In our Part 2 of our “Ftag of the Week” regarding sufficient and competent staffing for behavioral health needs, we are going to look at the competency-related requirements in more details. In our first part of the post for F741, we reviewed sufficiency and reminded providers about the importance of the Facility Assessment. In the next two posts, we will review some important things to think about related to competency. Hopefully, these CMSCG Blog posts are more just “friendly reminders” for providers, as these regulations are already in effect, but some additional information was included in the revised guidance to surveyors, so we are reviewing the regulations as a whole.
Skills and Competencies
The intent of the regulation as it relates to competency is the expectation that provider staff have “basic competencies” and skill sets to provide care and services, including implementation of nonpharmacological interventions, for residents living with mental and psychosocial disorders, those who are trauma survivors, and those who may have a history of substance use. It’s up to you to determine, through your Facility Assessment and other means, the skills and competencies necessary to provide care for your resident population and to only admit residents that can be competently cared for.
It’s up to you to determine, through your Facility Assessment and other means, the skills and competencies necessary to provide care for your resident population and to only admit residents that can be competently cared for.
This may mean digging a bit deeper into a resident’s history and preferences during the admissions process to identify something that may indicate a prior trauma or history of illicit substance use so you can accurately care plan to meet each resident’s unique needs. We should also remember not everyone may willingly share mental health information, but wouldn’t it help to know if there was a history of suicidal ideation or an attempt or another significant concern that you should be aware of to develop and provide resident-centered care.
Non-Pharmacological Interventions
“Non-pharmacological intervention” is defined in the guidance as approaches to care that do not involve medications. The interventions are typically implemented to stabilize and/or improve a resident’s mental, physical and psychosocial well-being.
What’s also important to be aware of is that implementation of non-pharmacological interventions is considered a competency of staff and it is woven throughout the revised guidance to surveyors as it relates to behavioral health. You can likely expect more targeted focus from surveyors on what person-centered interventions have been put in place to avoid triggering a resident with a past history of trauma. How well will your staff be able to explain those interventions and why they are in place to a surveyor? It’s important to educate staff and prepare them for success. This will not only help with the provision of care for the residents, but also help reduce their likelihood of burnout. If your staff can “manage” a resident’s behaviors successfully, this will empower them.
The Interpretive Guidance provides a list of examples of nonpharmacological interventions that could be helpful to meet the behavioral health needs of your residents. This list includes many commonly utilized interventions in nursing homes, including individualized daily routines, including sleeping and dining, creating a more soothing homelike environment by using soft lighting, and the use of consistent staff. The revised guidance to surveyors now includes additional examples for consideration, including:
- Focusing the resident on activities that decrease stress and increase awareness of actual surroundings by offering verbal reassurance, familiar activities and acknowledging that the resident’s experience is real to him/her
- Providing support with skills related to verbal de-escalation, coping skills and stress management
These areas present some topics where staff could likely benefit from additional education. Plus, your staff could even have the added benefit of learning more about coping skills and managing their own stress.
Let’s look at an actual survey citation to understand why CMS is emphasizing the need for staff to be competent in addressing resident behavioral health needs.
Standard Survey Citation F741 S/S: D
A severely cognitively impaired resident who exhibited behaviors including hallucinations, physical and verbal behavioral symptoms directed towards others and rejection of care experienced a significant change and several falls. The resident’s care plan included providing the resident with reality orientation, reinforcing the use of a calendar and newspaper for orientation, encouraging the resident to attend out of room group activities (preferences not specified) and validating the resident’s feeling if she becomes frustrating with memory deficit.
The resident was found on the floor in front of a chair and stated she was trying to see a rodent that went under her dresser. The facility’s immediate intervention was to put a chair alarm on the resident’s recliner. Within the same week, the resident was found on the floor next to her bed, and she stated that she thought someone was in the room, so she was getting up to meet them. The IDT noted that the resident was increasingly confused and had a decrease in safety awareness. The intervention implemented was to put a bed alarm on the resident’s bed and do rounds every 2 hours. The facility did not take steps to manage the resident’s behavioral symptoms and hallucinations and failed to develop and implement an individualized plan for staff to address and respond to the resident’s behavioral symptoms to address the resident’s safety. The resident continued to experience hallucinations resulting in additional falls, which ultimately resulted in the facility placing the resident in her wheelchair at the nurses’ station for monitoring.
Not much more is needed to paint a picture of how the facility missed the boat on meeting this resident’s mental health needs – you have to wonder if the staff were provided with sufficient information on meeting behavioral health needs. I am not even going to address how the team came to the decision of implementing bed and chair alarms and choosing to place the resident at the nurses’ station for monitoring. We all know that there is no guarantee that staff is at the station 24/7 to do such monitoring and alarms do not take the place of a real set of eyes!
Linda Elizaitis, President, CMS Compliance Group
In Part 3 of our CMSCG Blog “Ftag of the Week” for F741, we will review some key staff skills and what you can expect on survey.
