Long Term Care Facility Resident Assessment Instrument User's Manual

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Documentation Standards for Wounds in Long-Term Care

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BACKGROUND: Documentation is a critical component of resident care. The Office of the Inspector General (OIG) of the US Department of Health and Human Services has stated that providers carry the burden of proving that care was actually rendered to patients (residents). If health care providers are unable to prove that they rendered appropriate care because it was not documented, the OIG and other fraud enforcement agencies may conclude that claims submitted are false. Those who provide hands-on care also risk liability for negligence when they fail to document care provided. (2)
The Social Security Act mandated “the establishment of minimum health and safety standards that must be met by providers and suppliers participating in the Medicare and Medicaid programs”. The Centers for Medicare and Medicaid Services (CMS) has been tasked by the Secretary of the Department of Health and Human Services (DHHS) to administer these programs and ensure compliance. CMS therefore provides regulatory guidance to providers and suppliers through a document known as the State Operations Manual (SOM). Appendix PP of the SOM contains, among other items, minimum standards for wound care documentation in the long-term care setting. (4)
These standards are specifically found in Section 483.25 of Appendix PP of the SOM which gives rise to multiple F-tags, including the F-tag 686 (F686: Treatment/Services to Prevent/Heal Pressure Ulcers) and the F-tag 684 (F684: Quality of Life). F686 specifically addresses the minimum assessment, daily monitoring, and weekly documentation requirements when a pressure ulcer/injury is present. F684 then addresses documentation requirements for any skin ulcer/wound. (3,5)
In addition to the SOM, other regulatory documents, such as the Resident Assessment Instrument (RAI), provide guidance to providers and suppliers on minimum wound documentation and reporting requirements in long term care. As such, it is important to be aware of these various documents and comply with the directions for each.(1,3)
RECOMMENDATIONS: To help ensure compliance regarding care provided, a facility should make sure their documentation meets or exceeds, the requirements set forth in the F686. These requirements can be distilled down into three main elements: assessment, daily monitoring and weekly documentation. It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility for all wound types. The minimum content of each element is outlined below.
F686 – Pressure Ulcers/Injuries
It is important that each existing pressure ulcer/injury be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional injuries or for the deterioration of the pressure ulcer/injury be recognized, assessed and addressed. Any new pressure ulcer/injury suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers/injuries.
When assessing the ulcer/injury itself, it is important that documentation addresses:
  • Type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury;
  • PU/PI’s stage;
  • Description of the PU/PI’s characteristics;
  • Progress toward healing and identification of potential complications;
  • If infection is present;
  • Presence of pain, what was done to address it, and the effectiveness of the intervention; and
  • Description of dressings and treatments(3)

F684 – Non-Pressure Ulcer/Injury Wounds
Residents may develop various types of skin ulcerations. At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, registered nurses and certified wound care specialists, etc.) should document the clinical basis for any determination that an ulcer is not pressure- related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.
At minimum, documentation should address:​
  • Underlying condition contributing to the ulceration
  • Ulcer edges and wound bed
  • Location
  • Shape
  • Condition of surrounding tissues (3)

It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. When a pressure injury is present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include:
  • An evaluation of the ulcer, if no dressing is present;
  • An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking);
  • The status of the area surrounding the ulcer (that can be observed without removing the dressing);
  • The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and
  • The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and
  • Whether pain, if present, is being adequately controlled. (3)

The amount of observation possible will depend upon the type of dressing that is used, since some dressings are meant to remain in place for several days, according to manufacturers’ guidelines. With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer should be documented.
At a minimum documentation, in the medical records, should include the date observed and:
  • Location, wound etiology and/or staging;
  • Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract;
  • Exudate, if present: type (serous, serosanguinous, purulent, etc.), color, odor and approximate amount;
  • Pain, if present: nature and frequency (e.g., whether episodic or continuous);
  • Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation issue), or necrosis (slough or eschar); and
  • Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate. (3)

Photographs may be used to support this documentation, if the facility has developed a protocol consistent with accepted standards (e.g., frequency, consistent distance from the wound, type of equipment used, means to assure digital images are accurate and not modified, inclusion of the resident identification/ulcer location/dates/etc. within the photographic image, and parameters for comparison).
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REFERENCES

  1. Centers for Medicare & Medicaid Services. Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Version 1.15. Released October 2017.
  2. Office of Inspector General Website. Available at: https://www.oig.hhs.gov/fraud/strike-force/
  3. State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities. Revised 11/22/17. pp. 248-266, 272, 273.
  4. State Operations Manual-Chapter 1 - Program Background and Responsibilities. Revised 10-3-14. p. 3.
  5. Pressure Ulcer/Injury Critical Element Pathway. Department of Health and Human Services Centers for Medicare and Medicaid Services. CMS Form 20078, 5/2017.
11/1/2018 01:51:43 am

Thanks for this blog, having such crucial information is important for common people as well.


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  1. Long Term Care Facility Resident Assessment Instrument User's Manual Free
  2. Long Term Care Facility Resident Assessment Instrument User's Manual 2016

The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term 'swing bed' refers to the Social Security Act's authorizing small, rural hospitals to use their beds in both an acute care and Skilled Nursing Facility (SNF) capacity, as needed.)[1] This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems.

Long Term Care Facility Resident Assessment Instrument User's Manual Free

Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing homes, including SNFs, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as Registered Nurses, Licensed Practical/Vocational Nurses, Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS).

Minimum Data Set (MDS 3.0) for long-term care is a resident assessment instrument that is which of the following? Required by long-term care facilities that are certified to participate in the Medicare and Medicaid programs b. The first component of the RAI c. Used to gather information about specific health status factors and include. Assessment of a resident’s needs, strengths, goals, life history, and preferences using the Resident Assessment Instrument (RAI) specified by the Centers for Medicare & Medicaid Services (CMS). Access the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s. In its manual for the RAI, CMS specifically states that.

Long Term Care Facility Resident Assessment Instrument User's Manual 2016

  • Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (V 1.16; October 2018) This manual is intended to provide clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. (V 1.16; October 2018) View Resource.
  • State Operations Manual. Appendix R - Resident Assessment Instrument for Long-Term Care Facilities - (Rev. 1, 05-21-04) Transmittals for Appendix R. 1819(f)(6) and 1919(f)(6) of the Social Security Act (the Act) require that the Secretary specify a minimum data set (MDS) of core elements and common definitions.

Sections of MDS (Minimum Data Set):

  1. Identification Information
  2. Hearing, Speech and Vision
  3. Cognitive Patterns
  4. Mood
  5. Behavior
  6. Preferences for Customary Routine and Activities
  7. Functional Status
  8. Functional Abilities and Goals
  9. Bladder and Bowel
  10. Active Diagnoses
  11. Health Conditions
  12. Swallowing/Nutritional Status
  13. Oral/Dental Status
  14. Skin Conditions
  15. Medications
  16. Special Treatments, Procedures and Programs
  17. Restraints
  18. Participation in Assessment and Goal Setting
  19. Care Area Assessment (CAA) Summary
  20. Correction Request
  21. Assessment Administration

The MDS is updated by the Centers for Medicare and Medicaid Services. Specific coding regulations in completing the MDS can be found in the Resident Assessment Instrument User’s Guide. Versions of the Minimum Data Set has been used or is being utilized in other countries.

References[edit]

Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.16 October 2018

  1. ^Medicare, Centers for; Baltimore, Medicaid Services 7500 Security Boulevard; Usa, Md21244 (2017-11-13). 'SwingBed'. www.cms.gov. Retrieved 2019-07-08.
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