The Social Security Act mandated “the establishment of minimum health and safety standards that must be met by providers and suppliers participating in the Medicare and Medicaid programs”. The Centers for Medicare and Medicaid Services (CMS) has been tasked by the Secretary of the Department of Health and Human Services (DHHS) to administer these programs and ensure compliance. CMS therefore provides regulatory guidance to providers and suppliers through a document known as the State Operations Manual (SOM). Appendix PP of the SOM contains, among other items, minimum standards for wound care documentation in the long-term care setting. (4)
These standards are specifically found in Section 483.25 of Appendix PP of the SOM which gives rise to multiple F-tags, including the F-tag 686 (F686: Treatment/Services to Prevent/Heal Pressure Ulcers) and the F-tag 684 (F684: Quality of Life). F686 specifically addresses the minimum assessment, daily monitoring, and weekly documentation requirements when a pressure ulcer/injury is present. F684 then addresses documentation requirements for any skin ulcer/wound. (3,5)
In addition to the SOM, other regulatory documents, such as the Resident Assessment Instrument (RAI), provide guidance to providers and suppliers on minimum wound documentation and reporting requirements in long term care. As such, it is important to be aware of these various documents and comply with the directions for each. (1,3)
RECOMMENDATIONS: To help ensure compliance regarding care provided, a facility should make sure their documentation meets or exceeds, the requirements set forth in the F686. These requirements can be distilled down into three main elements: assessment, daily monitoring and weekly documentation. It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility for all wound types. The minimum content of each element is outlined below.
F686 – Pressure Ulcers/Injuries
It is important that each existing pressure ulcer/injury be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional injuries or for the deterioration of the pressure ulcer/injury be recognized, assessed and addressed. Any new pressure ulcer/injury suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers/injuries.
When assessing the ulcer/injury itself, it is important that documentation addresses:
F684 – Non-Pressure Ulcer/Injury Wounds
Residents may develop various types of skin ulcerations. At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, registered nurses and certified wound care specialists, etc.) should document the clinical basis for any determination that an ulcer is not pressure- related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.
At minimum, documentation should address:
It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. When a pressure injury is present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include:
The amount of observation possible will depend upon the type of dressing that is used, since some dressings are meant to remain in place for several days, according to manufacturers’ guidelines. With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer should be documented.
At a minimum documentation, in the medical records, should include the date observed and:
Photographs may be used to support this documentation, if the facility has developed a protocol consistent with accepted standards (e.g., frequency, consistent distance from the wound, type of equipment used, means to assure digital images are accurate and not modified, inclusion of the resident identification/ulcer location/dates/etc. within the photographic image, and parameters for comparison).
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Dear Partners in Care,
We have seen a tremendous interest in our Quarterly webinars as well as the presentations for some of our corporate clients related to Infection Management and Antibiotic Stewardship. This link and these handouts were mentioned and referenced in one of our last presentations and we wanted to take this opportunity to share them with all of you.
Here is the link to the National Healthcare Safety Network (NHSN) which has some great documents that will serve you related to surveillance. (https://www.cdc.gov/nhsn/ltach/index.html)
Below is the link from the CDC’s Antibiotic Stewardship page. This is a GREAT page for you to find documents to assist you and your team with education as you begin framing your antibiotic stewardship program. (https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html)
Also remember to refer to the new State Operation Manual (November 2017) with the updates from the Final Rule. This is a critical document for every facility management team to have, as it contains the updated F-Tags. You should note that the new Infection Control tag, F880 (previously F441) has been significantly updated.
And lastly, remember to look at the infection prevention and control and antibiotic stewardship pilot survey that is being done this year. The surveyor worksheet in this document is very important for your program developers and management to review, as it guides the surveyor to review the building’s antibiotic stewardship program, which will be mandated for facilities to have in place by November 28, 2017 – just a few weeks away!
Please reach out to your AMT representative for education related to this or other topics pertinent to wound care and infection management.
Enjoy your week!
Lynn Tabor MS, RN, WCC
Director of Education & Training
Dear Partners in Care,
As part of this week’s EdMail we want to share with you the vision of AMT, as well as an overview of our newest offering. AMT is extremely excited to roll out the supply of urological, ostomy and tracheostomy products. The AMT Vision “Improving the quality of life of senior patients through innovative and value based risk management programs to support their long term care needs across all settings.”
Attached you will find an overview of the: AMT UROLOGICAL, OSTOMY AND TRACHEOSTOMY PROGRAM
As your trusted partner in the long term care arena we look forward to working with your facility in providing the ultimate experience in both support and education. For further information regarding this new program or wound related questions/education feel free to reach out to your AMT representative.
Have a wonderful week!
“This information is provided for informational purposes only. Patient management decisions should be based on a number of factors, including (but not limited to) professional society guidelines and published clinical literature relevant to a patient’s condition. Providers are encouraged to rely on their training and expertise, as well as any and all available information, prior to making management or treatment decisions for any individual patient.”
Lynn Tabor MS, RN, WCC
Director of Education & Training