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Dementia Care Rules for SNFs Cheat Sheet by

Dementia Care Rules for SNFs F-Tags
rules     federal     care     snf     healthcare     dementia     f-tags


The Centers for Medicare and Medicaid Services (CMS) outlined revisions to State Operations Manual (SOM) regula­tions, effective November 28, 2016, in a survey & certif­ication memo. For nursing facilities caring for residents with dementia, the new rules have a particular bite; dementia care and cognitive impairment are mentioned over 150 times, directly impacting 10 federal deficiency tags and cross-­ref­ere­ncing multiple others.

Rule #1: Facility Assessment F490

The most signif­icant change to the State Operating Manual (SOM) is the requir­ement for every nursing home to develop a compre­hensive facility assessment by November 28, 2017. In F490, Admini­str­ation, facilities “must conduct and document a facili­ty-wide assessment to determine what resources are necessary to care for its residents compet­ently during both day-to-day operations and emerge­ncies.” By defini­tion, the facility plan must include the facility’s dementia management programs. After analyzing their resident popula­tion, facility leaders must detail residents’ needs, required staff compet­encies, physical enviro­nmental needs, emergency response and much more.

Rule #2: Quality of Care - F309 Tag

The 61 pages of instru­ction to the surveyors in F309, Quality of Care, deserve a thorough review by facility staff. In this section, CMS provides an overview of dementia and behavioral health and defines behavioral interv­ention, person­-ap­pro­priate care, and approp­riate medication use in residents with dementia.

Rule #3: Unnece­ssary drugs - F329 Tag

F329 focuses on whether medica­tions ordered to treat conditions are being “monitored for effect­iveness and for adverse conseq­uences, including whether any symptoms could be related to the medica­tions.” For residents with dementia, the SOM added that facility staffing should be arranged to “optimize famili­arity and consis­tency for a resident with symptoms of dementia” as a nonpha­rma­cologic interv­ention. Oversight of medication regimens by consistent staff who know their residents is an effective approach to avoiding unnece­ssa­ry-drug citations.

In the most signif­icant change, effective November 28, 2017, residents are not to receive PRN antips­ychotic medica­tions unless for a specific, documented diagnosis. PRN orders for psycho­tropic drugs must not be given beyond 14 days without the prescr­ibing practi­tioner docume­nting the rationale. Time frames for continued PRN use must be documented in the medical record.

Rule #4: Dignity - F241 Tag

F241 details privacy during care, covering of catheter bags in public, and much more that should be consid­ered. Surveyors will also observe whether “staff members respond in a dignified manner to residents with cognitive impair­ments, such as not contra­dicting what residents are saying.

Rule #5: Profic­iency of Staff - F498

Competency of staff to care for cognit­ively impaired residents is in surveyors’ bull’s­-eye. Facility staff must ensure that “nurse aides are able to demons­trate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assess­ments, and described in the plan of care.” In F498, the SOM mandates that staff competency assessment “include dementia management training and resident abuse prevention training.” This is a repeat of language in F226, Policies and Procedures (described above), so citations in one tag could lead to a cross-­ref­erenced citation tag.
Additi­onally, F361 requires: The facility must employ sufficient staff with the approp­riate compet­encies and skills sets to carry out the functions of the food and nutrition service, taking into consid­eration resident assess­ments, individual plans of care and the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assess­ment.

Rule #6: Activities - F248 Tag

Revised definition in the Activities section of the SOM (F248)? Pay close attention to the new language (in italics):

The facility must provide, based on the compre­hensive assessment and care plan and the prefer­ences of each resident, an ongoing program to support residents in their choice of activi­ties, both facili­ty-­spo­nsored group and individual activities and indepe­ndent activi­ties, designed to meet the interests of and support the physical, mental, and psycho­social well-being of each resident, encour­aging both indepe­ndence and intera­ction in the commun­ity.

Rule #7: Social services - F250 Tag

Under F250, facilities can be cited when a resident with dementia lashes out at another resident and staff fail to evaluate the aggressive resident’s behavior. Reside­nt-­to-­res­ident abuse is a huge problem in nursing homes, and your facility’s social services profes­sionals should be integrally involved in evaluating the root cause of aggressive behaviors. Interv­entions should be establ­ished and contin­ually monitored for effect­iveness

Rule #8: Activities of Daily Living - F310 Tag

Residents with dementia are at risk for ADL decline when staff members perform the care instead of allowing residents to care for themse­lves. Cueing residents and allowing them to dress, eat, and toilet themselves takes more time, but facilities can be cited, under F310, for failing to 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.” The SOM emphasizes that staff must base ADL care on compre­hensive assess­ments of residents’ needs and choices. Providing indivi­dua­lized ADL care is essential to slowing the disease process and improving quality of life.

Rule #9: Facility Policies & Procedures - F226

A list of required policies and procedures has been added to the SOM under F226. These include staff training on dementia management and the prevention of resident abuse, neglect, and (newly added) exploi­tation of residents with dementia. The rule states that policies and procedures should have seven compon­ents: “scree­ning, training, preven­tion, identi­fic­ation, invest­iga­tion, protection and report­ing­/re­spo­nse.” Ensure your policies are up to date by reviewing the SOM’s defini­tions of all seven compon­ents.

Rule #10: Facility Sound Levels - F258 Tag

Staff should regularly assess the hearing needs of residents with dementia to ensure that facility noise levels are comfor­table (F-Tag 258). The SOM encourages facility staff to “consider if it is difficult for residents to concen­trate because of distra­ctions or background noises such as traffic, music, equipment, or staff behavior.” Cognit­ively impaired residents can be partic­ularly agitated by other residents’ shouting and the blare of buzzers; reasonable efforts should be made to reduce unnece­ssary noise.

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