Long-Term Care Survey Alert

Follow this five-point guide to F-tag proof your facility.

With the new Psychosocial Severity Outcome Guide now in effect, your facility's psychosocial care will benefit from a check-up to see if its programs are on track in meeting residents' needs.

The survey reality: The new guide "will put more pressure on facilities to provide surveyors evidence to show that a resident's negative psychosocial condition is not related to a deficient practice," predicts Nancy Shellhorse, an attorney with Thompson & Knight LLP in Austin, TX.

The good news: You can sidestep G-level and higher tags under the new Psychosocial Outcome Severity Guide by ensuring your facility performs these essential functions.

1. The interdisciplinary staff routinely assess for and address residents' indicators of depression and anxiety. "Facilities should make sure they evaluate any resident who triggers the depression quality measure [residents who have become more depressed or anxious] and/or quality indicator [prevalence of symptoms of depression without antidepressant therapy]," says Shellhorse.

Good advice: Consider implementing a policy and procedure that standardizes how the interdisciplinary team does a more in-depth assessment of residents with depression and anxiety indicators on the MDS, suggests Shellhorse.

To assess for depression, facilities can administer the Geriatric Depression Scale short form, a 15-item test to screen residents, says Susan Scanland, MSN, APRN, BC-GNP, president of GeriScan Geriatric Consulting in Clarks Summit, PA. The patient who flags for depression on that scale may benefit from a referral for a psych consult.

Look for antecedents to depression: Surveyors may scour the resident's medical record to see if they can tie an increase in the person's depression to a change in condition or some other event, cautions Shellhorse. Then they will look to see "if the team updated the care plan." In other words, "facilities will have to address psychosocial issues on a constant basis."

2. The team examines the interplay between a resident's physical outcomes, such as weight loss, pressure ulcers and pain and psychosocial issues. For example, depression is a risk factor for pressure ulcers because it causes immobility. And "the relationship between depression and pain is so strong that pain assessment should be part of a depression assessment and vice versa," says Scanland. "Staff may describe a person as a complainer or 'somatic' when the person really has a clinical depression," she notes.

Depression and loneliness can also affect appetite and lead to weight loss. "You have to be around people who give you some motivation to want to eat and live," observes Joanne Hayden, PhD, an activities and quality-of-life consultant in Indianapolis.

Proactive strategy: As part of the psychosocial assessment, ask residents if they feel lonely--and if they say "yes," find out why. One elderly gentleman admitted to a facility complained of being lonely until staff figured out that he missed his dog, which had become the man's constant companion since his wife's death five years before. The man's family arranged to bring the dog in for a regular visit, which alleviated the man's loneliness, reports Hayden.

Assessment gem: If the resident says he feels lonely, ask him if he feels that way even when in the company of loved ones and friends, suggests Hayden. If the answer is yes, then counseling might help.

3. The facility has the proper systems in place, including activities, to assess, prevent and address residents' behavioral symptoms. If the facility has residents with behavioral symptoms and lacks "properly enhanced environments and staff training"--including individualized plans of care for identified behavioral symptoms--"it's going to be vulnerable under the new psychosocial guide," says Reta Underwood, president of Consultants for Long Term Care in Buckner, KY. "Surveyors may [also] look at how a resident spends leisure time," adds Jane Belt, RN, MS, a consultant with Plante & Moran Clinical Group in Columbus, OH. "If the surveyors see the person always in his room or staring out the window, that's going to be a potential problem if the person has depression and shows signs of lack of stimulation."

4. The facility care plans promote each resident's ability to make choices and participate in his care to the extent possible. "Part of good care is learning what a resident can do for himself in a safe way--and helping the person continue to do those things," said Judah Ronch, PhD, in a recent Centers for Medicare & Medicaid Services' surveyor training Webcast on the Psychosocial Out- come Severity Guide. "Learned dependencies can lead to depression ... that is entirely preventable and reversible," Ronch added.

Tip: When assisting the memory-impaired resident with her care, break down instructions so you provide them one at a time using simple words, suggests Barbara Brock, a health researcher in aging and cognitive assessment and president of Communication Art Inc. in Toledo, OH. That way "you won't overwhelm the person," she adds.

5. The facility has standardized documentation systems that capture everything staff does for residents in the psychosocial realm. Documen- tation of your care can make or break your survey. For example, "sometimes social services provides a lot of one-to-one visits to address depression and other issues," observes Robert Reed, MSN, RN, clinical care manager at Legacy Health Services, which operates nursing homes in Ohio.

The problem: In many facilities, the social worker only writes a quarterly progress note to sum up her visits with residents, which fails to reflect all of her efforts, says Reed.

Solution: The social worker should document each therapeutic encounter with the resident, including the purpose, a summary of what was discussed and the outcome, advises Reed.