August 2018 Comprehensive Review of Regulations & Interpretive Guidance for Top F-Tags Activities of Daily Living F676-F677 Objectives 1. Identify the regulatory requirements 3. Identify examples of how F-Tags related to Activities of Daily Living related to Activities of Daily Living are commonly cited in the new LTCSP 2. Identify survey procedures that describe how Activities of Daily Living 4. Identify tools for the leadership team requirements are reviewed for to use for monitoring compliance with compliance during the annual survey Activities of Daily Living requirements process 5. Explain strategies for incorporating survey preparedness related to Activities of Daily Living into facility QAPI processes 2 2 Housekeeping Announcements • Handouts are posted on the toolbar at the right of your screen. • Technical problems during the webinar – Contact Proactive Medical Review Office at 812-471-7777 or – Contact the State Association with whom you registered – All phone lines are muted • All questions will be held until the end of the session – If you have a question/comment type your question using the Go-To webinar toolbar • Contact the association with whom you registered for any questions regarding continuing education credits & certificates. 3 3 www.proactivemedicalreview.com 1
August 2018 Act Activities o ties of Da Daily L ily Living ng Overview of F-Tag Regulations & Interpretive Guidance 4 Quality of Life Regulations F483.24 Quality of Life F675 Quality of Life F676 Activities of Daily Living (ADLS)/Maintain Abilities F677 ADL Care Provided for Dependent Residents F678 Cardio-Pulmonary Resuscitation (CPR) F679 Activities Meet Interest/Needs of Each Resident F680 Qualifications of Activity Professional F676 - Regulatory Language • §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident’s needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: – §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section … 6 www.proactivemedicalreview.com 2
August 2018 F676 - Regulatory Language • §483.24(b) Activities of daily living. • The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: – §483.24(b)(1) Hygiene –bathing, dressing, grooming, and oral care, – §483.24(b)(2) Mobility—transfer and ambulation, including walking, – §483.24(b)(3) Elimination-toileting, – §483.24(b)(4) Dining-eating, including meals and snacks, – §483.24(b)(5) Communication, including • (i) Speech, • (ii) Language, • (iii) Other functional communication systems. 7 F677- Regulatory Language • §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and 8 Definitions • Oral Care – Refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues. This involves not only activities such as brushing of teeth or oral appliances, but also maintenance of oral mucosa. • Speech, language or other functional communication systems – Refers to the resident’s ability to effectively communicate requests, needs, opinions, and urgent problems; to express emotion, to listen to others and to participate in social conversation whether in speech, writing, gesture, behavior, or a combination of these (e.g., a communication board or electronic augmentative communication device). 9 www.proactivemedicalreview.com 3
August 2018 Definitions • Assistance with the bathroom – Refers to the resident’s ability to: • Use the toilet room (or commode, bedpan, urinal) • Transfer on/off the toilet • Clean themselves • Change absorbent pads or briefs • Manage ostomy or catheter • Adjust clothes 10 Definitions • Transfer – Refers to resident’s ability to move between surfaces • To/from: – Bed – Chair – Wheelchair – Standing positions. • Excludes to/from bath/toilet 11 F676 & F677 Interpretive Guidance • Conditions that may demonstrate an unavoidable ADL decline: – The natural progression of a debilitating disease with known functional decline – The onset of an acute episode causing physical or mental disability while the resident is receiving care to restore or maintain functional abilities – Refusal of care & treatment 12 www.proactivemedicalreview.com 4
August 2018 F676 & F677 Interpretive Guidance • Refusal of Care & Treatment – Must document in medical record • Care planned interventions to minimize or decrease functional loss that were refused by resident/representative • Any interventions that were substituted with consent of resident/representative to minimize further decline • Attempts to identify underlying cause of the refusal 13 F676 & F677 Interpretive Guidance • When unavoidable decline in ADLS occur, must: – Identify interventions to assist resident – Immediately implement identified interventions • Appropriate treatment & services includes all care provided to maximize resident’s functional abilities 14 F676 & F677 Interpretive Guidance • Independent – Completed activity with no help or oversight every time during 7-day look-back period • Supervision – Oversight, encouragement or cueing provided 3 or more times during last 7 days • Limited Assistance – Resident highly involved in activity & received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during last 7 days • Extensive Assistance – While resident performed part of activity over last 7 days, weight bearing support provided 3 or more times or full staff performance of activity provided during part, but not all, of last 7 days • Total Dependence – Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. 15 www.proactivemedicalreview.com 5
August 2018 Activi tivities of es of Daily Daily Livin Living L LTC C Sur Survey Pr Procedur ocedures es Survey procedures for assessing compliance with the F-Tag and citation examples 16 Initial Pool Process Resident Interview Care Areas • ADL Care Area – Do you get the help you need to get out of bed or to walk? – Do you get the help you need when you need to use the bathroom? – Do you get the help you need to clean your teeth or get dressed? – Do you get the help you need during meals? – If not, please describe. 17 Initial Pool Process Resident Interview Care Areas • ADL Decline Care Area – Has your ability to dress yourself or to take a bath changed? • If so, please describe. – Has your ability to get to the bathroom or use the bathroom changed? • If so please, describe. – Do you need more help now to clean your teeth or eat meals? – Do you need more help with getting out of bed or walking now? • Has this been happening for a long time? • About how long? – What are staff doing to stop you from getting worse or to help you improve in these areas? 18 www.proactivemedicalreview.com 6
August 2018 Initial Pool Process Resident Interview Care Areas • Vision & Hearing Care Area – Do you have any problems with your vision or hearing? – Do you wear glasses or use hearing aids? – Are your glasses and/or hearing aids in good repair? If not, what are the facility staff doing to help you with this problem? – Do you need glasses or a hearing aid? – Have you lost your glasses or hearing aids at the facility? – What did the facility do if you lost them? – Does the facility help you make appointments and help with arranging transportation? – If resident has either/both - how are they working for you? 19 Initial Pool Process Resident Observation • Language/Communication Care • ADLS Care Area Area – Are any of the following observed? – Does the resident speak a different • Hair disheveled, uncombed or greasy language, use sign language or other • Facial hair unkempt or present on a female resident alternative communication means? • Face, clothing or hands unclean or with – Does staff know how to communicate food debris with the resident? • Fingernails untrimmed, jagged or dirty – Are there communication systems • Body or mouth odor available at the bedside (cards, note • Teeth or dentures not brushed pad, others)? • Clothing visibly soiled or in disrepair • Dentures stored in an unsanitary manner, if visible – If the situation presents itself, are there other concerns with the assistance provided for other ADLs (e.g., dressing or transfers)? Initial Pool Process Limited Record Review • ADL Decline – Has the resident had a decline in their bed mobility, transfer, eating or toilet use recently and is not receiving therapy or restorative for the decline in the last 120 days? 21 21 www.proactivemedicalreview.com 7
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