An advance copy of the revised guidance for Accidents and Supervision [483.25(h)(1) and (2) - F323] has been posted by CMS, with implementation August 6, 2007. 

(http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=4&sortOrder=descending&itemID=CMS1201011&intNumPerPage=10).  Please make sure this whole http address gets copied/pasted into your web browser if the link doesn’t work for you; if you’re unable to access the zipfile, let me know! The analysis below is from AAHSA:

• Current F-tags 323 and 324 have been combined into one tag:  F323. 
• Consistent with previously released revised guidance, the Advance Copy is posted by CMS as a zipped file with 4 components:  (1) the Survey and Cert Letter announcing the issuance; (2) the Transmittal containing the Guidance to be incorporated into Appendix PP of the State Operations Manual (SOM); (3) Instructor Training Guide; and (4) PowerPoint presentation.
• The Advance Copy of the Guidance to Surveyors for 483.25(h)(1) includes:

        + Statement of INTENT:  "…to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents…"

        + DEFINITIONS - Including "accident- an unexpected or unintentional incident that may result in resident injury or illness, excluding incidents resulting from treatment or care consistent with current standards of practice; "avoidable
accident" - an occurrence as referenced above due to facility failure to identify, evaluate, implement and/or monitor the         effectiveness of interventions related to environmental hazards; and "unavoidable accident" - an occurrence despite facility    efforts to identify, evaluate, implement and monitor interventions related to environmental hazards. 
                - definitions for "assistive device," "environment and resident environment," fall" (*the definition is the same as used in the RAI/MDS process, i.e., that “…an intercepted fall is a fall,” and was strongly objected to by AAHSA as an           inherent contradiction to the application of this tag, i.e., accidents/supervision.  In the context of this tag, the                definition should address the facility's ability to mitigate risk, i.e., prevent occurrences to the degree possible);                "hazards," "risk," and "supervision/adequate supervision."

        + OVERVIEW - Including a reiteration of the facility's regulatory obligations, and addressing a "commitment to safety", with sections:
                - A SYSTEMS APPROACH to resident safety, addressing  identification of hazards and risks, evaluation and analysis, implementation of Monitoring and Modification of interventions;
                - SUPERVISION - as "...an intervention and a means of mitigating accident risk"; adequacy "...is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident's environment."  There are carve-outs under this section on resident smoking and resident-to-resident altercations.
                - RESIDENT RISKS AND ENVIRONMENTAL HAZARDS, that discusses "common…hazards found in the resident environment", including that there must be accessibility by a "vulnerable" resident.  Subsections include Resident  Vulnerabilities, e.g., falls, unsafe wandering/elopement; Physical Plant Hazards, e.g., chemicals and toxins, Water Temperature, Electrical Safety, and Assistive Devices/Equipment Hazards
           
        + INVESTIGATIVE PROTOCOL - for use with sampled residents at risk for or who have a history of accidents, falls or unsafe wandering/elopement and/or who create a risk for others; and for identified hazards/risks. 
                - Procedures: Observation of the general and resident environment, Resident/family/Staff Interviews, Record  Review (Assessment/Plan of Care), and Review of Facility Practices; DETERMINATION OF COMPLIANCE: Criteria for Compliance / Noncompliance, Potential Tags for Additional Investigation; and V. DEFICIENCY CATEGORIZATION, i.e., severity levels with examples.  (*The initial proposal had all "unsafe wandering/elopement" at IJ, but CMS ultimately agreed that facilities may have back-up practices/measures in place that limit exposure to hazards/harm.)  

• The Instructor's Training Guide for 483.25 (h) (1) and (2);
• The Guidance Training / Power Point Presentation for 483 (h) (1) and (2). 

The next guidance to be released will reportedly be the one for feeding assistants, with a probable implementation date of 9/28/07.