MDS Alert

Find out what specific practices surveyors are scrutinizing.

If you want to know how surveyors are approaching the Focused Dementia Care Surveys, you now have an insider’s view on exactly what they’re searching for.

In a Nov. 27, 2015 Survey & Certification (S&C) memo, the Centers for Medicare & Medicaid Services (CMS) released the tools that it furnished to surveyors for use in the Focused Dementia Care Survey Pilot during 2014 and 2015. Although the pilot survey aimed to examine how nursing homes prescribe antipsychotic medications and assessed compliance with dementia care-related regulations, the recently released tools reveal that surveyors had a far broader scope.

Assess Your Facility’s Standing in These Areas

The survey tool has four parts: (1) Nursing Home Characteristics; (2) Dementia Care — Policies, Leadership, Training, Documentation; (3) Quality Assessment and Assurance (QAA); and (4) Dementia Care & Related Practices. Surveyors must fill out the first three parts once for each facility, and then fill out the fourth part for each resident in the facility sample.

You can expect the surveyor to sample five residents if you have a medium-sized facility of 120 to 150 beds, according to the CMSCompliance Group (CMSCG). For large facilities with more than 150 beds or facilities with dementia care-related citations at F-309 — Quality of Care, surveyors may expand the sample size to 10 residents.

The fourth part covering dementia care and related practices includes the following subsections:

• Comprehensive Evaluation of Each Resident on Admission by the Interdisciplinary Team — surveyors’ observations in this section focus on staff directly involved in the admission process (e.g., admission coordinator, social worker, nurses, CNAs, therapists, etc.)
• Recognition, Assessment and Cause Identification of Behavioral Manifestations of Dementia — surveyors’ observations focus on staff directly involved in patient care (e.g., nurses, CNAs, therapists, etc.)
• Care Planning — surveyors must determine whether the facility has developed a plan of care with measurable goals and approaches to address the care and treatment for a resident with dementia (related to the resident’s expressed or indicated distress or behaviors that appear to be stress-related, in accordance with the assessment, resident’s wishes and current standards of practice)
• Individualized Approaches and Treatment: Care Plan Implementation and Staffing — surveyors’ observations focus on staff interactions with residents who have dementia to determine whether staff consis­tently applies basic dementia care principles
• Monitoring, Follow-Up and Oversight — surveyors’ observations focus on staff identifying resident distress and making adjustments/updates to the care plan based on this monitoring function

Evaluate 8 Dementia-Care Practices

Additionally, CMS provides in the survey tools “specific practices to consider.” Although not all-inclusive, CMS provides examples of common practices, both positive and negative, to evaluate during the Focused Dementia Care Survey.

Overall, the practices CMS cites “address the issue of meeting the resident where he/she is and entering that world, as opposed to requiring [the resident] to conform to nursing home routines.” Some specific practices that surveyors may consider include:

1. Dignity & Function: Observe for language or routines that could have an impact on dignity and/or function, such as:

a. Use of bibs, crescent “feeding” tables;

b. High percentage of residents wearing socks/non-skid socks and institutional gowns instead of their own clothes and shoes; high percentage of residents with soiled hands or nails, unshaven or with hair not combed or brushed (a high percentage of these observations may indicate that staff does not try to re-approach residents or find ways to enable them to accept needed care/grooming; surveyors should investigate further);

c. Staff use of terms such as “feeders,” “total care residents,” etc. in communication versus person-centered language;

d. Failure to respond to residents’ communication/behavioral manifestations of distress/emotional needs versus attention to preventing escalation of distress;

e. Attempts to keep residents “quiet” or prevent them from moving around versus efforts to walk or talk with residents who appear distressed; and/or

f. Lack of social interaction or communication between staff and residents during direct care versus engaging residents in conversation or speaking to them even if they are unable to respond.

2. Dining Experience: Observe for social dining atmosphere or individualized dining setting (if appropriate) with staff sharing the dining experience with residents (not standing over them). Observe for staff talking with residents, not talking only with other staff or ignoring residents. Observe for culturally appropriate meals.

3. Environmental Stimulation: Observe for whether staff assesses the environment regularly for too much or too little noise, light and stimulation. (Since this may be difficult to ascertain during observations alone, speak with staff about how they address environmental issues for individuals with dementia).

4. Care Approaches: Observe for other basic dementia care approaches such as:

a. Using soft, low voice and speaking where resident may read lips/see face clearly;

b. Not approaching resident from behind;

c. Providing adequate time during resident care and meals (not rushing);

d. Encouraging maximal independence (not performing activities/care routines that resident could perform him/herself if given adequate time and task segmentation, cues);

e. Encouraging time outdoors;

f. Encouraging physical activity;

g. Redirecting resident away from high-stress environment;

h. Allowing a resident to remain in preferred location/environment (e.g., to remain in bed) if safe, and re-approaching that resident later on if they express a desire/choose to remain where they are (staff recognizing this as preference/choice, even in someone who has dementia);

i. Providing stimulation (to avoid boredom); ensuring an adequate number and type of activities on all shifts, on W/E’s;

j. Addressing loneliness/isolation; and/or

k. Appropriately limiting choices to avoid frustration/confusion.

5. Sleep: Assess for adequate sleep and individualized sleep hygiene in care plan (sleep facilitators, such as reducing interruptions for continence care or pressure relief through use of appropriate continence products and mattresses); sleep log or diary if indicated. Assess for residents sleeping often during activities.

6. Pain: Evaluate for adequate pain assessment in all residents with particular attention to those with difficulty communicating about pain.

7. Sensory Impairments: Assess for sensory deficits and how these deficits may impact cognition. Is there an assessment for use of adaptive equipment, and is it used appropriately and consistently?

8. Transitions & Transfers: Assess for issues during care transitions. For example, was there a unit or room change? What prompted this change? How was information transferred effectively among care providers (“warm handover”)? Consider issues related to accepting residents back after a hospital transfer (communication with state Ombudsman Program may be helpful).

Watch Out for F-309 Citations

Beware: Keep in mind that the Focused Dementia Care Survey can yield real citations, particularly F-309. “The end of the tools remind surveyors that if the nursing home has not provided the necessary care and services for each resident with dementia to support his/her highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, that F-309 should be cited,” CMSCG warned.

Resources: You can view the Focused Dementia Care Survey Tools in S&C: 16-04-NH at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-04.pdf.