This week’s Ftag of the Week is Part 4 of CMSCG’s blog series for F697 Pain Management. Now that we have looked at recognizing pain and gathering all the necessary information to conduct a pain assessment, let’s look at pain management and pain management interventions.
Pain Management
Once all of the above-mentioned information has been gathered, the interdisciplinary care planning team (IDCPT), including the resident’s physician, should develop and implement interventions that manage or prevent the resident’s pain. A plan for pain management should be in place at the time of admission and interventions implemented at the same time. The IDCPT should meet with the resident/ resident representative to collaboratively identify realistic treatment goals for the resident’s pain. At the same time, the IDCPT should use the opportunity to educate the resident and/or representative about different approaches to pain management that are available, the need to report pain when it occurs, and how the effectiveness of interventions needs to be monitored. The resident representative/ family members, who spend time with the resident, can assist with identifying potential changes with the resident that may be indicative of pain or ineffective pain management.
The Pain Recognition and Management CE Pathway instructs surveyors to dig deeper into the resident/representative’s involvement in developing the pain management plan. Surveyors should ask how the facility involves the resident/representative in defining the approaches and goals of the care plan and in the development of the overall plan.
Surveyors are also expected to ask about how the resident’s goals and preferences have been considered in development of the plan, including:
- If the interventions reflect the resident’s choices and preferences
- What treatment options were discussed and attempted
- If the interventions have been effective
- If the resident has refused any interventions, and if so, was there a discussion about the potential impact to the resident and if other approaches were offered instead
- How the resident/rep is involved in pain management strategies if current strategies are not effective and new interventions need to be developed and put into place
The Foundation for Developing Effective Pain Management Interventions
The IG for F697 provides a comprehensive picture of what a facility is expected to identify in order to develop and implement effective pain management interventions. This includes:
- Recognizing the resident’s needs and goals
- Understanding the type and severity of all pain the resident experiences
- Maintaining awareness of available pain treatment options that follow professional standards of practice
- Identifying who is responsible for managing the resident’s pain, whether it is implementing the intervention, such as an RN or LPN, or supplying a service, such as a therapist
- Ensuring communication occurs between the physician, staff and resident/ representative before and while an intervention is in place, as well as when the need to change an intervention occurs
Interventions – Nonpharmacological and Pharmacological
The IG for F697 discusses two options for interventions, noting that a pain management regimen needs to consider:
- Cause(s) of pain
- Location(s) of pain
- Severity of pain
- Potential benefits of pharmacological interventions
- Potential risks and adverse consequences of medications
- Resident’s desired level of relief and tolerance for adverse consequences
This last bullet, regarding the resident’s desired level of relief and tolerance for any adverse consequences of pharmacological interventions, reminds providers of their responsibility to develop and implement a person-centered care plan for each resident to address his/her pain.
Some residents may be willing to tolerate less pain relief if it means that they will feel less tired/foggy from a medication side effect. Others may have less tolerance for pain and wish for a greater level of pain relief, regardless of the potential side effects. It is important to identify this when developing a pain management regimen and to utilize nonpharmacological interventions where possible to develop a comprehensive pain management plan. Where we falter most often is in identifying the level of pain a resident is willing to tolerate.
Where we falter most often is in identifying the level of pain a resident is willing to tolerate.
Linda Elizaitis, President, CMS Compliance Group, Inc.
The IG states that multiple attempts may be required to identify and implement the right interventions when medications are being utilized. The selection of medications and appropriate doses needs to consider not only the nature, cause and severity of the resident’s pain, but consider the resident’s medical condition and other medications that the resident is taking. There are multiple approaches to providing pharmacological pain management to identify what provides the best results for the resident.
Pharmacological Considerations
These considerations should include:
- Administering medications continuously rather than PRN doses
- Combining long-acting medications with PRN medications for breakthrough pain
- Starting with low doses of a medication initially and titrating the dose upwards slowly to provide pain relief with the lowest possible dose of the medication that is effective
- The need to use several types of analgesics together or include adjuvant medications depending on the resident’s clinical status
- If opioids are to be used for a resident with more severe acute or chronic pain that has not been alleviated with non-opioid meds, the selection and dosing of the opioids should be made in accordance with manufacturers’ guidelines and professional standards of practice – we also need to take into consideration the almost guaranteed side effect of constipation which calls for further expansion of the plan of care
Nonpharmacological Considerations
Nonpharmacological interventions include, but are not limited to:
- Physical therapy and/or exercise
- Restorative nursing programs
- Ice packs/ cold compresses/ mid heat
- Repositioning
- Massage
- Baths/Showers
- Use of assistive devices
- Use of pressure-relieving devices, including mattresses that are appropriately set
- Relaxation techniques
- Activities/ music therapy/ reminiscing/ diversions
- Spiritual comfort/support
- Changes to the physical environment, including changing the room temperature and adjusting linens to make them smooth
Most facilities need to up their game related to nonpharmacological interventions for pain management – just because a “pill” is easier, it is not necessarily the best course of action. Just look at this citation:
Citation Example – F697 S/S: E: This citation identified a lack of non-pharmacological interventions being attempted before the use of PRN pain medications for multiple residents with pain. One resident in the survey sample had an order for an opioid PRN for moderate-severe pain, as well as an order for when the resident experienced mild pain. Not only was it identified that nonpharmacological interventions were not attempted prior to PRN med administration, the resident was given meds multiple times for a pain level of zero. There was no documented evidence that the pain parameters for PRN pain meds were consistent.
Don’t Forget About the Medical Record
Some regulations include many statements about the resident’s medical record and about documentation, and others don’t. F697 Pain Management is one of those regulations where the Interpretive Guidance stresses the need for documentation.
When the decision has been made to utilize pharmacological interventions, CMS is very clear about what information should be available surrounding the treatment decision. The expectation is that documentation will be in place that provides a clear rationale for the pain treatment regimen that has been put in place and acknowledges any associated risks. The medical record is expected to reflect ongoing communication between the prescribing physician and facility staff when pain medications are being used. There should also be documented evidence that the resident’s pain is being evaluated on an ongoing basis.
. This evaluation should include:
- Pain status – presence of pain/ increase in pain/ reduction in pain
- Status of underlying causes of pain
- Response to pain prevention or pain management interventions that have been put into place
- Presence of adverse consequences – and what is being done to prevent/reduce them
Lack of post-treatment pain level documentation is relatively common, and it is a bigger deal than just simply documenting a level. Documenting the effectiveness – or lack of effectiveness – of an intervention helps the care planning team to recognize the need for revising the current interventions, including the need to augment the interventions with additional treatment.
Citation Example – F697 S/S: G (Actual Harm): This citation provides a good example of when a change in pain level should have been communicated to the resident’s physician:
- Resident had experienced increasing pain for approximately four months from a toothache which resulted in the resident using PRN pain medications on a daily basis. The resident’s pain was documented as ranging from a 7 to 10 on a scale of 1-10, indicating that the resident’s pain was not well managed, but the physician was not notified that the resident had increased/worsening dental pain and an increased use of PRN pain meds.
As you can see from the past few weeks’ of Ftag of the Week posts, there are many facets of an effective pain management program. If a facility does not have sound protocols in place, not only can it lead to pain and diminished quality of life for its residents, it can also result in some pretty high-level citations. The examples provided throughout these posts are only a handful of the Actual Harm and Immediate Jeopardy-level citations handed out in 2020. Effective pain management should be part the clinical team’s routine review process to identify potential quality of care and quality of life concerns.
If you missed one of CMS Compliance Group‘s “Ftag of the Week” posts for F697 Pain Management, you can view the links below to catch up.
CMS Compliance Group, Inc. is an interdisciplinary regulatory compliance and quality improvement consulting firm. CMSCG’s consultants work with providers across the post-acute spectrum. For information on how your organization can work with CMSCG, please call 631.692.4422 or fill out the contact form below:
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