Getting personal: Providers can expect greater demands from state surveyors once CMS's new guidance of incontinence care passes final clearance

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By its very nature, incontinence care is one of the most personalized endeavors in healthcare. Well, it's about to get even more personal.

New federal guidelines will mandate that state surveyors look to see that individualized incontinence care plans are made and followed for all nursing home residents. For months now, providers have been awaiting the new Centers for Medicare & Medicaid Services guidance for F-tags 315 and 316 to be officially introduced.
Once it clears final review, a new era will have begun.
"Way, way tougher," is how Reta Underwood, the president of Consultants for Long-Term Care, Louisville, KY, describes it.
 "They're going to force providers and caregivers to assess patterning for sure, and proper care when there is incontinence. Staff will have to be trained to provide good care techniques, and to ensure that only residents who are incontinent are treated that way."
That is one of the biggest criticisms today about incontinence care: Many residents are essentially expected to either be or become incontinent. It doesn't have to be that way.
Among other things, the new guidance will not allow providers simply to put residents in adult diapers automatically upon admission.
"It's putting the focus on continence management rather than incontinence care. If it does that, we will have a completely different mindset and orientation that we don't have now," Underwood said. "If it does just that one thing, we're in for a world of change, a tremendous shift in culture."
Underwood said she hopes CMS will draft the final guidance much the way it handled F-314, which addresses pressure ulcer care.
"It was heavily laden with the prospect of non-compliance because every step has to be proven it was completed," she said. "I expect CMS will draft this the same way. They're going to tighten it up."
Surveyor, doc views critical
The real challenge with the new guidelines will be how individual surveyors react to them, says Catherine DuBeau, associate professor in the section of geriatrics at the University of Chicago.
"It's unclear whether surveyors will look beyond documentation to care the care process," she said. "This is a huge concern in the field right now."
DuBeau also said staffing issues will once again come into the spotlight.
"Right now there's not really enough staffing for everyone who would benefit from toileting programs," she said. "So the DONs could be caught between administration and the surveyors."
Direct-care staff members are not the only ones who should be put on the spot, she added.
"The other group that needs to be at the table with this with incontinence care is physicians and nurse-practitioners," she said. "Now, all the accountability is on the staff side, which in some ways, isn't fair.
"There's more that can be done on the physician side," DuBeau said. "I won't make a lot of friends – I'm a nursing home practitioner, too – we certainly are not held accountable at all."
The American Medical Directors Association posts clinical guidelines at (www.amda.org), she noted.
The key to making any new guidelines work is caregiver involvement, says Judy Dutcher, chairwoman of the clinical practice committee for the Wound, Ostomy & Continence Nurses Society. She's skeptical about the new surveyor guidance.
"It's kind of like asking me what I thought of OBRA (the Omnibus Budget Reconciliation Act of 1987): I thought OBRA was great – theoretically," Dutcher said. "There can be a big bridge between what you put on paper and what is operationalized.
"I don't think we have moved forward much in terms of incontinence care in long-term care. The culture within long-term care is unique. Many front-line caregivers see incontinence care as an activity in futility."
Yet "up to 40%" of incontinent nursing home residents respond "very well" during the daytime to a toileting program, say nationally prominent researchers Drs. Joseph Ouslander and Theodore M. Johnson II, writing recently in the Journal of the American Medical Directors Association.
Thus, Dutcher notes, the need for caregiver "buy-in" has never been greater.
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