Preparing for CMS's continence care revisions: how to get a head start on the new requirements in this key area.

On March 10, 2005, Thomas E. Hamilton, the Centers for Medicare & Medicaid Service's (CMS) director of survey and certification, issued a memorandum to state agency directors informing them of the expected revisions of F315 and F316--Catheter Use and Bladder Care, respectively. While providers anxiously await the long overdue revisions of F315 and F316 (which may have been issued by the time you read this), many are wondering what they might do to get a jump on compliance.

It is worth noting, for starters, that OSCAR data from 2004 indicate that F316 Bladder Care was cited in 10.11% of surveys and made CMS's top 20 list of most-cited deficiencies. F315 Catheter Use was number 75, with only 1.43% of facilities cited. However, revisions to both will require careful attention by facilities wanting to meet current standards of care.

So, how to "get ahead of the game"? A good place to start is becoming knowledgeable of your residents' specific continence care needs and classification. Data show, for example, a very high rate of incontinence in apparently low-risk residents, who lose control of bowel and/or bladder function at a rate of 47% after admission to a facility. This indicates that most urinary retention strategies and restorative toileting programs are proving ineffective, or at the very least they are not providing the level of success one would expect. Nor are toilet-prompting (or prompted voiding) programs being developed and used sufficiently. In fact, a good remedial action to start with is to check on the facility's compliance with the "toileting every two hours" standard. That may soon prove to be outdated--new technology and closer attention to toileting schedules tend to obviate it--but it is a positive approach.

Additionally, reflect on your facility's bladder and bowel assessment practices. A cross-comparison of the facility's quality indicators against resident care performance, as reported by the caregivers, can be very enlightening. Determine whether incontinence risk assessments are in fact completed for each resident. If not, start doing them now.

If a resident has the ability to be transferred onto the toilet and has good trunk control, a scheduled toileting or prompted voiding program should be used. Bladder retraining programs are effective but require the resident to have cognitive processing ability, along with the ability to discern urge sensation and to toilet independently or with assistance. In general, facility-wide implementation of restorative programs would increase tremendously the number of residents receiving needed care and would contribute to the facility's financial bottom line, considering that continence care programs such as these are acknowledged in RUG-III case-mix classifications. But such recognition has responsibilities--therefore, expect the forthcoming revisions to include restorative care and toilet program outcome measurements.

Accurate assessment is important because causal factors and treatment options vary from type to type. Accurately determining your resident classifications will allow you to be able to introduce alternative care measures and treatment programs with confidence. Classify residents for urinary incontinence by the following:

* Urge, defined as involuntary loss of urine associated with a strong sensation of urinary urgency.

* Stress, defined as urethral sphincter failure, usually associated with increased intraabdominal pressure.

* Mixed, defined as a combination of urge and stress urinary incontinence.

* Overflow, defined as a result of bladder overdistension.

* Functional, defined as caused by chronic impairments of physical or cognitive functioning.

* Unconscious or reflex, defined as the result of neurologic dysfunction.

Attention to staff training is imperative. Scheduled and prompted voiding programs often are viewed as a headache by caregivers because of their perception that they will face added documentation requirements and frequent interruptions in their schedules. Providing caregiver education regarding time management as it relates to continence care and, if possible, designating a routinely scheduled restorative/toileting staff will contribute to effective continence care programming and resident success.

New products and services are available for today's incontinence care. By embracing the use of technology, providers have available an increasing number of options. The Web site www.techforltc.org has information on some of these innovative products. For additional information regarding restorative continence care programs, visit www.cltcinc.com.

With a well thought out assessment and treatment program in place, the new survey requirements for urinary incontinence will pose few worries for you.

BY RETA A. UNDERWOOD, ADC 

Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc. For further information, call [phone]. To send comments to the author and editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].