substance use disorders or OUD. OUD is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress.

The Ftag guidance recommends facility use of the CDC and SAMHSA website for resources on use of opioids in treating chronic pain and opioid management resources for prescribers. Language was added regarding the need for facilities to assess residents for a history of addiction or OUD and related treatments to implement strategies to address pain. These strategies may include MAT, if appropriate, non‐opioid pain medications, and non-pharmacological approaches. Guidance also states that a facility needs to pay attention if there is a pattern of resident reports or has signs/symptoms of increased pain to ensure the problem is not due to drug diversion. Residents need to be monitored for side effects of opioids (tolerance, physical dependance, increased sensitivity to pain, constipation, nausea/vomiting and diarrhea, sleepiness, dizziness, and/or confusion, depression, and itching/sweating), and addresses the prevention of opioid overdoses by administering naloxone. More information can be found in F697.

SNF Questions?

Please email Elena Madrid, or call at 1 (800) 562-6170, ext. 105.