Q's and A's about the new Psychosocial Outcome Severity Guide.

CMS's new Psychosocial Outcome Severity Guide (PSG) became effective June 1, 2006. Here are some questions you may have about it, and answers that might prove helpful.

What's the purpose of the PSG?

It is intended to be a guide for surveyors in determining the severity of negative psychosocial outcomes or of a related deficiency during identified noncompliance. Although the PSG was not designed to replace the scope-and-severity grid, it does override it if the severity of the negative psychosocial outcome is greater than that of the negative physical outcome. It is noteworthy to mention that the PSG applies to all regulatory requirements and is not exclusive to the Quality of Life tag F249 Activities Director found in the State Operations Manual Appendix PP.

"Survey Survival" Suggestion: Educate all staff to recognize adverse reactions, such as signs and symptoms of depression, anxiety, and sad mood state.

When and how is the PSG to be applied during the survey process?

When noncompliance has been identified, the PSG is to be applied in order to determine the level of negative psychosocial severity of the deficiency. This is to be done using information gathered during Task 5, the information-gathering portion of the survey process. A thorough surveyor will include information gathered from the medical record; a combination of interviews with staff, family, and/or the resident; and surveyor observations of the resident. In addition, the PSG is to be used when the facility has failed to assess and develop an adequate care plan that addresses preexisting psychosocial issues.

"Survey Survival" Suggestion: All residents receiving a psychopharmacologic medication or diagnosis of psychosis or an altered mental state should have a comprehensive assessment and an implemented plan of care.

Residents may or may not be able to voice negative psychosocial outcomes. What instructions are provided for a surveyor to follow?

There are two avenues by which a surveyor will apply the PSG. The first applies to those residents capable of communicating a psychosocial reaction to a deficient practice in which the surveyor uses resident feedback as a base in determining negative outcomes severity. This response is compared with the PSG to determine severity. The second applies to those residents who are unable to express but noticeably demonstrate a nonverbal response to a deficient practice; this response is then applied to the PSG--and this begins yet again a new saga in the debate over surveyor subjectivity. Because we are dealing with so many variables and degrees of personal reactions in thousands and thousands of scenarios, it becomes a surveyor's judgment call, leaving the "deficiency-no deficiency" debate door wide open.

"Survey Survival" Suggestion: Assessing each resident's communication ability levels is an important step in achieving and continuing compliance. For those determined as having good communication ability, one would offer a "strength-based" plan of care; for someone with little to no ability to communicate verbally yet who expresses negative feelings, one would offer a "problem-based" plan of care.

The application of the Reasonable Person Concept is to be used in the PSG, although it is not applied or included in the practice of common law defenses. How and when is it to be applied?

CMS uses the Reasonable Person Concept by defining it through this example: "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 Reasonable Person Concept is to be applied during circumstances of no discernible response by the resident, when direct evaluation of the resident's psychosocial outcome is obstructed, or when the resident's reaction to a deficient practice is markedly incongruent with the level of reaction a "reasonable person" would have to the deficient practice.

"Survey Survival" Suggestion: If cited during a survey in which the PSG's Reasonable Person Concept was implemented, be prepared with a real life "similar situation" example that would counter the claimed deficiency severity level as experienced by a "reasonable person."

What is the legal application of the Reasonable Person Concept, and how does this differ from CMS's approach?

To answer this I sought out professional friend Carmin Grandinetti, practicing attorney for Tachau Maddox Hovious & Dickens, PLC, and formerly senior vice-president and general counsel for Atria Senior Living Group. He explains, "The 'reasonable person' was developed under common law to determine whether a defendant acted negligently. In other words, it is a standard used to determine if someone acted in a manner that is inconsistent with what a reasonable person would do in like circumstances. Interestingly, the standard would apply to the person harmed only to determine whether that person is also at fault in his or her own injury. The use by CMS is confusing and runs counter to another basic common law concept that protects the rights of individuals whose preexisting fragility makes them particularly susceptible to injury."

How important is the MDS 2.0 in the PSG process?

Because CMS considers the MDS to be the primary document and uses it to measure the resident's status during the survey process, it becomes a very important tool in the use of the PSG during the survey outcomes process. For example, section AB--Demographic Information, questions 9 and 10, in which historic mental illness and mental retardation and developmental disabilities are noted--could apply to the use of the Reasonable Person Concept, while Section B--Cognitive Patterns--validates the resident's inability to respond appropriately or to correctly and effectively interpret and communicate with others. (For further explanation of this, join me at the American Association of Nurse Assessment Coordinators [AANAC] National Fall Conference, October 19-20, in Louisville, Kentucky, for a step-by-step review. For more information on the conference, visit www.aanac.org.)

Our behavior management program has not addressed the definitions used in the PSG and instead uses professional guidelines such as the DSM-IV for this. How should one use the "clarification of terms" found in the PSG?

Of the terms clarified in the PSG, anger, apathy, depressed mood, and anxiety should be defined in facility Behavior/Mood Management programs, policies, and procedures for the sake of continuity. This would be a wise and proactive gesture, given the potential for conflicting definitions between the MDS 2.0 User's Manual and the PSG.

"Survey Survival" Suggestion: Consider using current reference materials such as the DSM-IV in developing facility policy, procedures and practices, and definitions for use in applicable care systems.

The PSG has various severity levels; what are they and how do these relate to the survey?

The PSG has four levels of severity:

Level 1: No actual harm with potential for minimal harm. Level 1 of the PSG is not applicable as per CMS in defining a reduction of psychosocial well-being that would be actionable.

Level 2: No actual harm with potential for more than minimal harm that is not immediate jeopardy. No more than minimal discomfort that compromises the resident's ability to maintain the highest practicable level of well-being, with the potential for greater harm to occur if interventions are not provided.

Level 3: Actual harm that is not immediate jeopardy. Indicative of significant decline in former social patterns, persistent depressed mood state, and various diminished levels of functioning.

Level 4: Immediate jeopardy to resident health or safety. Having allowed, caused, or resulted in (or is likely to do so) serious injury, harm, impairments, or death, and requiring immediate correction.

Again, PSG and its levels are applied only after noncompliance has been determined on a regular survey.

"Survey Survival" Suggestion: Scope-and-severity grid remedies and sanctions still apply, so do not construe PSG as a replacement for these.

Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky. For more information, call [phone] or visit www.cltcinc.com. To send your comments to the author and editors, please send e-mail to [e-mail].

BY RETA A. UNDERWOOD, ADC