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F Tag 314: Examined by Expert

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F-Tag 314
Making It Stick!
A national expert examines F-Tag 314 and how to avoid the situations that can result in an F-Tag by state surveyors.

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While it has been 18-months since F-314 for pressure ulcers was revised to give better clarity, the subject remains a sore spot for many nursing home staff still trying to decipher the updated guidelines issued by the Centers for Medicare & Medicaid Services (CMS).f314

Nursing homes are not alone

State surveyors sometimes also have difficulty interpreting the Federal regulations (also known as F-Tags) that govern long-term care facilities, causing the notorious F-314 to be the most commonly cited and misinterpreted tag in the nation. While things may not have changed for nursing homes, the Guidance to Surveyors document has been expanded significantly with the hopes of offering clarity on F-314.

F-314 was the most cited tag nationally in 2003 by state surveyors, according to Dr. Courtney Lyder, a senior consultant for the U.S. Department of Health and Human Services (DHHS) who assisted in the revision of the F-Tag. Lyder serves as the University of Virginia Medical Center’s Professor of Nursing, Professor of Internal Medicine Geriatrics and Acting Chairman for the Department of Acute and Specialty Care.

“As time moves on there are new ways, knowledge and technology that didn’t exist when the F-Tag was originally written. This caused too much variability between state and federal interpretations. So, F-314 was revised for more consistency across all states, surveyors and the Feds involved,” Lyder explained. “We consider it a win-win for all involved.”

On a conference call in April, Lyder shared his comments and insights into F-314. This call was the first in a series of multi-state calls for nursing homes that will be hosted by QSource and six other quality improvement organizations.

The F-Tag guidance document is clear in its intent to encourage all long-term care facilities to adopt evidence-based pressure ulcer protocols of care and emphasizes the use of pressure ulcer risk assessment and prevention strategies, pain assessment and treatment, and monitoring the care outcomes. CMS has clearly raised the bar on pressure ulcer care.

Good Intentions

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Interpretation is best done by examining the F-Tag’s intent, Lyder said. For F-314, the tag’s official intent is to promote the healing and prevention of pressure ulcers and to ensure that a resident does not develop a pressure ulcer unless the resident’s clinical condition makes it unavoidable.

Interpreting this intent is best done by examining the definition of avoidable and unavoidable pressure ulcers, he said, which a state surveyor does by noting if one or more items have or haven’t been done.

If a pressure ulcer is deemed avoidable, the state survey bases their F-Tag citation on whether the nursing home failed to evaluate clinical condition or risk factors, define and implement interventions consistent with resident needs and goals, recognize standards of practice, monitor and evaluate impact of interventions and revise those interventions appropriately.

To avoid an F-Tag citiation, Lyder said nursing homes need to understand that what surveyors clarify as avoidable can also be deemed as unavoidable depending on the documentation. Appropriate documentation may ward off an F-Tag when the nursing staff has done everything it can possibly do, but the resident still develops a pressure ulcer because of health factors beyond the staff’s control.

“Never argue with the state surveyors if you think that there is a discrepancy in the interpretation,” Lyder said. “Take it to CMS and let them render the interpretation since the state follows the Fed’s interpretation.”

Lyder’s favorite saying is “if it isn’t documented, it didn’t happen” and this saying rings true time and time again in situations where an F-Tag citation is at question by a nursing home. Documentation starts when a resident is admitted and an assessment is conducted.

Assessing the Situation

The best preventative treatment for pressure ulcers is assessing the resident — from head to toe — both upon initial admission and through regular follow-up. Nursing staff should do a comprehensive assessment of a resident’s condition that includes risk factors, skin assessment, nutrition, hydration and moisture on skin on a regular basis, Lyder said.

Assessing a resident’s condition can be done by using any of the various assessment tools available online such as the Norton Scale (the first tool of its kind developed in 1962) and the Braden Scale for Predicting Pressure Sore Risk. Lyder began his career as an assistant to Dr. Barbara Braden who, with Dr. Nancy Bergstrom, developed the widely used research-based tool. The tools was designed to estimate the level of risk for pressure ulcers and predict which patients are most likely to develop pressure ulcers.

Risk assessment on admission has been found to be highly predictive of pressure ulcer development in all settings and most predictive when completed again 48 to 72 hours after admission. Therefore, a periodic assessment is appropriate, Lyder said. The Agency for Health Care Policy and Research (AHCPR) Treatment Guideline for pressure ulcers recommends assessments be conducted “at least weekly.”

Based upon the results of the risk assessment, pressure ulcer care plans that include preventative measures specific to the area of risk should be formulated. It is important to create these individualized pressure ulcer care plans within 24 to 48 hours, since many pressure ulcers begin to develop within 24 to 48 hours and most within three to four weeks.

“The most critical time for a resident to develop a pressure ulcer is during the first four weeks after admission,” he said. “A facility should be consistently and constantly assessing residents, because none of the tools we have right now are going to predict who and when a pressure ulcer will develop.”

Managing the Pressure

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The cost of treating a pressure ulcer can be as high as $50,000 per patient and require several months or even years to heal, according to CMS billing data. With budgets being tightened and pay-for-performance for nursing homes on the horizon, the ability to prevent and manage pressure ulcers is crucial from a business perspective, along with the obvious quality of life benefits.

Training is key in the management of pressure ulcers. Successful programs to reduce their incidence and severity in nursing homes require careful coordination involving all personnel. All members of the health care team need to know their responsibilities and how their tasks relate to each other in the prevention and management of pressure ulcers.

Licensed practical nurses (LPNs) and registered nurses (RNs) should receive training in the assessment, documentation, and treatment of pressure ulcers. Certified nursing assistants (CNAs) should also receive training in prevention and understand how good skin care protects against pressure ulcer development. Physicians who work in long-term care should take an active role in evaluation, monitoring and treatment.

To reiterate his point, Lyder emphasized that the importance of documentation by everyone involved in the care of a resident is essential. Documentation can “make or break you”, especially in regards to an F-Tag citation.

F Tag 314 are worrisome penalty citations for SNF’s and LTC’s.