CMS New Guidance to LTC Surveyors Effective June 27: F 315 — Urinary Incontinence and Catheters

    The Centers for Medicare and Medicaid Services (CMS) Survey and Certification Group will release a new long-term care surveyor guidance document for incontinence and catheters on June 27, effective the same day. Mirroring the format of the revised F 314 Guidance Document for Pressure Ulcers (effective November 12, 2004), the new guidance document contains sections that define terminology used in the document; provide an overview of urinary incontinence; provide a list of resources available to long-term care providers to assist in establishing facility-wide best practice to prevent, manage, and treat urinary incontinence, urinary catheterization, and urinary tract infections (UTIs); and discuss appropriate interventions. The new “tag” collapses the current F 315 and F 316 into one.

    The new F 315 addresses two issues: 1) a resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; and 2) a resident who is incontinent of bladder receives appropriate treatment and services to prevent UTIs and to restore as much normal bladder function as possible.

    The document clearly states that “urinary incontinence is not normal” and is “not a normal part of aging”¹ — it is usually a symptom of a condition (or multiple conditions) and may be reversible. Therefore, the onus is on the facility to identify the etiologies, understand if they are reversible, take appropriate actions to reverse them, and address the incontinence to the best extent possible. If the underlying etiologies are not reversible, the facility is required to manage or treat the incontinence in an effort to reduce complications, such as UTIs and perineal skin breakdown.

    Multiple management and treatment interventions include bladder retraining, pelvic floor muscle rehabilitation, intermittent catheterization, prompted voiding, scheduled voiding, medication therapy, devices, absorbent products, toileting devices, and external collection devices. Care providers are expected to be able to distinguish between and determine appropriate interventions for various types of urinary incontinence.

    The intent of the document is to ensure that:
  • Each resident with urinary incontinence is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible
  • An indwelling catheter is not used unless valid medical justification exists
  • An indwelling catheter is discontinued as soon as clinically warranted when it is not medically justified
  • Services are provided to restore or improve normal bladder function to the extent possible after the removal of the catheter
  • A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible.

    The document also contains a section on incontinence-related skin problems and appropriate perineal care to treat and prevent these problems. The document recommends the use of moisture barriers and no-rinse incontinence cleansers instead of a soap and water regimen for perineal cleansing. Moisturizers are recommended to help preserve or restore skin moisture, but overuse of moisturizers, especially on macerated or excessively moist skin, is to be avoided.

    Comprehensive, regular interdisciplinary patient assessments are emphasized as a means of identifying residents at risk of becoming incontinent of urine, the reversible causes of the individual resident’s urinary incontinence, and the signs and symptoms of a UTI in catheterized and non-catheterized residents.

    Surveyors will be determining 1) whether the facility used clinical indications in deciding whether to initially insert or continue the use of an indwelling catheter; 2) the adequacy of interventions to prevent, improve, and/or manage urinary incontinence; and 3) whether appropriate treatment and services were provided to prevent and/or treat UTIs.

    Echoing the format of F 314 (Pressure Ulcers), F 315 emphasizes the importance of having a best practice-based comprehensive plan of care available to all levels of an educated direct care staff and the need to revaluate the effectiveness of the plan of care on an ongoing basis.

    Severity levels of facility non-compliance are similar to those in F 314. The minimum severity level is Level 2. Examples of Level 2 negative outcomes may include medically unjustified use of an indwelling catheter, complications associated with inadequate care and services for an indwelling catheter, and potential for decline or complications. Level 3 non-compliance may include the development of a symptomatic UTI; failure to identify, assess, and manage urinary retention; failure to provide appropriate catheter care; and decline in or failure to improve continence status. Examples of Level 4 non-compliance are complications resulting from utilization of urinary appliances without medical justification and extensive failure in multiple areas of incontinence care and/or catheter management.

    The entire document is available at: https://www.cms.hhs.gov/medicaid/survey-cert?sc0523.pdf.

1. Centers for Medicare and Medicaid Services. Center for Medicaid and State Operations/Survey and Certification Group. Nursing Homes: Delay in Effective Date for Revision of Appendix PP, State Operations Manual (SOM), Surveyor Guidance for Incontinence and Catheters. Ref: S&C-05-23. Available at: www.cms.hhs.gov/medicaid/survey-cert/sc0523.pdf. Accessed May 1, 2005.