Attached are the links to two new LTC Survey and Certification Letters issued by the Centers for Medicare and Medicaid Services (CMS), effective September 29, 2006:

I. Some Basic Principles of Using Photography During the Survey

CMS provides basic principles that State Survey Agencies (SAs) electing to incorporate photographic evidence into their survey process may use.

CMS clarifies that use of photography during the survey process is not required; that these principles are a tool to be used at a State's discretion to support a finding of noncompliance.

Photographs may enhance findings of noncompliance by providing visual evidence (e.g., abuse, such as contusions, bruises; improper use of restraints or positioning; pressure ulcers, safety hazards), but maybe referenced only in surveyor notes, and are not to be included as part of the Statement of Deficiencies (CMS Form 2567)

The SA is responsible for the acquisition, accountability, and security of the camera and film; the camera and film must be the sole property of the State; surveyors should not use their own equipment, including camera [cell] phones.

CMS states, “Surveyors may use photography as a tool, supplementing written documentation, to assure accurate and effective records of observations made during surveys with the intent to produce photographs that are relevant to possible deficiencies. However, without written documentation, photographs cannot stand alone and have little benefit.”

The basic principles for taking photographs during a survey include:

+ Requesting written permission form the resident or his/her surrogate prior to taking the photograph

+ Obtaining a complete series of photographs, i.e., each relevant object in the scene should appear in at least three photographs: an overview, a mid-range photograph, and a close-up.

+ Documentation of Photographs

- Only non-personal identifiers should be used;

- Photographs must enhance, not replace written documentation.

- Original photographs may not be modified.

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-33.pdf

II. Nursing Homes--Exceptions to the Observation Requirement When Determining Significant Medication Errors

Current interpretive guidance in the State Operations Manual at F333 (483.25(m)(2)-Quality of Care; Medication Errors) directs surveyors to observe a medication preparation or administration before citing significant medication errors.
CMS notes that surveyors have not cited F333 for medication errors, even if the errors were significant, unless they occurred during an observed medication pass.
This Letter clarifies that, while observation is the preferred measure, it is possible to cite medication errors based on a collection of other supporting corroborating evidence.
It is acceptable for surveyors to cite a significant medication error at F333 in the absence of a medication pass observation under certain circumstances, i.e., based upon either resident review, and/or observation of medication preparation or administration.
The Letter includes three examples of situations of identification of a significant medication error when observation of a medication pass would not be necessary.
Surveyors are instructed that significant and non-significant medication errors observed at 5% or greater should continue to be cited at F332 (483.25 (m)(1)). However, any significant medication error included in the F332 citation should also be cited at F333.

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-30.pdf