Life under psychosocial outcomes: what CMS' important new initiative means to your facility.

With the release of the new Psychosocial Outcome Severity Guide, CMS is telling nursing homes to focus as much on the word "home" as you do "nursing." The new guidance--which went into effect June 8, 2006--has caused much anxiety and concern in the long-term care community, as it instructs surveyors to evaluate psychological harm to residents in addition to any physical harm that results from facility noncompliance.

Why the focus on psychosocial outcomes?

Unlike other CMS releases, the Psychosocial Outcome Severity Guide is not a regulation or an F-Tag, but rather a guide to help surveyors determine the severity of psychosocial outcomes resulting from noncompliance under an F-Tag.

The guide will be used to determine the severity of a deficiency in any regulatory grouping (e.g., quality of care, quality of life) that has resulted in a negative psychosocial outcome. This guide is not intended to replace the current scope and severity grid but will be used in conjunction with it.

A nursing home resident can experience either a negative physical outcome or a negative psychosocial outcome or both. Both of these are considered equally important and both will be considered by surveyors. The severity level assigned will reflect the most significant negative outcome or highest level of harm/potential harm.

For example, if during a dressing change observation, a nurse was observed not washing her hands, putting the resident at risk for infection, this would likely result in a potential for harm deficiency or "D" level deficiency. However, under the new guidelines, if during that same dressing change observation, the nurse failed to provide adequate privacy, exposed the resident unnecessarily, and the resident expressed persistent ongoing feelings of humiliation as a result, the psychosocial outcome would result in this being cited at the actual harm level or at a "G" level. That's the difference with the new guidance.

Take another example: A resident who was slapped by a staff member may experience only a minor physical outcome from the slap but suffer a greater psychosocial outcome. In this case, the severity level based on the psychosocial outcome is more significant and would be used as the level of severity for the deficiency.

Because any facility noncompliance that results in a reduction of psychosocial well-being or psychological outcome is considered to have at least the potential for harm and diminishes the resident's quality of life, at a minimum any deficiency at any F-Tag that results in a negative psychosocial outcome or potential must be cited at a "D" level.

How surveyors use the guide

In order to apply the guide, the surveyors must show a connection between a facility's noncompliance and the resident's negative psychosocial outcome.

The surveyors must show that an action or inaction on the part of the facility caused or contributed to the psychosocial outcome or that the facility failed to assess and treat a pre-existing condition which led to continuation or worsening of the condition. Psychosocial outcomes of interest to surveyors are those caused by the facility's noncompliance with any regulation.

The presence of a given effect--that is, the behavioral manifestation of mood demonstrated by the resident--does not necessarily indicate a psychosocial outcome that is the direct result of noncompliance. A resident's reactions and responses (or lack thereof) also may be affected by pre-existing psychosocial issues, illnesses, and medical conditions, medication side effects, or a range of other factors.

For example, a resident who experiences a stroke may thereafter have a sad and apathetic appearance that is not due to any noncompliance on the part of the facility. Residents may exhibit sadness, anger, loss of self-esteem, and other emotions in reaction to normal life experiences. The survey team must have determined that the negative psychosocial outcome is a result of the noncompliance.

In applying the guide, surveyors will compare residents' behavior (e.g., their routine, activity, and responses to staff or to everyday situations) and mood both before and after the noncompliance. The surveyor will be comparing Minimum Data Set (MDS) assessments as well as social service notes, activity assessments, participation logs and nursing assessments (including depression and pain assessments) to determine the impact of the facility's noncompliance.

It is important your facility clearly document if there is a reasonable explanation for a resident's psychosocial outcome or change in psychosocial condition that is unavoidable.

Situational use of the guide

Surveyors can use the guide in the following situations:

* If a resident can verbally express an outcome (saying he or she is suicidal or are humiliated);

* If the resident is unable to express her/himself verbally but shows a noticeable nonverbal response that is related to the deficient practice (e.g., crying, cowering, withdrawal, teeth grinding);

* When there is no discernable response from the resident;

* When circumstances obstruct the direct evaluation of the resident's psychosocial outcome.

In the last situation, such circumstances may include, but are not limited to the following:

* Subsequent injury

* Cognitive impairments

* Physical impairments

* The resident's death

* Insufficient documentation by the facility

The idea of reasonable people

The survey team may use the "reasonable person concept" to evaluate the severity of the deficient practice.

For example, if a resident in a coma is sexually assaulted, he or she would not able to respond verbally, nor show any physical response. But this is a situation where reasonable people would agree that there would likely be serious negative psychosocial outcome.

Another case would be if the resident's reaction to a deficient practice is markedly incongruent with the level of reaction the reasonable person would have to the deficient practice. In this situation, the survey team may use the reasonable person concept to evaluate the potential severity of the deficient practice.

For example, suppose a resident is not provided needed incontinent care during the night and when interviewed by the surveyor states that he or she is "used to it, it doesn't matter" and it is "just the way things are." This is a situation also where reasonable people would agree that it would be embarrassing and humiliating to have to sit or sleep in soiled undergarments.

In order to apply the reasonable person concept, the survey team must deter mine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance).

The release and implementation of this part of the guide has not been without controversy. Long-term care organizations filed comments on the proposed guidelines, expressing concern about the subjective nature of the guide, particularly the instructions that surveyors evaluate harm in part by whether a "reasonable person" and not necessarily the resident in question would be offended or upset by the actions of the facility or facility staff. In addition, questions continue to mount about the statutory and regulatory authority of CMS to use the reasonable person concept.

There also may be cultural, religious, ethnic, or age considerations that would impact whether an individual would experience a negative psychosocial outcome from a given situation. It will be important for the facilities to clearly document these situations--like so many situations in long-term care, it is a judgment call that should be supported by written evidence.

A proactive approach

It is important to remember the guide can only be applied after the surveyors have determined facility noncompliance with an F-Tag has resulted in a negative psychosocial outcome to a resident.

Facilities should make sure they are taking credit for all interventions they provide. The most common intervention for pain is medication. However, there are many things a facility may do to address pain that it fails to take credit for, including the following:

* Turning and repositioning 

* Use of a specialized support surface in the bed and chair

* Use of a topical dressing that adds moisture to a dry wound

* Diversion activities

Throughout the guide, CMS has continually used the word "facility" which emphasizes that this is not just a social service issue. It is every staff member's responsibility to ensure residents have good psychosocial outcomes and well as good clinical outcomes.

Many facilities already include evaluation of "technical care" or clinical care as part of their skills reviews and quality improvement (QI) process. It is important to add an evaluation of psychological and emotional care to these areas as well.

For example, while evaluating the nurse's skill in completing a dressing change, facilities should focus as much on whether the nurse provided privacy and completed the dressing in a manner that enhanced resident dignity as on whether the nurse washed his or her hands prior to the treatment and followed correct dressing change protocol. Both actions are considered equally important by CMS and the resident!

Adding an evaluation of quality of life and psychosocial outcomes to the quarterly QI meeting in addition to the traditional areas of evaluating the number of residents with pressure ulcers, incontinence, and psychoactive medications can be helpful in ensuring compliance and positive resident outcomes. Interviewing residents and family members about their perception and satisfaction with psychosocial care and interventions as well as with clinical care will also be helpful.

"Caught you caring"

How about rewarding your staff for good attention to psychosocial needs of residents? Implementing "caught you caring" programs to recognize these efforts will also help put a focus on this important area.

And, finally, embracing the principles of culture change will help promote positive psychosocial outcomes and enhance quality of life for residents. While this may seem overwhelming, there are many simple things you can do to aid this process. For example, if introducing buffet style dining to give residents choice at mealtime seems overwhelming, start off with a juice cart at breakfast and a dessert cart at lunch and dinner. Even those small changes will improve the quality of life and the psychosocial outcomes of your residents.

Go to www.cltcmag.com for the latest industry news!

Learn how to comply with the new guidance by listening in on HCPro's audioconference Meet CMS' new Psychosocial Outcomes requirement on November 17. Call 877/727-1728 or go to www.hcmarketplace.com for more information.

RELATED ARTICLE: By definition.

In the Psychosocial Outcome Severity Guide, CMS has provided clarification of often vague terms such as anger apathy dehumanization and humiliation It's a good idea to read over definitions to understand what the guide is getting at.

For example, anger refers to an emotion caused by the frustrated attempts to attain a goal, or in response to hostile or disturbing actions such as insults, injuries, or threats that do not come from a feared source. Not having choice in their lives could cause residents to have anger.

Dehumanization refers to the deprivation of human qualities or attributes such as individuality, compassion, or civility. Dehumanization is the outcome resulting from having been treated as an inanimate object or as having no emotions, feelings, or sensations. Being talked over instead of talked to while being assisted at mealtime or being referred to as "feeder" could cause a resident to feel dehumanized.--Molly Morand

by Molly Morand, RN, BSN, BC

Molly C. Morand, RN, BSN, BC, is a Board Certified Gerontological Nurse and former long-term care surveyor. President of the Morand Group LLC, a health care consulting firm, she provides consultation to long term care facilities, hospitals, provider organizations, QIOs, consumer organizations, and suppliers throughout the United States on regulatory, compliance, and quality of life issues. She can be reached at 513/470-4894 or [e-mail].