In this second part regarding how Nursing Home and Hospital Surveyors look at pain management in the nursing home we are going to look at some of the definitions they use for common concepts. If you remember, the State Operations Manual (SOM) provides much guidance to Nursing Home and Hospital surveyors on how to investigate and survey facilities. In regards to pain managment, the guidance provides the following definitions at F309 in Appendix PP:

“Addiction” – a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by an overwhelming craving for medication or behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Adjuvant Analgesics” refers to any medication with a primary indication other than pain management but with analgesic properties in some painful conditions.

“Adverse Consequence” – an unpleasant symptom or event that is due to or associated with a medication.  Examples would include impairment or decline in a resident’s mental or physical condition or functional or psychosocial status and various types of adverse drug reactions and interactions.

“Adverse drug reaction” (ADR) is a form of adverse consequence that may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. The guidance goes on to explain to nursing home and hospital surveyors that the term “side effect” is often used interchangeably with ADR; however, side effects are actually one of five ADR categories. The other categories of ADRs are hypersensitivity, idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence.

Complementary and Alternative Medicine” (CAM) –  a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.

Non-pharmacological interventions” are approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical or psychosocial well-being.

“Pain” – an unpleasant sensory and emotional experience that can be acute, recurrent or persistent. The guidance then breaks this down further and provides the following descriptions of several different types of pain:

“Acute Pain” – generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness;

“Breakthrough Pain” – an episodic increase in (flare-up) pain in someone whose pain is generally being managed by his/her current medication regimen;

“Incident Pain” – typically predictable pain that is related to a precipitating event such as movement or certain actions; and

“Persistent Pain” or “Chronic Pain” – a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years.

“Physical Dependence” is a physiologic state of neuro-adaptation that is characterized by a withdrawal syndrome if a medication or drug is stopped or decreased abruptly, or if an antagonist is administered.

“Standards of Practice” refers to approaches to care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies.

“Tolerance” is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect or a reduced effect is observed with a constant dose.

So with those definitions Nursing Home and Hospital Surveyors are more prepared to evaluate the pain management program in a Long Term Care Facility. The knowledge they gain from these guidelines also serve them well as they look at pain management in other facility types. It is, though, more common to find inadequate pain management in a long term facility. We will continue with the discussion of pain management the n ext time. Meanwhile, keep yourself informed as to what is required of facilities, whether nursing home, clinic, hospital, hospice, dialysis or whatever. You are then more empowered to watch for, comment on, and report problems you see.

Remember, Be your own advocate!


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Admin Note: After some further discussion with MSH, I also provided her with the following information. MSH stated under duress she had to sign admission papers saying they would only use particular physicians. I provided this information in hopes that it would be of help to her, and to you if you find yourself in similar circumstances.

I shared certain portions of the federal regulations and the guidance to surveyors with MSH that applied to her situation. The regulation itself is in black, the information in purple is not the regulation, but is guidance CMS uses to interpret the regulation, and my statements are in blue

The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights


All residents in long term care facilities have rights guaranteed to them under Federal and State law. Requirements concerning resident rights are specified in §§483.10, 483.12, 483.13, and 483.15. Section 483.10 is intended to lay the foundation for the remaining resident’s rights requirements which cover more specific areas.

These rights include the resident’s right to:
Exercise his or her rights (§483.10(a));
Be informed about what rights and responsibilities he or she has (§483.10(b));
If he or she wishes, have the facility manage his personal funds (§483.10(c));
Choose a physician and treatment and participate in decisions and care planning (§483.10(d));  


§483.10(d)(1) Free Choice – The resident has the right to choose a personal attending physician

The right to choose a personal physician does not mean that the physician must or will serve the resident, or that a resident must designate a personal physician. If a physician of the resident’s choosing fails to fulfill a given requirement, such as §483.25(l)(1), Unnecessary drugs; §483.25(l)(2), Antipsychotic drugs; or §483.40, frequency of physician visits, the facility will have the right, after informing the resident, to seek alternate physician participation to assure provision of appropriate and adequate care and treatment. A facility may not place barriers in the way of residents choosing their own physicians. For example, if a resident does not have a physician, or if the resident’s physician becomes unable or unwilling to continue providing care to the resident, the facility must assist the resident in exercising his or her choice in finding another physician.

Before consulting an alternate physician, one mechanism to alleviate a possible problem could involve the facility’s utilization of a peer review process for cases which cannot be satisfactorily resolved by discussion between the medical director and the attending physician. Only after a failed attempt to work with the attending physician or mediate differences in delivery of care should the facility request an alternate physician when requested to do so by the resident or when the physician will not adhere to the regulations.

If it is a condition for admission to a continuing care retirement center (CCR), the requirement for free choice is met if a resident is allowed to choose a personal physician from among those who have practice privileges at the retirement center. (If the facility your loved one is at is not a CCR then this paragraph does not apply – and he/she should not be required to choose from a certain set of physicians)

A resident in a distinct part of a general acute care hospital can choose his/her own physician, unless the hospital requires that physicians with residents in the distinct part have hospital admitting privileges. If this is so, the resident can choose his/her own physician, but cannot have a physician who does not have hospital admitting privileges.

If you feel what they are doing is in violation of this information (they are not allowing the choice of physician), then I suggest you call in a complaint to the department of health for your state, the division that oversees the licensing and certification of nursing homes.

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In the previous post we started talking about the Quality Improvement Programs in nursing homes and hospitals. We will continue it here with a discussion of the program hospitals should have in place.

Hospitals also have regulations that nursing home and hospital surveyors look at to see if the hospital is in compliance. They are a bit different than the nursing home regulations. The hospital regulations are located at CFR 482.21 and state:

The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.
§482.21(a)(1) – The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors.
§482.21(a)(2) – The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.
§482.21(b) The hospital must ensure that the program data requirements are met.
§482.21(b)(1) – The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital’s Quality Improvement Organization.
§482.21(b)(2) – The hospital must use the data collected to–
(i) Monitor the effectiveness and safety of services and quality of care; and
§482.21(b)(2)(ii) – Identify opportunities for improvement and changes that will lead to improvement.
§482.21(b)(3) – The frequency and detail of data collection must be specified by the hospital’s governing body.
§482.21(c) The hospital must ensure that the program activities requirements are met.
§482.21(c)(1) – The hospital must set priorities for its performance improvement activities that-
(i) Focus on high-risk, high-volume, or problem-prone areas;
(ii) Consider the incidence, prevalence, and severity of problems in those areas; and
(iii) Affect health outcomes, patient safety, and quality of care.
§482.21(c)(2) – Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.
§482.21(c)(3) – The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained.
As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects.
§482.21(d)(1) – The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations.
§482.21(d)(2) – A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes.
§482.21(d)(3) – The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and measurable progress achieved on these projects.
§482.21(d)(4) – A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort.
§482.21(e) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:
§482.21(e)(1) – That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained.
§482.21(e)(2) – That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.
§482.21(e)(3) – That clear expectations for safety are established.
§482.21(e)(4) – That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients.
§482.21(e)(5) – That the determination of the number of distinct improvement projects is conducted annually.

As you can see, these are much longer than the regulations for a nursing home. They pretty much mean the same thing, though. It is just spelled out a bit more prescriptively; actually, much more prescriptively. The nursing home and hospital surveyor will review the hospital’s quality program for each of these aspects, and again, as in a nursing home, the hospital is to be actively looking for problems and correcting them. There is no frequency in the hospital regulations for how often they meet, but they will need to meet frequently enough to be able to handle everything that is reqiured of them. They will need to gather and analyze data in order to determine where their areas of problems are and how they can improve those areas. The hospital must also be conducting quality improvement programs on a constant basis.

Both nursing homes and hospitals should have a system in place to allow visitors and patients/resident, as well as all staff, to bring issues and problems to the attention of the quality assurance/quality improvement program in the facility.

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Nursing Home and Hospitals are responsible for ensuring their systems are correct and are working. This involves quality improvement activities. Nursing homes and hospitals have federal and state regulations that address quality assessment and assurance.  The nursing home and hospital surveyors will use these regulations and the guidance at the regulations to determine if a nursing home or hospital is indeed in compliance with the regulations.

In nursing homes these regulations are located at CFR 483.75(o), which is F-tag 520.

The nursing home regulation states:
(1) A facility must maintain a quality assessment and assurance committee consisting of –
(i) The director of nursing services;
(ii) A physician designated by the facility; and
(iii) At least 3 other members of the facility’s staff.
(2) The quality assessment and assurance committee –
(i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

What this says, in a nutshell, is that the facility is responsible for finding out what its problem areas are and then is responsible for fixing them.

When a surveyor goes into a nursing home they will be looking to see that the nursing home has a quality assessment and assurance committee that includes the director of nursing, a physician, and at least three other staff. The physician on the committee does not have to be the Medical Director of the facility. The other staff, in a really good facility, will include staff who have the authority to change systems that need changing. This would include the administrator or the assistant administrator. It would also include the medical director, since part of his/her responsibilities includes guiding the facility in developing, implementing, and coordinating resident care & medical care. Other staff who should be involved in a good Quality Assessment and Assurance committee includes “front line” staff who do actual care for the residents. A nurse’s aide or two can provide valuable insight to help the committee determine where its weaknesses are. Therapy representatives, dietary staff, activity personnel, maintenance, housekeeping, and laundry staff would all be a part of an effective quality committee.

The nursing home and hospital surveyor will also look to see that the committee meets at least 4 times a year. In reality a good committee would me more frequently than that, usually once a month, but the requirement is only 4 times a year.

The committee needs to identify the problems in the facility and develop and implement policies and procedures to correct these problems. The committee also needs to monitor the things they implement to ensure they do correct the problem and that they continue to keep the problem corrected.

The committee looks at the entire facility, not just nursing areas, it looks at all levels of the facility staff, meaning the lowest person to the highest manager. It especially looks at all the issues that affect residents, meaning all issues, since all issues affect residents in one way or another. It looks at contracted services as well as services provided in house. The reason a good quality assessment and assurance committee looks at all these areas is to continually evaluate facility systems with in order to keep systems functioning satisfactorily and consistently. The committee is charged with preventing problems with care processes in the facility, and for correcting care processes that are not correct.

The QAA committee should be keeping minutes and documents to show the problems it identifies and the fixes it put into place to correct the problems, as well as documentation on the ongoing monitoring and surveillance that is performed throughout the facility. It is this ongoing monitoring and surveillance that will help the committee determine where the problems are and if the fixes are working. The committee’s minutes should include a thorough analysis of the problem(s) as well as action plans designed to correct the problem.

When a nursing home and hospital surveyor goes into the nursing home, he/she may not review the minutes of the committee, unless the committee chooses to provide them. It is usually suggested even if the facility provides them, that the surveyors not look at them. It is better for the surveyors to fid the problems through good methods of investigation than to rely on what the facility found. Not reviewing the facility minutes will help the survey agency if the facility decides to “fight” the deficiencies. They can’t say that the surveyors found the problems by looking at the facility’s own quality improvement activities.

What the nursing home and hospital surveyor does need to do, though, is look at the process the committee has in place and the types of documents they use to collect data.  When a facility has repeated, systemic problems, the quality regulation at F 520 is also usually in non compliance too. This is basically because a well functioning quality assessment and assurance committee should have found the problem and corrected it before the state survey agency did.

We will discuss Hospitals in the next post.


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