A year later, facilities are still struggling to adapt to new incontinence care guidelines. More citations may occur.

Ultimately, new federal guidance on incontinence care will be a good pill for the nursing home community to swallow, experts and providers agree.
But right now it looks and feels like a horse pill.
Despite preparations by some, experts say too many nursing homes and surveyors still are not ready or equipped to cope with it. As a result, some observers believe it will take a wave of painful surveyor citations for facilities to truly come to grips with the new guidance.
Diane Newman, an incontinence expert at the Penn Center for Continence and Pelvic Health who helped write the new guidance, has been talking to facilities about the guidance since it came out at the end of June 2005.
“What’s astounding is most of my audience is not aware of it,” she said. “Most have not read it. The knowledge base for urinary incontinence is really not there. It disturbs me because this is a condition they’ve dealt with for many years.”
Providers find it difficult to break the old habit of “check and change” with products, she says. Some have been surprised by F-315-related deficiencies, other experts note.
Incontinence product companies, which have tried to help smooth the transition period with in-services and training manuals, acknowledge that facilities are hungering for information about how to deal with the revised guidance.
Not ‘getting it’
Last summer, the Centers for Medicare & Medicaid Services implemented the new surveyor guidance for F-tag 315, combining the incontinence (F-315) and catheter (F-316) tags into one. The guidance aims to minimize inconsistencies among surveyors and promotes a new resident-centered approach to the problem.
A primary focus of the new guidance is assessment – evaluating the causes of incontinence and determining the proper intervention.
“The end result may be what they are doing now,” Newman said. “But Medicare is saying, please come up with a plan of care based on assessment. I think that’s an eye opener. They don’t see it as a condition that should be treated. I think that’s a paradigm shift that has to occur.”
Experts acknowledge that it is still too early to judge any impact of the guidance on survey results.
As of March 2006, 13.5% of facilities had been cited with a F-315-related citation, according to statistics from the Centers for Medicare & Medicaid Services’ Online Survey, Certification and Reporting (OSCAR) data. That’s a slight uptick from 2005, when F-315 was cited 13% of the time in standard surveys.
Frustrations emerge
CMS officials told McKnight’s they have received positive feedback from providers and surveyors who appreciate that the guidance is clinically based and that it is available to providers as well as surveyors. The officials said they have not been aware of major problems or challenges.
Anecdotally, though, it appears there is confusion throughout the industry. Many nursing homes feel they have been caught off-guard by the new guidance, said Catherine DuBeau, associate professor of medicine in the section of geriatrics at the University of Chicago.
In January, DuBeau participated in two workshops on the guidance for surveyors and nursing home workers in a Midwest state she did not want to disclose. Approximately 600 people attended the two sessions. She handed out a paper survey and received an astounding 500 responses with comments from both facility staff and surveyors.
Survey responses indicated that providers had already seen a jump in deficiencies from 20% to 67% per quarter from nine months before the guidance came out to the three months after it went into effect.
“There’s a ton of frustration on the part of facilities, where they feel they are already seeing deficiencies without a ramp-up and instruction to get them and surveyors on the same page, which I think is key,” DuBeau said.
Other experts also are aware of facility deficiencies related to the guidance. Karen Merk, a clinical consultant in senior care with Briggs Corp., said she fields 20 to 25 calls each week related to the incontinence guidance.
Some facilities are cited for not following their own policies and procedures, she noted. For example, providers are getting cited for saying they have a bladder retraining program when it is really just a toileting program.
Many of her calls also have come from nurses who complain that doctors won’t diagnose the type of incontinence a resident has. The guidance says diagnosis is a critical part of the assessment process.
“I don’t know if there’s a good enough job being done educating the staff,” she said. “I think there might be an education component that has broken down. It’s great for nurses to know it, but you have to train the CNAs.”
Some facilities also are being cited for dignity-related issues, such as using a paper product that is too bulky, said Lucille Levine, director of clinical services for First Quality Products.
‘False hope’
Still, some facilities say they have not noticed particular surveyor interest in F-315 yet. That is sure to change, says Diane Johnson, group segment marketing manager with Smith & Nephew.
“If nursing homes think that it’s not going to be a focus, it’s sort of a false hope,” she said.
Historically, CMS has chosen key areas to focus on, she explained. In the 1980s, it was fire drills. In the early 1990s, it was restraints. Pressure ulcers and nutrition have been focal points in recent years.
Unfortunately, it may take more citations to get many providers’ full attention.
Deficiencies will indeed be the wake-up call for facilities, believes Spencer Deane, vice president of marketing for SCA Healthcare. Facilities are now still operating under a grace period, he thinks.
“As we move into 2007, we’ll see a growing demand to make sure the guidelines are being used correctly,” he said.
Optimistic results
But it’s not all grim.
Mary Ann Anichini, director of Operation Excellence for Pres-
byterian Homes, based in Evanston, IL, has some uplifting statistics: At Lake Forest Place, which has about 61 skilled nursing residents, 10% of those skilled residents who were at low risk of incontinence were incontinent in the last quarter of 2005. Two years earlier, it was 60%.
Anichini likens the challenge of dealing with incontinence to removing restraints — a major hurdle in the late 1990s.
“We didn’t think we could do it,” she said. “I think (incontinence) is even harder because it’s hidden.”
Presbyterian Homes has taken pains to understand the guidance. The homes received a copy of the pre-regulations and put together a complete training program in 2004. In-services focused on the main objectives of the guidance: assessing the resident to determine the cause and contributing factors of the incontinence and then developing an appropriate individualized intervention. This might entail removing underlying “reversible” factors such as medication that contributes to the problem or training the resident in behavioral therapies.
While difficult to adopt initially, the incontinence guidance reinforces good clinical practice, many experts contend.
“The better facilities were doing this anyhow,” says Thomas Harkin, director of marketing for incontinence care at Tyco Healthcare’s Kendall division. “I think it does clarify for facilities what needs to be done and gets more into the individualized aspect of the care.”
The guidance has provided clinicians with more support for the long-term care incontinent person, adds Vicki Nordby, former director of clinical services for Prestige Care, a chain of 19 skilled nursing homes in Oregon and Washington.
“We didn’t really see a big change in practice, but what we did see is improvement in assessment and documentation,” Nordby said.
To work effectively, the guidance requires buy-in from a senior medical professional, Anichini and others in the field say.
“The biggest challenge is to get nurses to understand how to synthesize the data into a meaningful plan for the residents, and the key ingredient is having someone on staff who understands and wants to champion what needs to happen,” Anichini said.
Another big piece of the puzzle is training – for surveyors and facilities. And both the government and incontinence product companies are stepping in to help. Information about the guidance is available from CMS.
Most companies also offer comprehensive and free F-315 materials. Medline Industries, for example, provides a kit to customers consisting of four DVDs, a clinical DON manual, assessment guides and other tools.
“We just know it’s a hot topic with a lot of facilities and they’re looking for information on how to interpret F-315 and make sure they have the educational tools so they can be survey compliant,” said Dan Love, division president of the personal care division for Medline.
Facilities are “hungering for information,” adds First Quality’s Levine.
“It’s spelled out, but it’s scary,” Levine says of the guidance. “It’s intimidating for a person to look at a 38-page document and say, ‘How does this relate? And how do I present it to my staff?'”

Types of incontinence

Urge – Characterized by abrupt urgency, frequency and nocturia.

Stress – Loss of small amount of urine with physical activity such as coughing, sneezing, laughing, walking stairs or lifting.

Mixed – Combination of urge incontinence and stress incontinence.

Overflow – Occurs when bladder is distended from urine retention. Symptoms include weak stream, hesitancy, frequency, or dribbling.

Functional – Secondary to factors other than inherently abnormal urinary tract function. May be related to physical weakness or poor mobility, cognitive problems, or medications.

Transient – Temporary or occasional incontinence. May be related to delirium, infection, some pharmaceuticals or other causes.

Deficiencies rising
National percentage of facilities with F-315 citations:
March 2006: 13.5%
2005: 13%
2004: 11.3%
2003: 10.8%
Source: The Centers for Medicare & Medicaid Services, 2006
Source: F-315 guidance, Centers for Medicare & Medicaid Services.

Continence care resources
For more information on F-315, see the following references and corporate Web sites:
http://siq.air.org — For experts and resources on F-315
www.cms.internetstreaming.com — For a satellite broadcast/online
courses
www.smith-nephew.com
www.briggscorp.com
www.medline.com
www.firstquality.com
www.sca.com
www.3m.com
www.tyco.com