CMS Checklist Review of Care and Services for Dementia Patients Part I
Jeannine LeCompte, Compliance Research Specialist
Inspectors from the Centers for Medicare and Medicaid (CMS) use a checklist when touring a facility caring for residents diagnosed with dementia. To generate an effective care program, it is helpful to know what they are looking for.
First is an assessment and underlying cause identification. The inspector will ask the following questions:
– Did staff describe behavior (onset, duration, intensity, possible precipitating events or environmental triggers, etc.) and related factors (appearance, alertness, etc.) in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible?
– If the behaviors represent a sudden change or worsening from baseline, did staff contact the attending physician/practitioner immediately for a medical evaluation, as appropriate?
– If medical causes are ruled out, did staff attempt to establish other root causes of the behavior using individualized knowledge about the person and when possible, information from the resident, family, previous caregivers, and/or direct care staff?
In addition, the inspector will determine if, as part of the comprehensive assessment, the facility staff evaluated the resident’s usual and current cognitive patterns, mood, and behavior, and whether these present a risk to the resident or others.
The inspector will also evaluate how the resident typically communicates a need such as pain, discomfort, hunger, thirst, or frustration, and study prior life patterns and preferences and customary responses to triggers such as stress, anxiety, or fatigue, as provided by family, caregivers, and others who are familiar with the resident before or after admission.
The inspector will ask if staff, in collaboration with the practitioner, identify risk and causal/contributing factors for behaviors, such as:
- Presence of co-existing medical or psychiatric conditions, or decline in cognitive function
- Adverse consequences related to the resident’s current medications
The inspector will cite the facility if it did not comprehensively assess the physical, mental, and psychosocial needs of the resident prior to admission.
An inspector will also establish if the resident and/or family/representative was involved (to the extent possible) in discussions about the potential use of any interventions, and whether this was documented in the medical record.
With regard to the care plan, the inspector will look to see if the plan reflects an individualized team approach with measurable goals, timetables, and specific interventions for the management of behavioral and psychological symptoms. Specifically, the inquiry will ask if the care plan includes the following elements:
- Involvement of the resident/representative to the extent possible
- A description of and how to prevent targeted behaviors
- Why behaviors should be prevented or otherwise addressed (e.g., severely distressing to resident)
- Monitoring of the effectiveness of any/all interventions
- If the resident or family/representative refused a recommended treatment or approach, was counseled on consequences, and alternative approaches to address behavioral symptoms were provided
- If the facility had developed a plan of care with measurable goals and interventions to address the care and treatment for a resident with dementia related to the behavioral and/or mental/psychosocial symptoms, in accordance with the assessment, resident’s wishes, and current standards of practice
Failure to adhere to any of these demands can result in a citation.
Source: National Partnership to Improve Dementia Care in Nursing Homes, Checklist Review of Care and Services for a Resident with Dementia (for use with the Interpretive Guidance at F309), Centers for Medicare & Medicaid Services
