anderson health information systems, inc.. ahis web training jan-05 presented by rhonda anderson,...

Anderson Health Anderson Health Information Systems, Inc.Information Systems, Inc.

AHIS Web Training Jan-05AHIS Web Training Jan-05

Presented byPresented by

Rhonda Anderson, RHIARhonda Anderson, RHIA

Anderson Health Information Systems, IncAnderson Health Information Systems, Inc

940 W. 17940 W. 17thth Street, Suite B Street, Suite B

Santa Ana, CA 92706Santa Ana, CA 92706

(714) 558-3887(714) 558-3887

[email protected]@ahis.net


Today’s TopicsToday’s Topics

CMS Transmittal 4 - Nov. 12, 2004CMS Transmittal 4 - Nov. 12, 2004 Revision of F-Tag 309, Quality of Care (as Revision of F-Tag 309, Quality of Care (as

relates to Pressure Ulcers)relates to Pressure Ulcers) Replacement of F-Tag 314, Pressure UlcersReplacement of F-Tag 314, Pressure Ulcers


Pressure Ulcer Regulatory Pressure Ulcer Regulatory Changes - BackgroundChanges - Background

Published November 12, 2004Published November 12, 2004 Effective upon ReleaseEffective upon Release Result of a 3 year effort by:Result of a 3 year effort by:

CMS expert panelCMS expert panel Stakeholder comments on draftsStakeholder comments on drafts Revisions based on stakeholder CommentsRevisions based on stakeholder Comments


Pressure Ulcer Regulatory Pressure Ulcer Regulatory Changes Changes

Contains survey protocol and background Contains survey protocol and background information on pressure ulcersinformation on pressure ulcers Care of resident with existing pressure ulcersCare of resident with existing pressure ulcers Prevention strategies for residents at risk for Prevention strategies for residents at risk for

pressure ulcers pressure ulcers See Att. #1 CMS Transmittal 4 – Original See Att. #1 CMS Transmittal 4 – Original

Publication (pdf file)Publication (pdf file)


F309 - §483.25 Quality of Care F309 - §483.25 Quality of Care

Each resident must receive/facility provide Each resident must receive/facility provide necessary care and services to attain or necessary care and services to attain or maintain the highest practicable physical, maintain the highest practicable physical, metal and psychosocial well-being in metal and psychosocial well-being in accordance with the comprehensive accordance with the comprehensive assessment and plan of careassessment and plan of care


F309 - §483.25 Quality of Care F309 - §483.25 Quality of Care -2-2

Expands Definition of Skin Ulcer/WoundExpands Definition of Skin Ulcer/Wound Clinician expected to document the clinical Clinician expected to document the clinical

basis* which permit differentiating the ulcer basis* which permit differentiating the ulcer type type ESPECIALLY ESPECIALLY if the ulcer has if the ulcer has characteristics consistent with a pressure characteristics consistent with a pressure ulcer but is determined ulcer but is determined NOT NOT to be oneto be one


F309 DefinitionsF309 Definitions

Arterial UlcerArterial Ulcer Result of arterial occlusive disorderResult of arterial occlusive disorder Non-pressure related disruption or blockage Non-pressure related disruption or blockage

of arterial blood flow to an areaof arterial blood flow to an area Blockage causes tissue necrosisBlockage causes tissue necrosis


F309 Definitions F309 Definitions -2-2

Arterial UlcerArterial Ulcer May be present in individuals withMay be present in individuals with

• Moderate to severe peripheral vascular diseaseModerate to severe peripheral vascular disease• Generalized arteriosclerosisGeneralized arteriosclerosis• Inflammatory or autoimmune disordersInflammatory or autoimmune disorders• Significant vascular disease elsewhere*Significant vascular disease elsewhere*



Arterial UlcerArterial Ulcer Affected foot may exhibitAffected foot may exhibit

• Diminished or absent pedal pulseDiminished or absent pedal pulse• Coolness to the touchCoolness to the touch• Decreased pain when hanging down or Increased pain when Decreased pain when hanging down or Increased pain when

elevatedelevated• Blanching upon elevationBlanching upon elevation• Delayed capillary fill timeDelayed capillary fill time• Hair loss on top of foot or toesHair loss on top of foot or toes• Toenail thickeningToenail thickening



Arterial UlcerArterial Ulcer Characteristically painfulCharacteristically painful Usually occurs in distal portion of the lower Usually occurs in distal portion of the lower

extremity*extremity* May be over ankle or bony areas of the footMay be over ankle or bony areas of the foot Wound bed frequently dry, pale w/ little or no Wound bed frequently dry, pale w/ little or no

exudateexudate



Diabetic Neuropathic UlcerDiabetic Neuropathic Ulcer Requires dx. of Diabetes Mellitus AND Requires dx. of Diabetes Mellitus AND

peripheral neuropathyperipheral neuropathy Characteristically occurs on footCharacteristically occurs on foot


Review Diabetes Codes and Review Diabetes Codes and Sequencing ICD-9 CodesSequencing ICD-9 Codes

Chronic Ulcer Lower LimbChronic Ulcer Lower Limb Codes 707.10-707.15; 707.19Codes 707.10-707.15; 707.19 Code first any associated underlying condition Code first any associated underlying condition

(i.e. diabetes mellitus)(i.e. diabetes mellitus) 5th digit allows for coding to a specific site on 5th digit allows for coding to a specific site on

the lower legthe lower leg Exclude pressure ulcers (decubitus) –707.0Exclude pressure ulcers (decubitus) –707.0


ICD-9 Codes - SequencingICD-9 Codes - Sequencing

DO NOT assume a causal relationship DO NOT assume a causal relationship between diabetes and other conditions between diabetes and other conditions unless the physician specifically unless the physician specifically documents the link.documents the link.

• For the diagnostic statements: 1) Foot ulcer and For the diagnostic statements: 1) Foot ulcer and 2) Adult onset diabetes, the conditions would be 2) Adult onset diabetes, the conditions would be coded:coded:

Ulcer of lower limbs, except decubitus – 707.1Ulcer of lower limbs, except decubitus – 707.1 Diabetes without mention of complications – 250.0xDiabetes without mention of complications – 250.0x


ICD-9 CodingICD-9 Coding

Use as many codes as needed from the Use as many codes as needed from the 250 category to describe the patient’s 250 category to describe the patient’s condition (diabetic retinopathy, diabetic condition (diabetic retinopathy, diabetic neuropathy), along with the specific neuropathy), along with the specific complications from each categorycomplications from each category


F309 - §483.25 Quality of Care F309 - §483.25 Quality of Care – Definitions– Definitions

Venous Insufficiency UlcerVenous Insufficiency Ulcer Previously known as “Stasis Ulcer”Previously known as “Stasis Ulcer” Open lesion of skin and subcutaneous tissue Open lesion of skin and subcutaneous tissue

of lower legof lower leg Most common venous ulcerationMost common venous ulceration Difficult to healDifficult to heal May occur after relatively minor traumaMay occur after relatively minor trauma


F309 - §483.25 Quality of Care F309 - §483.25 Quality of Care – Definitions – Definitions -2-2

Venous Insufficiency UlcerVenous Insufficiency Ulcer Wound bedWound bed

• Moist granulatingMoist granulating• May be superficialMay be superficial• Minimal to copious serous drainage unless Minimal to copious serous drainage unless

infectedinfected• Increased pain when limb is dependentIncreased pain when limb is dependent



Venous HypertensionVenous Hypertension May be caused by one or more factors May be caused by one or more factors

including:including:• Loss of/compromised valve functionLoss of/compromised valve function• Partial or complete vein obstructionPartial or complete vein obstruction• Deep vein thrombosisDeep vein thrombosis• ObesityObesity• MalignancyMalignancy• Paralysis, decreased activityParalysis, decreased activity



Venous Hypertension/InsufficiencyVenous Hypertension/Insufficiency May result in: May result in:

• Edema and induration, dilated superficial veins, Edema and induration, dilated superficial veins, cellulitis on lower third of leg cellulitis on lower third of leg

• Dermatitis typically characterized by change in skin Dermatitis typically characterized by change in skin pigmentationpigmentation

Darkened skin, tan or purple areas in light skinned Darkened skin, tan or purple areas in light skinned residentsresidents

Black or dark brown or dark purple in dark skinned Black or dark brown or dark purple in dark skinned residentsresidents


F-314 §483.25(c) Pressure F-314 §483.25(c) Pressure Ulcer Regulatory Changes Ulcer Regulatory Changes

Completely replaces prior version of F314 Completely replaces prior version of F314 in the State Operations Manual (SOM)in the State Operations Manual (SOM)


Enhanced Focus on Quality and Enhanced Focus on Quality and Facility ProcessesFacility Processes

SOM Guidance to SurveyorsSOM Guidance to Surveyors Determine what the facility is doing or has Determine what the facility is doing or has

done to identify residents at riskdone to identify residents at risk• To prevent and treat ulcersTo prevent and treat ulcers

Determine how well the facility is doing Determine how well the facility is doing meeting objectives in providing care and meeting objectives in providing care and utilizing preventive measuresutilizing preventive measures


F314 - §483.25(c) Pressure F314 - §483.25(c) Pressure SoresSores

Based on Comprehensive AssessmentBased on Comprehensive Assessment A resident who enters the facility without A resident who enters the facility without

pressure sores does not develop pressure pressure sores does not develop pressure sores unless the individual’s clinical condition sores unless the individual’s clinical condition demonstrates that they we unavoidabledemonstrates that they we unavoidable


F314 - §483.25(c) Pressure F314 - §483.25(c) Pressure Sores Sores -2-2

Intent Intent Facility provides care and services toFacility provides care and services to

• Promote prevention of pressure ulcersPromote prevention of pressure ulcers• Promote the healing of pressure ulcers that are present Promote the healing of pressure ulcers that are present

(including preventing infection)(including preventing infection)• Prevent development of additional pressure ulcersPrevent development of additional pressure ulcers

Note: Nomenclature in Regulation refers to Note: Nomenclature in Regulation refers to Pressure SoresPressure Sores, guidance uses the term , guidance uses the term Pressure UlcersPressure Ulcers (term widely accepted in the (term widely accepted in the field)field)


F314 - §483.25(c) Pressure Sores - F314 - §483.25(c) Pressure Sores - DefinitionsDefinitions

Provided to clarify clinical terms related to Provided to clarify clinical terms related to pressure ulcers and their evaluation and pressure ulcers and their evaluation and treatmenttreatment

Significant differences from the prior SOM*Significant differences from the prior SOM* Useful as a resource for the facilityUseful as a resource for the facility Sets expectations for facility practiceSets expectations for facility practice Guides surveyors in determining facility Guides surveyors in determining facility

compliancecompliance


F314 - §483.25(c) Pressure Sores - F314 - §483.25(c) Pressure Sores - IntroductionIntroduction

Meant to educate facilities Meant to educate facilities Includes Includes

DefinitionsDefinitions Overview of pressure ulcer development, Overview of pressure ulcer development,

prevention, healingprevention, healing Monitoring of effectiveness of treatment and Monitoring of effectiveness of treatment and

preventive measurespreventive measures


F314 - §483.25(c) Pressure Sores - F314 - §483.25(c) Pressure Sores - DefinitionsDefinitions

Pressure UlcerPressure Ulcer Avoidable/Unavoid-Avoidable/Unavoid-

ableable Cleansing/IrrigationCleansing/Irrigation Colonized/Infected Colonized/Infected

WoundWound

DebridementDebridement Autolytic Autolytic EnzymaticEnzymatic MechanicalMechanical Sharp or SurgicalSharp or Surgical Maggot Debridement Maggot Debridement

therapy (MDT)therapy (MDT)


F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Definitions – Definitions -2-2

Eschar/SloughEschar/Slough ExudateExudate Friction/ShearingFriction/Shearing Granulation TissueGranulation Tissue

Tunnel/Sinus Tract Tunnel/Sinus Tract UnderminingUndermining TunnelingTunneling Sinus TractSinus Tract UnderminingUndermining


F314 - §483.25(c) Pressure Sores - F314 - §483.25(c) Pressure Sores - AssessmentAssessment

AssessmentAssessment Identifying Risk, particularly upon admissionIdentifying Risk, particularly upon admission States that a resident “may develop a States that a resident “may develop a

pressure ulcer within 2 to 6 hours of the onset pressure ulcer within 2 to 6 hours of the onset of pressure”of pressure”

Underlying causes that increase risk of skin Underlying causes that increase risk of skin breakdown should be clearly documentedbreakdown should be clearly documented


AssessmentAssessment

Identify any pre-existing signs of skin Identify any pre-existing signs of skin breakdown suggesting that deep tissue breakdown suggesting that deep tissue damage has already occurreddamage has already occurred Purple or very dark area surrounded by Purple or very dark area surrounded by

profound redness, edema, or indurationprofound redness, edema, or induration


Preexisting ConditionsPreexisting Conditions

Factors contributing to further skin Factors contributing to further skin breakdown include:breakdown include: Pressure resulting from immobility during Pressure resulting from immobility during

hospitalization or surgical procedureshospitalization or surgical procedures Prolonged ambulance transportProlonged ambulance transport Waiting to be discovered after a debilitating Waiting to be discovered after a debilitating

event (fall, CVA)event (fall, CVA)


F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Assessment– Assessment

Facility should have a system/procedure to Facility should have a system/procedure to assure assure Assessments are timely and appropriateAssessments are timely and appropriate Interventions are implemented and monitored Interventions are implemented and monitored

and revised as appropriate and and revised as appropriate and Changes of Condition are recognized, Changes of Condition are recognized,

evaluated, reported to the practitioner and evaluated, reported to the practitioner and addressedaddressed


F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Comprehensive Assessment– Comprehensive Assessment

Includes the RAI InstrumentIncludes the RAI Instrument Evaluates intrinsic risks, skin condition and Evaluates intrinsic risks, skin condition and

causal factorscausal factors Assessment should identify which risk Assessment should identify which risk

factors can be removed or modifiedfactors can be removed or modified May include factors that lead to May include factors that lead to

unavoidable skin breakdown, e.g.unavoidable skin breakdown, e.g. Refusal of careRefusal of care End of life conditionEnd of life condition


F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Risk Factors– Risk Factors

ExamplesExamples Impaired/decreased mobility/functioningImpaired/decreased mobility/functioning Co-Morbid Conditions (e.g. ESRD, DM)Co-Morbid Conditions (e.g. ESRD, DM) Drugs (Steroids)Drugs (Steroids) Impaired blood flowImpaired blood flow Resident refusal of treatment/careResident refusal of treatment/care Cognitive ImpairmentCognitive Impairment Urinary/Fecal incontinenceUrinary/Fecal incontinence Under-nutrition, malnutrition, dehydrationUnder-nutrition, malnutrition, dehydration History of/healed ulcerHistory of/healed ulcer


Risk of Pressure UlcerRisk of Pressure Ulcer

Facility must care plan for identified or Facility must care plan for identified or potential riskspotential risks

Care Planning and treatment must look at Care Planning and treatment must look at stabilizing conditions that put the resident stabilizing conditions that put the resident at risk, for example incontinenceat risk, for example incontinence


Avoidable vs. UnavoidableAvoidable vs. Unavoidable

Facility processes or systems are Facility processes or systems are responsible for determining whether skin responsible for determining whether skin breakdown is avoidable or unavoidablebreakdown is avoidable or unavoidable Evaluation of clinical condition and risk factorsEvaluation of clinical condition and risk factors Defining and implementing interventions Defining and implementing interventions

consistent with resident’s goals and objectives consistent with resident’s goals and objectives and w/ standards of practiceand w/ standards of practice


Advance Directives (AD)Advance Directives (AD)

Facility’s care must reflect the resident’s wishes. Facility’s care must reflect the resident’s wishes. HOWEVER, the AD does not absolve the facility HOWEVER, the AD does not absolve the facility of its obligation to provide supportive care and of its obligation to provide supportive care and treatment that is not prohibited by the AD.treatment that is not prohibited by the AD.

DNRDNR order is order is NOTNOT sufficient to indicate the sufficient to indicate the resident is declining other appropriate care. It resident is declining other appropriate care. It ONLYONLY indicates that the resident should not be indicates that the resident should not be resuscitated if respirations or cardiac functions resuscitated if respirations or cardiac functions cease.cease.


RepositioningRepositioningSupport Surfaces and RedistributionSupport Surfaces and Redistribution

Repositioning plans should be outlined in Repositioning plans should be outlined in the plan of care consistent with the the plan of care consistent with the INDIVIDUALINDIVIDUAL resident’s needs resident’s needs

Pressure RedistributionPressure Redistribution Function or ability to redistribute a load over a Function or ability to redistribute a load over a

surface or contact areasurface or contact area Specific devices and surfaces are addressed Specific devices and surfaces are addressed

and suggestions given for using and and suggestions given for using and evaluating effectiveness of such devicesevaluating effectiveness of such devices


Types of UlcersTypes of Ulcers

Facility must have a system in place to Facility must have a system in place to assure that protocols for daily monitoring assure that protocols for daily monitoring and periodic documentation of and periodic documentation of measurements, terminology, frequency of measurements, terminology, frequency of assessment and that documentation is assessment and that documentation is implemented consistently throughout the implemented consistently throughout the facilityfacility

Ulcer characteristics and Staging ulcers Ulcer characteristics and Staging ulcers consistent with the system used in the RAIconsistent with the system used in the RAI


HealingHealing

Addition of “delayed” healing to existing Addition of “delayed” healing to existing terms of healing or non-healingterms of healing or non-healing

Terms used to judge facility’s quality of Terms used to judge facility’s quality of care care Is facility’s care enabling healing?Is facility’s care enabling healing? Is the rate of healing within acceptable limits?Is the rate of healing within acceptable limits?

Surveyors directed to look at facility Surveyors directed to look at facility processes that monitor the effectiveness processes that monitor the effectiveness of treatmentof treatment


PainPain

Surveyors to directed to use painSurveyors to directed to use pain To determine complianceTo determine compliance As an indicator of the severity of deficienciesAs an indicator of the severity of deficiencies As a way to examine the facility’s approach to As a way to examine the facility’s approach to

carecare• Are pain medications offered prior to dressing Are pain medications offered prior to dressing

changes? changes? • Is pain included as part of the Plan of Care related Is pain included as part of the Plan of Care related

to skin breakdown?to skin breakdown?


InfectionsInfections

Classic signs and descriptive terms for Classic signs and descriptive terms for identifying infected wounds identifying infected wounds

Current literature reports that Stage II, III, & IV Current literature reports that Stage II, III, & IV Decubs may be colonized with bacteria but not Decubs may be colonized with bacteria but not be infectedbe infected

Identification, diagnosis, and treatment of Identification, diagnosis, and treatment of infection critical to healing the woundinfection critical to healing the wound

Infection occurs when bacteria have invaded the Infection occurs when bacteria have invaded the tissue surrounding or within the pressure ulcertissue surrounding or within the pressure ulcer


Dressings and TreatmentsDressings and Treatments

Many different approaches and products Many different approaches and products available for treating Pressure Ulcersavailable for treating Pressure Ulcers

No universal “cure”No universal “cure” Product selection should be based on the Product selection should be based on the

relevance of the product to the identified relevance of the product to the identified ulcers characteristics, the treatment goals ulcers characteristics, the treatment goals and the manufacturers recommendations and the manufacturers recommendations for usefor use


F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Monitoring Systems– Monitoring Systems

Consultants (in conjunction with Facility) Consultants (in conjunction with Facility) willwill Review Facility Quality Indicators related to Review Facility Quality Indicators related to

skin conditions to determine the most skin conditions to determine the most appropriate monitoring system, tools, training; appropriate monitoring system, tools, training; intensity, frequency and focus of monitoringintensity, frequency and focus of monitoring

Use the Consultant Grid to plan and Use the Consultant Grid to plan and document training given, needed, completed document training given, needed, completed as well as to document the frequency of as well as to document the frequency of Consultant reviews over timeConsultant reviews over time


AHIS MonitorsAHIS Monitors Qualitative Treatment Monitor (Att. #2.1)Qualitative Treatment Monitor (Att. #2.1) Change of Condition MonitorChange of Condition Monitor Admission/7/14 day MonitorAdmission/7/14 day Monitor QA/QI’sQA/QI’s

• Pressure Ulcer/Sore (Att. #2.2)Pressure Ulcer/Sore (Att. #2.2) General Review of Facility System for monitoring Complete, accurate General Review of Facility System for monitoring Complete, accurate

treatment documentationtreatment documentation• Pressure Ulcer/Sore – Dietary Att. #2.3)Pressure Ulcer/Sore – Dietary Att. #2.3)

Use to focus on Dietary system of documentationUse to focus on Dietary system of documentation• Pressure Ulcer/Sore – Risk (Att. #2.4)Pressure Ulcer/Sore – Risk (Att. #2.4)

Very exhaustiveVery exhaustive Consultant may do a sampling of new admissions to determine if Consultant may do a sampling of new admissions to determine if

problem exists problem exists Review all sentinel events (Skin breakdown on resident identified as Review all sentinel events (Skin breakdown on resident identified as

low risk) low risk)

F314 - §483.25(c) Pressure Sores F314 - §483.25(c) Pressure Sores – Monitoring Systems – Monitoring Systems -2-2


Quality Assurance/ Assessment Quality Assurance/ Assessment Committee Committee

The committee may:The committee may: Help the facility develop strategies to reduce Help the facility develop strategies to reduce

development and progression of pressure development and progression of pressure ulcersulcers

Monitor the incidence and prevalence of Monitor the incidence and prevalence of pressure ulcers within the facilitypressure ulcers within the facility

Ensure that facility P&P’s are consistent with Ensure that facility P&P’s are consistent with current standards of practicecurrent standards of practice


Investigative ProtocolInvestigative Protocol

Surveyors will use the protocol to Surveyors will use the protocol to determinedetermine If a pressure ulcer is avoidable or unavoidableIf a pressure ulcer is avoidable or unavoidable If care planning and assessment was initiated If care planning and assessment was initiated

upon Admission with appropriate follow up upon Admission with appropriate follow up and revisions to the plan of careand revisions to the plan of care

Deviations from the plan of careDeviations from the plan of care


Investigative Protocol Investigative Protocol -2-2

For New Admission who develops skin For New Admission who develops skin breakdown within a day or two of breakdown within a day or two of admission surveyor willadmission surveyor will Interview staffInterview staff Review documentationReview documentation

Look at facility efforts to reduce risk and Look at facility efforts to reduce risk and treat existing ulcertreat existing ulcer

Look for justification for the choice of Look for justification for the choice of treatment plantreatment plan


Record ReviewRecord Review

Review of RAI and other documentation Review of RAI and other documentation re: assessment of resident’s overall re: assessment of resident’s overall condition, risk factors and presence of a condition, risk factors and presence of a pressure ulcerpressure ulcer Consider the appropriateness of facility’s Consider the appropriateness of facility’s

response taking into account the resident’s response taking into account the resident’s overall conditionoverall condition

Review facility’s efforts to remove, modify or Review facility’s efforts to remove, modify or stabilize risk and underlying causal factorsstabilize risk and underlying causal factors


Revision of Care PlanRevision of Care Plan

Determine whether care plan reflects Determine whether care plan reflects residents problems and needs and that residents problems and needs and that approaches meet or are revised to meet approaches meet or are revised to meet the resident’s needs and healing processthe resident’s needs and healing process


Determination of ComplianceDetermination of Compliance

Facility actions must be consistent with the Facility actions must be consistent with the steps of assessment, identification of risks, steps of assessment, identification of risks, defining and implementing interventions, defining and implementing interventions, monitoring and revising approaches as monitoring and revising approaches as needed.needed.


Deficiency CategorizationDeficiency Categorization

Based on three factorsBased on three factors 1. Presence of harm/negative outcome(s) or 1. Presence of harm/negative outcome(s) or

potential for negative outcome(s) because of potential for negative outcome(s) because of lack of appropriate treatment or carelack of appropriate treatment or care

2. Degree of harm (actual or potential) 2. Degree of harm (actual or potential) related to non-compliancerelated to non-compliance

3. The immediacy of correction required3. The immediacy of correction required


Thanks for Attending!Thanks for Attending!Have a great dayHave a great day

anderson health information systems, inc.. ahis web training jan-05 presented by rhonda anderson,...

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