LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

F Tag 314 309 Quality of Care Part 1 Guidance Long Term Care Facilities





CMS article on Quality of Care F Tag 314 and 309; Guidance to Surveyors of Long Term Care Facilities CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-07 State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS) Transmittal 4 Date: NOVEMBER 12, 2004

  • SUBJECT: Guidance to Surveyors for Long Term Care Facilities
    I. SUMMARY OF CHANGES: Appendix PP, Tag F314, current Guidance to Surveyors, is entirely replaced by this revision which is to be inserted in the Appendix immediately after the regulatory text for F314. To complement the revision of F314, new language is being added to Tag F309 309 to include certain definitions of non-pressure related ulcers. Hypertext links are added for all Web sites listed in the Overview, (www.ahrq.gov, www.npuap.org, www.amda.org, www.medqic.org, www.wocn.org, and www.healthinaging.org ). Hypertext link is added in the Endnotes section to link to a CMS site ( www.cms.hhs.gov/medicaid/survey-cert/siqhome.asp) for further information. NEW/REVISED MATERIALEFFECTIVE DATE: November 12, 2004 IMPLEMENTATION DATE: November 12, 2004 Disclaimer for manual changes only: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.
    II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.) (R = REVISED, N = NEW, D = DELETED) – (Only One Per Row.) R/N/D CHAPTER/SECTION/SUBSECTION/TITLE R Appendix PP/483.25/Quality of Care/Tag F309 R Appendix PP/483.25©/Pressure Sores/Tag F314
    III. FUNDING: Medicare contractors shall implement these instructions within their current operating budgets. IV. ATTACHMENTS: Business Requirements x Manual Instruction Confidential Requirements One-Time Notification Recurring Update Notification. Unless otherwise specified, the effective date is the date of service. F309 (Rev.4, Issued 11-12-04, Effective: 11-12-04, Implementation: 11-12-04) §483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Use F309 for quality of care deficiencies not covered by §483.25(a)-(m). Intent: §483.25 The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.
    Definitions: §483.25
    • “Highest practicable? is defined as the highest level of functioning and well-being possible, limited only by the individual’s presenting functional status and potential for improvement or reduced rate of functional decline. Highest practicable is determined through the comprehensive resident assessment by competently and thoroughly addressing the physical, mental or psychosocial needs of the individual.
    • “Skin Ulcer/Wound? NOTE: Skin ulcer definitions are included to clarify clinical terms related to skin ulcers. At the time of the assessment and diagnosis, the clinician is expected to document the clinical basis (e.g., underlying condition contributing to the ulceration, ulcer edges and wound bed, location, shape, condition of surrounding tissues) which permit differentiating the ulcer type, especially if the ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.
    o “Arterial Ulcer? is ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis. Inadequate blood supply to the extremity may initially present as intermittent claudication. Arterial/Ischemic ulcers may be present in individuals with moderate to severe peripheral vascular disease, generalized arteriosclerosis, inflammatory or autoimmune disorders (such as arteritis), or significant vascular disease elsewhere (e.g., stroke or heart attack). The arterial ulcer is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot (e.g., top of the foot or toe, outside edge of the foot). The wound bed is frequently dry and pale with minimal or no exudate. The affected foot may exhibit: diminished or absent pedal pulse, coolness to touch, decreased pain when hanging down (dependent) or increased pain when elevated, blanching upon elevation, delayed capillary fill time, hair loss on top of the foot and toes, toenail thickening.
    o “Diabetic neuropathic ulcer? requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot, e.g., at mid-foot, at the ball of the foot over the metatarsal heads, or on the top of toes with Charcot deformity.
    o “Pressure ulcer?. See Guidance at 42 CFR 483.25©-F314.
    o “Venous insufficiency ulcer? (previously known as “stasis ulcer?) is an open lesion of the skin and subcutaneous tissue of the lower leg, usually occurring in the pretibial area of the lower leg or above the medial ankle. Venous ulcers are reported to be the most common vascular ulceration and may be difficult to heal, may occur off and on for several years, and may occur after relatively minor trauma. The ulcer may have a moist, granulating wound bed, may be superficial, and may have minimal to copious serous drainage unless the wound is infected. The resident may experience pain which may be increased when the foot is in a dependent position, such as when a resident is seated with her or his feet on the floor. Recent literature implicates venous hypertension as a causative factor. Earlier, the ulceration was believed to be due to the pooling of blood in the veins. Venous hypertension may be caused by one (or a combination of) factor(s) including: loss of (or compromised) valve function in the vein, partial or complete obstruction of the vein (e.g., deep vein thrombosis, obesity, malignancy), and/or failure of the calf muscle to pump the blood (e.g., paralysis, decreased activity). Venous insufficiency may result in edema and induration, dilated superficial veins, cellulitis in the lower third of the leg or dermatitis (typically characterized by change in skin pigmentation). The pigmentation may appear as darkening skin, tan or purple areas in light skinned residents and dark purple, black or dark brown in dark skinned residents. requirement.