In Part 1 of our CMSCG “Ftag of the Week” for F742 Treatment/Svc for Mental/ Psychosocial Concerns, we reviewed information related to pertinent diagnoses and the regulatory requirements under F742. In this post, Part 2, we want to highlight the Investigative Protocol for this tag, because it’s an activity that facilities could use internally to gauge the effectiveness of the care being provided for residents with psychosocial/ mental concerns.
Per SOM Appendix PP, the purpose of the protocol is to determine if a facility has ensured that a resident who displays or is diagnosed with a mental or psychosocial adjustment difficulty or has a history of trauma/PTSD receives appropriate care and services. The surveyors are first instructed to briefly review the resident’s comprehensive assessment and the interdisciplinary care plan. This alone can be problematic – especially those generic care plans.
Once surveyors have taken a look at the resident’s assessment and plan of care to help guide their observations, they will conduct their observational rounds – not just of the resident, but how staff interact with this resident in various situations. This will help them determine if the staff are implementing the interventions which were included in the plan of care. Let’s look at how this can be cited on survey:
F742 S/S: D – Recertification Survey Citation
A surveyor observed a resident seated across from the nurses’ station crying, and when the surveyor said good morning to her, she replied that no, it was not a good morning. The surveyor later observed the resident following a nurse down the hallway and crying, stating that she wanted to leave. A review of progress notes by the surveyor found that the resident’s distress/ anger/ sadness and stating she wanted to be discharged or would leave AMA had been documented nearly 40 times in a 2-month period. An absence of physician documentation related to these concerns was also observed, and the physician stated he did not remember facility staff indicating that the resident was distressed. The Social Worker had attempted discharge planning for the resident but had not yet been successful.
Then, of course, the surveyor interviewed nursing staff. The unit manager told the surveyor that there was no special process for the IDT to review behaviors or psychosocial needs. An LPN told the surveyor that the resident is happy one minute and crying the next, but that staff had not been in-serviced or given special instructions on how to address the resident’s sadness and crying, and that she had not seen anyone do anything specific for the resident. Ring any bells for you regarding what occurs in your own facility?
That brings us to the next area of discussion related to the Investigative Protocol – interviews.
Interviews – Resident, Rep and Staff
Surveyors are expected to interview the resident/ representative/ family to identify their awareness of their current condition, history of the condition/ diagnosis and the validity of their observations. They are also guided to ask if the resident and/or representative participated in the development of the person-centered care plan and whether the resident’s choices and preferences have been considered.
Do you have evidence that the resident and/or representative are aware of how you are managing the resident’s needs – including use of psychotropic medications for the same? This brings up concerns related to psychotropic medication use authorizations which are initiated on admission, for example, but then there is limited documentation indicating discussion when such medications are ordered/ adjusted.
Don’t forget – the family can be a great resource for information, and a care plan that’s developed in collaboration with the resident and/or representative would likely include individualized interventions for that resident.
Don’t forget – the family can be a great resource for information, and a care plan that’s developed in collaboration with the resident and/or representative would likely include individualized interventions for that resident. It’s hard to imagine that the only insight a family has to offer related to the resident is an intervention to make sure staff introduce themselves when speaking to the resident or should speak to the resident and make eye contact. What happened to our responsibility to know the resident so that we can best meet their needs?
The surveyors are also supposed to interview members of the IDT to determine if the care provided is consistent with the resident’s plan of care. They are also supposed to determine if staff are knowledgeable about how to support a resident. As mentioned in the citation example above, staff can’t implement interventions that aren’t in the plan of care or leverage their knowledge of the residents’ preferences if they haven’t been identified and shared with the staff responsible for carrying out those interventions.
While the deficient practice discussed earlier was identified via observation and then confirmed with interviews and record review, there are multiple citations which identified deficient practice under F742 related to psych consults not being completed, psych recommendations not being addressed and more issues than any of us would like related to medications. We’ll review some actual citation examples and continue reviewing the Investigative Protocol in Part 3 of this “Ftag of the Week” Blog Series.
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