Ftag of the Week – F677 ADL Care for Dependent Residents

Next up in our “Ftag of the Week” series on the CMSCG Blog, we will review F677 ADL Care Provided for Dependent Residents, which is the seventh most frequently cited Ftag on recertification surveys in the United States for 2022 (as of May 2022). In a prior post, we reviewed the requirements for the companion regulations F677, F676 Activities of Daily Living (ADLs)/Maintain Abilities, which you can view here. Appendix PP of the State Operations Manual (SOM) directs the reader to look at the Interpretive Guidance for F677 when reviewing the requirements for F676, so let’s see what’s required.

The regulation itself is short, but the requirements tend to not be followed as extensively as they should be, given that F677 is so frequently cited. F677 requires that “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 on survey, the Activities of Daily Living Critical Element (CE) Pathway, along with the Interpretive Guidance, will be used to determine compliance with these requirements. Nursing facilities are required to have practices in place that identify, evaluate and include interventions that allow for improvement in a resident’s abilities, maintains their current level of function, or prevents an avoidable decline in ADLs for each individual resident.

There’s also lots of definitions included in this regulation, so let’s review those.

“Oral Care” – Includes everything needed to maintain a healthy mouth (teeth, lips, gums and supporting tissue), including brushing of teeth or oral appliances and maintenance of oral mucosa.

“Speech, language or other functional communication systems” – Relates to a resident’s ability to effectively communicate, including making requests or making needs known, expressing his/ her opinions and expressing emotion. This also includes a resident’s ability to communicate by listening to another person and participate in social conversations. The format of the conversation may include oral, written, gesture, behavior or a combination of these, along with the appropriate devices to assist with conversation, such as a communication board.

“Assistance with the bathroom” – Refers to a resident’s ability or inability to use the bathroom, or alternative, such as a commode, urinal or bedpan. It also includes the resident’s ability to transfer on/off the toilet, clean his/herself, change briefs or absorbent pads, manage a catheter or ostomy, and adjust his/her clothes.

“Transfer” – For the purposes of this regulation, transferring refers to a resident’s ability to move between surfaces such as from bed to chair or wheelchair and standing positions, but excludes to and from the bath/toilet.

Guidance to Be Aware of

The key premise for F677 is that facilities need to have plans in place to ensure that residents who need assistance with ADLs receive it, and that there is no decline in ADLs unless it is unavoidable. The Interpretive Guidance notes that unless a resident’s “clinical picture” shows the normal progression of a condition or disease that would result in an unavoidable decline in ADL performance, that the existence of a clinical diagnosis is not enough to justify a decline in ADLs, which means that the resident record needs to reflect everything that is in place to help avoid that decline and assure that the resident is receiving the care and assistance he/she needs. This is because if it is determined during survey that a resident’s inability to perform ADLs occurred post-admission due to an unavoidable decline, there must be evidence that the facility immediately identified and implemented appropriate interventions for the resident when it became aware of this change.

On Survey

During your next survey, the surveyors will be on the lookout for ADL-related issues. It’s very easy for a surveyor to quickly do a visual observation and see residents in need of care, such as with grooming. There is the potential for a lot of documentation to be reviewed, including:

  • MDS
  • CCP
  • Physician orders
  • ADL documentation/ flow sheets across shifts

The surveyors will be looking to see if the facility has recognized a resident’s risk for decline in performing ADLs or inability to perform ADLs and assessed it and has developed and implemented interventions based on that assessment. The interventions should be based on the resident’s assessed needs, his/her goals for care, the resident’s preferences and recognized standards of practice. Documentation should also show that the resident’s response to the care planned interventions and treatment is being monitored and evaluated, and then the approaches are revised as necessary/ appropriate. Some other items that should be documented include:

  • Resident’s/representative’s decision to refuse care and/or treatment after the facility educated them regarding the benefits/risks of the proposed care and/or treatment
  • If consent is not given, interventions included in the care plan that have been implemented to minimize or decrease functional loss due to the resident/representative refusal, as well as interventions that were revised to minimize further decline that were approved by the resident/representative.

Don’t forget – in cases where a resident refuses or declines care, staff are responsible for attempting to identify the underlying cause, not just documenting that care was refused. Is that how it’s going in your building?

Let’s look at some actual survey citations to see how issues related to ADL care are identified and cited on survey.

Standard Survey Citation S/S: D

A facility was cited for failure to provide supervision and assistance to a dependent resident based on multiple surveyor observations of a resident. The resident who was identified as needing aspiration precautions was observed by a surveyor alone in his room during breakfast. He was eating at a rapid pace and not pausing between bites. At lunchtime, the resident was observed in his wheelchair unsupervised and not pausing between spoonfuls. The resident was care planned for verbal cueing and intermittent supervision during meals, which the facility failed to provide during multiple meal observations.

As they always say, a picture (sometime graphically documented in a 2567) is worth a thousand words – your responsibility is to make it a picture that you don’t mind an outsider viewing. 

Linda Elizaitis, President, CMS Compliance Group, Inc.
Standard/Complaint Survey Citation S/S: E

A facility was cited for failure to ensure residents who required assistance with ADLs received necessary services. It was identified that two residents were not provided with toileting care, another resident was not assisted with getting out of bed or provided care at the time he/she requested, another resident was not provided with regular showers/baths and another resident was not provided with timely care for dressing and toileting. These issues were identified by observations and interview during survey and additionally the citation was based on comments from two residents who attended the Resident Council meeting. Two observations of note:

  • One resident was observed by a surveyor walking around the unit and eating in the dining room with his pants unzipped after being toileted. The resident was then observed with a wet area on the rear leg of his pants while he attended an activity in the unit dining room and remained in wet pants until his family came to visit and he was observed wearing new pants.
  • Another resident was observed still in bed at 11:15AM by a surveyor. She told the surveyor that she preferred to be up and out of bed by 11AM. The surveyor returned to the resident’s room at 4:15PM and found her still wearing the same clothing from the prior day and the resident stated that she had not been helped out of bed yet.

CMSCG Survey Tip

The value of finding time to conduct observational rounds in your own facility to really look at the appearance of your resident population is worth the time and effort that it takes to complete such a simple task. The same is true of observing a resident and checking the associated care plan and ADL sheet / assignment to assess for consistency in information related to the plan of care to meet a resident’s ADL needs.

A Word from Linda Elizaitis, President, CMS Compliance Group, Inc.

I certainly don’t need to remind you of the amount of information that can be gleaned from a resident or their family / representative during a brief verbal interaction – and let’s not forget the comments the CNAs have to offer. As they always say, a picture (sometime graphically documented in a 2567) is worth a thousand words – your responsibility is to make it a picture that you don’t mind an outsider viewing. 

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