Ftag of the Week – F688 Increase/Prevent Decrease in ROM/Mobility (Pt. 3)

In Part 3 of our CMSCG “Ftag of the Week” blog series for F688 ROM/Mobility, we’ll close out our review of these regulatory requirements by looking at a key area – care planning. Then, CMSCG President Linda Elizaitis and CMSCG Clinical Consultant Mary Quinn will share some important compliance tips and reminders for F688.

Care Planning for Range of Motion and/ or Mobility

At the crux of the regulatory guidance under F688 for care planning is a long statement that includes a ton of components that are based on the comprehensive assessment. The assessment needs to identify the resident’s current ROM and mobility capability status in order to develop individualized interventions. The resident’s cognitive ability also needs to be assessed in order to determine the resident’s ability to independently participate, or to follow treatment instructions.

The care plan must include:

• specific interventions, exercises and/or therapy to maintain/improve ROM and/or mobility or to prevent, to the extent possible, decline/ further decline in the resident’s ROM or mobility.
• Provision of any needed equipment and/or services
• Use of equipment as ordered by the physician (as allowed by state law)
• Type of treatments, frequency and duration
• Measurable objectives which describe what the resident is expected to achieve within a specific timeframe
• Resident goals
• Presence of any contractures and necessary interventions
• Any dependence and/or decline in mobility and/or ROM
• Resident-specific risks for complications
• Interventions to mitigate potential complications, to the extent possible
• If complications related to a decrease in ROM and/or mobility are current present, interventions to address these complications must be addressed

Another important consideration for the care plan is that there is ongoing, documented evidence that the IDT has attempted to implement the plan of care and revised interventions to address the changing needs of the resident. The regulation recognizes that a decline or reduction in ROM or mobility may occur even though there is ongoing assessment, appropriate care planning and the resident is being provided with ongoing preventative care and interventions.

Things to Think About

The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals.

• ROM directives not clear – doesn’t address type (AROM/PROM- BID- # of reps)
• Resident refusals – no documentation of MD notification/education risks/benefits- offering of alternative
• Pain not effectively managed so that the resident is able to participate in the ROM/ambulation program or wear an adaptive device as ordered.
• Hand contractures – are resident nails trimmed to prevent pressure/potential issues with skin integrity?
• Device use is not addressed as a potential risk factor for skin impairment
• Skin impairment from a device
• Device is present/worn but soiled or in poor repair – what is the plan for maintenance or replacement?
• Device is not worn per plan of care – communicated on assignment? Wearing schedule clear?
• Device is not available – lost/thrown away?
• Device not applied properly – staff ed/competency?
• Omissions of documentation

It is not that difficult for a surveyor to identify issues that could potentially result in a citation without even looking at the MDS, care plan or medical orders initially. Think about how easy it is to walk down the hall and see a resident with their hands fisted or with bilateral foot drop. Such observations open the door for a review that may result in findings that you will not be happy with. Consider quarterly Rehab Rounds and ensure that the Nursing staff understands their responsibility to report resident refusals to wear an adaptive device or participate in an ambulation program.