Psychosocial Outcomes
Severity Guide
Guidance Training
By
Rebecca L. Hall, M.Ed.,
Long Term Care Educator
1
Psychosocial? Article: “Social Work
Services in Nursing Homes: Toward
Quality Psychosocial Care”

The term psychosocial describes a
constellation of:



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Social
Mental health and
Emotional needs and the care given to meet them
Quality of life focuses on the residents’
perspective on their total living experience in
the home, not just medical care
2
Article Continued:


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A lack of professionally qualified social
workers in nursing homes is one of several
factors that potentially contribute to
inadequate and inconsistent mental health
and psychosocial care in nursing homes
High rates of mental health disorders include
45 to 51 percent with dementia
35 percent with personality disorders
17 percent with behavior disorders
3
Are psychosocial needs
adequately met?


39 percent of residents with psychosocial
needs had care plans that were inadequate to
meet those needs
41 percent of those with psychosocial needs
addressed in their care plans did not receive
all of their planned psychosocial services and
5 percent received none of the services
4
Psychosocial


Psychosocial concerns include mental health
disorders such as depression, anxiety,
dementia, and delirium
Also includes:

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Loss of relationships
Loss of personal control
Loss of identity
Adjustment to the facility
5
What are some keys to promoting
improvement in quality of life
domains?

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Build on person directed values
Implement environmental interventions
Use knowledge of group processes to build
resident, staff, and family involvement
Address end-of-life issues
Address discharge planning needs with a
resident-centered perspective
Be involved in quality improvement efforts
6
Process Indicators


Is the psychosocial assessment timely?
Is the psychosocial assessment comprehensive?

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Are residents involved in care planning?

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Resident’s psychological and social circumstances are
assessed adequately?
Decision making
Are families involved in care planning?


Cultural factors
Lifestyle
7
Outcome Indicators



Resident satisfaction with choice
Are residents satisfied with the degree of
choice available in everyday matters in the
home?
Are problems resolved? Are resident’s
psychosocial problems relieved?
8
Other Psychosocial Issues and
Relevant Domains:

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Comfort and security
Enjoyment
Relationships
Meaningful activity
Functional competence
Individuality
Privacy
Autonomy
Dignity
Choices
Spiritual well-being
9
Appendix P – Survey Procedures
for Long Term Care Facilities

Psychosocial injury or deterioration is
referenced in Section E. Evidence Evaluation

1. Potential or Actual Physical, Mental or
Psychosocial Injury or Deterioration to a Resident
Including Violation of Residents’ Rights


Review examples
2. Lack of (or the Potential for Lack of) Reaching
the Highest Practicable Level of Physical, Mental or
Psychosocial Well-Being

Review examples
10
Possible F Tags Related to Psychosocial Care and Social
Service Provisions – “Blueprint for Measuring Social Work’s
Contribution to Psychosocial Care”

F 243

F 246


F 248
F 250
Residents have the right to organize
and participate in resident groups
Nursing home policies accommodate
residents’ needs and preferences
Meaningful activities for all residents
Nursing home provides medicallyrelated social services
11
F Tags (continued)

F 251

F 319

F 320
Nursing home with more than 120
beds employs a qualifies social
worker on a full-time basis
Nursing home provides resident
with appropriate treatment for
mental or psychosocial problems
Nursing home ensures that
residents do not have avoidable
decline in their psychosocial
functioning
12
Psychosocial Needs and
Problems

In the long term care facility, who is:



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Identifying residents’ psychosocial needs and
problems?
Assessing psychosocial needs and problems?
Developing interventions based on identified
psychosocial needs and problems?
Implementing interventions?
Monitoring psychosocial care for residents?
How are interventions documented?
13
Psychosocial Outcome Guide
Components
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Purpose
Overview
Instructions
Clarification of Terms
Psychosocial Outcome Severity Guide
Resources and Additional Information
14
Psychosocial Outcome Guide
Purpose

The Guide is to help surveyors determine severity of
psychosocial outcomes resulting from identified
noncompliance at an F Tag.


A deficiency has to be identified
Negative psychosocial outcomes may result from a
facility’s noncompliance with any regulatory
requirement in any regulatory grouping.


Quality of Care
Quality of Life
15
Psychosocial Outcome Guide
Purpose


The Guide is used in conjunction with
current scope and severity grid
Used to determine the severity of
outcome to each resident involved in a
deficiency that has resulted in a
psychosocial outcome
16
Psychosocial Outcome Guide
Overview

A resident may experience a negative
physical outcome, psychosocial
outcome or both resulting from the
facility’s deficient practice.

This severity guide will only be used for
psychosocial outcomes resulting from the
facility’s non-compliance.
17
Overview


Psychosocial outcomes (i.e., mood and
behavior) may result from a facility’s
noncompliance with any regulatory
requirement
The presence of a given affect (i.e.,
behavioral manifestation of mood
demonstrated by the resident) does not
necessarily indicate a psychosocial outcome
that is a direct result of noncompliance
18
Overview

What could cause a resident’s
reactions and responses (or lack
there of) that may not be
contributed to a facility’s
noncompliance with a regulatory
requirement?
19
Response to Question



Pre-existing psychosocial issues
Illnesses
Medication side effects
20
Psychosocial Outcome Severity
Guide Overview

Psychosocial and physical outcomes must
both be considered in determining severity.
 This Guide does not replace the current
scope and severity grid; however,
complements it
 The surveyor will address both physical
and psychosocial outcomes
 The surveyor will determine which
outcome is of greater impact on the
resident
21
Psychosocial Outcome Guide
Instructions

If noncompliance has resulted in negative
outcomes for more than one resident, the survey
team will evaluate the severity for each resident.


Each resident’s psychosocial response to the noncompliance is the basis for determining psychosocial
severity of a deficiency.
This is not new. The team bases severity on the
highest level selected for any of the residents.
22
Psychosocial Outcome Guide
Instructions (cont.)

To determine severity, the team will use information
gathered during the survey investigative process

Information Gathering Tools

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
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Observations
Interviews
Record Reviews
The team will compare the resident’s behavior (e.g.,
their routine, activity, and responses to staff or to
everyday situations) and mood before and after the
noncompliance.
23
Psychosocial Outcome Guide
Instructions (cont.)
The Guide may apply to four situations
involving psychosocial outcomes resulting
from a deficient practice:




When a resident verbally or non-verbally
communicates outcome
When a resident exhibits a response
When a resident has no discernable response
When a resident’s response is incongruent with a
response a reasonable person would have
24
Psychosocial Outcome Guide
Instructions (cont.)
The Guide can be used for:
 Residents who verbally or non-verbally
communicate outcome



What is the resident’s reaction or outcome to
the practice?
For example, a resident may report boredom,
fear, anger, etc., in response to the deficient
practice
This may be communicated verbally, in writing,
or using a communication board
25
Psychosocial Outcome Severity
Guide Instructions (cont.)



Residents who exhibits a response
This resident is unable to communicate
outcome
The surveyor will be monitoring the resident’s
non-verbal responses

For example, the surveyor observes a staff
member yelling at a resident and the resident
responds by cowering, crying, etc.
26
Psychosocial Outcome Guide
Instructions (cont.)
The Guide can be used in
conjunction with the Reasonable
Person Concept


How would a “reasonable person” react if
he/she were in the resident’s situation?
What degree of actual or potential harm
would one expect a reasonable person in
a similar situation to suffer as a result of
the noncompliance?
27
Psychosocial Outcome Severity
Guide Instructions (cont.)
The team will use this concept in
two situations:
First Situation:
The resident’s psychosocial outcome
may not be readily determined or
there is no discernable response
to the deficient practice
28
Psychosocial Outcome Severity
Guide Instructions (cont.)


Second Situation:
The resident’s reactions are
markedly incongruent with
the deficient practice (i.e.,
the resident “does not
mind” the deficient
practice.)
29
Psychosocial Outcome Severity
Guide Instructions (cont.)

Why would this happen?

When a resident has become
institutionalized to expect this
treatment by repetition of the
deficient practice over time.
30
Psychosocial Outcome Guide
Clarification of Terms
Possible Psychosocial Outcomes

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Anger
Apathy
Anxiety
Dehumanization
Depressed mood
Humiliation
31
Terms


The expert panel that helped develop this
new guidance provided definitions for these
terms from the psychological research
literature.
These words are key terms in the
determination of the level of psychosocial
outcome.
32
Clarification of Terms

Anger

Refers to an emotion caused by the
frustrated attempts to attain a goal, or in
response to hostile or disturbing actions
such as insults, injuries, or threats that do
not come from a feared source
33
Terms

Apathy

Refers to a marked indifference to the
environment; lack of a response to a
situation; lack of interest in a concern for
things that others find moving or exciting;
absence or suppression of passion,
emotion, or excitement
34
Terms

Anxiety

Refers to the apprehensive
anticipation of future danger or
misfortune accompanied by a feeling
of distress, sadness, or somatic
symptoms of tension (restlessness,
irritability)
35
Terms

What is dehumanization?
Refers to the deprivation of human
qualities or attributes such as
individuality, compassion, or civility
 Is the outcome resulting from having
been treated as an inanimate object
or as having no emotions, feelings, or
sensations

36
Terms

Depressed mood

Indicated by negative statements;
self-deprecation; sad facial
expressions; crying and tearfulness;
withdrawal from activities of interest
and/or reduced social interactions
37
Terms

Humiliation


Refers to a feeling of shame due to being
embarrassed, disgraced, or depreciated
Some individuals lose so much self-esteem
through humiliation that they become
depressed
38
Psychosocial Severity Guidance

The guide is only to be used
once the survey team has
determined noncompliance at a
regulatory requirement.
39
Psychosocial Outcome Severity
Guide


Remember that psychosocial outcomes of
interest to surveyors are those caused by the
facility’s noncompliance with any regulation
This also includes psychosocial outcomes
resulting from facility failure to assess and
develop an adequate care plan to address a
resident’s pre-existing psychosocial issues
which brought about continuation or
worsening of the condition
40
Failures

Failure to:
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Assess
Develop an adequate and workable care plan
Address psychosocial issues
Address pre-existing psychosocial issues

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As a result, the condition worsens
Implement care planning interventions
Assess progress or lack of progress
Change interventions and/or approaches
Communicate care planning approaches to direct care staff
41
Psychosocial Severity Guidance
Severity Determination
The key elements for severity
determination are:



Presence of harm or potential for negative
outcomes
Degree of harm or potential harm related
to noncompliance
Immediacy of correction required
42
Severity and Scope Grid
.
Immediate jeopardy
to resident health &
safety
Level 4
J
K
L
Actual harm that is
not immediate
jeopardy
Level 3
G
H
I
No actual harm, with
potential for more
than minimal harm
Level 2
D
E
F
No actual harm, with
potential for minimal
harm
Level 1
A
B
C
Isolated Pattern
43
Widespread
Deficiency Categorization
Severity Determination Levels

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Level 4: Immediate Jeopardy to resident
health or safety
Level 3: Actual harm that is not immediate
jeopardy
Level 2: No actual harm with potential for
more than minimal harm that is not immediate
jeopardy
Level 1: No actual harm with potential for
minimal harm
44
Deficiency Categorization
Severity Level 4: Immediate Jeopardy
Examples Of Outcomes To A Deficient
Practice:


Suicide attempt, suicidal thoughts,
preoccupation, planning (e.g., refusing to
eat or drink in order to kill oneself)
Engaging in self-injurious behavior that is
likely to cause serious injury, harm,
impairment, or death to the resident
45
Deficiency Categorization
Severity Level 4: Immediate Jeopardy

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Sustained & intense crying, moaning screaming
Expression of severe, unrelenting, excruciating
pain

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Pain that has become all-consuming and overwhelms the
resident
Recurrent debilitating fear/anxiety that may be
manifested as panic, immobilization, screaming,
and/or extremely aggressive or agitated behavior
46
Deficiency Categorization
Severity Level 4: Immediate Jeopardy


Ongoing, persistent expression of
dehumanization or humiliation in response
to an identifiable situation that persists
regardless of whether the precipitating
event(s) has ceased and has resulted in a
potentially life-threatening consequence
Expressions of anger at an intense and
sustained level that has caused or is likely
to cause serious injury, harm, impairment,
or death
47
Deficiency Categorization
Severity Level 3: Actual Harm
Examples Of Outcomes To A Deficient
Practice:


Significant decline in former social patterns
that does not rise to the level of immediate
jeopardy
Depressed mood that may be manifested
as:


Social withdrawal: hopelessness, tearfulness
Loss of interest or ability to feel pleasure
48
Deficiency Categorization
Severity Level 3: Actual Harm

Psychomotor agitation accompanied by sadness
Inability to sit still
 Pacing
 Hand wringing
 Pulling or rubbing of the skin, clothing
 Sad expression
Expressions of feelings of worthlessness
Recurrent thoughts of death or statements such
as, “I wish I were dead” or “my family would be
better off without me”.



49
Deficiency Categorization
Severity Level 3: Actual Harm

Verbal agitation


Repeated requests for help, groaning
accompanied by sad facial expressions
Markedly diminished ability to
think or concentrate
50
Deficiency Categorization
Severity Level 3: Actual Harm
Examples Of Outcomes To A Deficient Practice (cont.):
 Expressions of persistent pain or physical distress
that has compromised the resident’s functioning.
 Chronic or recurrent anxiety; sleeplessness due to
fear.
Expression of fear not to level of immobilization as in
level 4.


Ongoing expression of humiliation that persists after
precipitating event has ceased.
Aggression that could lead to injuring self or others.
51
Severity Level 3: Actual Harm


These outcomes show that there has been
compromise in the resident’s psychosocial
functioning due to the deficient practice
Severity Level 3 indicates noncompliance that
results in actual harm, and can include but
may not be limited to clinical compromise,
decline, or the resident’s inability to maintain
and/or reach his/her highest practicable wellbeing.
52
Deficiency Categorization
Severity Level 2: Potential for Harm
Examples Of Outcomes To A Deficient Practice:



Intermittent sadness, as reflected in facial
expression, tearfulness.
Feelings or complaints of discomfort or moderate
pain; irritability.
Fear or anxiety manifested as signs of minimal
discomfort that has the potential to compromise
well-being.
53
Severity Level 2


This level indicates noncompliance that
results in a resident outcome of no more than
minimal discomfort and/or has the potential
to compromise the resident’s ability to
maintain or reach his or her practical level of
well being
The potential exists for greater harm to occur
if interventions are not provided
54
Deficiency Categorization
Severity Level 2: Potential for Harm (cont.)
Examples Of Outcomes To A Deficient Practice (cont.):



Feeling of shame or embarrassment without
loss of interest in the environment and self.
Complaints of boredom accompanied by
expressions of periodic distress, that do not
result in maladaptive behaviors (e.g. verbal or
physical aggression).
Verbal or nonverbal expressions of anger that
do not lead to harm.
55
Severity Level 2


These are a lesser level of outcome
than the bullets that describe Level 3
At Level 2, the resident shows a
reaction of discomfort that has not
compromised functioning
56
Deficiency Categorization
Severity Level 1: Potential for Minimal Harm


Severity Level 1 is not an option because
any facility practice that results in a
reduction of psychosocial well-being
diminishes the resident’s quality of life.
The deficiency is, therefore, at least a
Severity Level 2 because it has the potential
for more than minimal harm.
57
Level 1


The Quality of Life tags and Quality of Care
tags in general concern issues of key
relevance to residents and will be cited at
Level 2 or above
Level 1 is intended for deficiencies such as
the requirement at F 167 which mandates
that the results of the survey must be made
available for review
58
Task 6 – Information Analysis
for Deficiency Determination

Section E. Evidence Evaluation

The survey team must evaluate the
evidence documented during the survey to
determine if a deficiency exists due to a
failure to meet a requirement and if there
are any negative resident outcomes due to
the failure.
59
Evidence Evaluation

Failure to meet requirements related to
quality of care, resident rights, and
quality of life generally fall into two
categories:

(1) Potential or Actual Physical, Mental or
Psychosocial Injury or Deterioration to a
Resident, including Violation of Residents’
Rights
60
Examples – Category 1



Development of, or worsening of, a pressure
sore
Loss of dignity due to lying in a urinesaturated bed for a prolonged period; and
Social isolation caused by staff failure to
assist the resident in participating in
scheduled activities
61
(2) Category


Lack of (or the Potential for Lack of)
Reaching the Highest Practicable Level
of Physical, Mental or Psychosocial WellBeing
No deterioration occurred, but the
facility failed to provide necessary care
for resident improvement.
62
Examples - Category 2

The facility identified the resident’s desire to
reach a higher level of ability, e.g.,
improvement in ambulation, and care was
planned accordingly. However, the facility
failed to implement, or failed to consistently
implement the plan of care, and the resident
failed to improve, i.e., did not reach his/her
highest practicable well-being
63
Examples - Category 2

The facility identified a need in the comprehensive
assessment, e.g., the resident was
withdrawn/depressed, but the facility did not develop
a care plan or prioritize this need of the resident,
planning to address it at a later time. The resident
received no care or treatment to address the need
and did not improve, i.e., remained
withdrawn/depressed. Therefore, the resident was
not given the opportunity to reach his/her highest
practicable well-being.
64
Examples - Category 2

The facility failed to identify the resident’s
need/problem/ability to improve, e.g., the
ability to eat independently if given assistive
devices, and, therefore, did not plan care
appropriately. As a result, the resident failed
to reach his/her highest practicable wellbeing, i.e., eat independently.
65
Scenario

During a resident interview on 7/16/06 at 2:15 pm in
the room 212 B, the resident stated that she was
slapped by a staff member on the night shift on
7/10/06. She stated that it was not a hard slap. She
thinks that the CNA was frustrated and tired due to
working a double shift. She complained about there
not being enough staff to toilet the residents. The
resident further stated that due to the side rails being
up, she was unable to get to the bathroom in time
and soiled herself. She had pressed her call bell
repeatedly, but no one came to help.
66
Scenario continued:

The resident further stated that she felt
humiliated. The CNA stated to the resident,
“what’s wrong with you; just use your diaper
like the other residents and keep your mouth
shut.” The resident stated that she is fearful
of leaving her room. Observations of this
resident: even though the resident enjoys
singing, the resident did not attend the
planned activity of singing. During the noon
meal observation, the resident ate 25% and
has lost 3 pounds since the incident.
67
Scenario continued:

During the second interview with the
resident, she tearfully stated, “I wish I were
dead”. “I want to go home; this is not my
home”. The surveyor asked the resident if she
had reported the incident and her feelings.
The resident stated that she had reported the
incident to the DON.
68
Concerns


What concerns do you have regarding what
you have learned from the interviews and
observations?
List your concerns.
69
Concerns


Do you think there is something wrong?
If so, what regulatory requirements do you
think best fits this situation?
70
Identification of the Regulatory
Requirement


What are the specific elements of the
regulatory requirements?
Write them down.
71
What’s Next?

How do you think the surveyors
would proceed in investigating this
scenario?
72
Do you have a deficient
practice?

Resident experienced minor physical outcome
from the slap


However, suffered a greater, more severe
psychosocial outcome
In this case, the severity level on the
psychosocial outcome would be used as the
level of severity for the deficiency.
73
Psychosocial Outcome Severity
Guide: Scenarios and Examples



For each example developed by CMS,
determine the level of severity you would
select.
Why would you choose this level?
Please note that for each example, limited
information is provided
74
Example 1



A comatose resident was raped by a
staff member
This would be Level 4
Rationale: Resident’s lack of discernable
response makes it necessary for the
team to decide based on the reasonable
person concept
75
Example 2


Staff do not toilet residents at night.
They tell residents to wet the bed and
they will clean them up and the bed in
the morning.
Resident interview: “It’s just how things
have to be” and he is “used to it.”
76
Example 2



With limited information, Level 2
Rationale: Reasonable person concept would
be used since the reaction is incongruent with
the deficient practice and shows that the
resident is institutionalized to expect
substandard treatment
Level 3 would not be selected because actual
harm has not been proven
77
Example 3

The team is citing a deficiency for activities.
There are few activities and most residents
are not included. One resident who is part of
the deficiency is a cognitively impaired
resident who does not verbalize. This resident
was observed during all days of the survey
sitting in the hall or in her room with nothing
to do.
78
Example 3



Level 2
Rationale: Level 2 is selected because
there is potential not yet realized for
compromise
Level 3 would not be selected since
actual harm or compromise has not
been proven
79
Example 4

A deficiency is being cited in
incontinence. One resident included
in this deficiency reports to the
surveyor that she is so upset that
she has become incontinent that
she cries every day and refuses to
leave her room.
80
Example 4


Level 3
Rationale: In this case, there is both physical
and psychosocial outcome from a deficiency
in Quality of Care. The physical outcome is
that the resident has declined in functioning,
which is Level 3, actual harm. The
psychosocial outcome matches this, as the
resident has become compromised in
psychosocial functioning.
81
Example 5

A resident with severe depression when
admitted, which was confirmed by
appropriate medical and psychiatric
evaluation, has not received any
nonpharmacologic or medication
interventions, despite appropriate indications
and lack of contraindications for treatment.
Resident continues to be severely depressed.
82
Example 5


Level 3
Rationale: This is a case in which the facility
failed to help the resident with a serious
medical condition with significant
psychosocial implications. This should be
cited at Level 3, actual harm, as the
continuance of her severe depression is harm
to the level of compromise.
83
Practical Example




Surveyor observes a resident is crying. The
resident is grieving the loss of her husband.
The surveyor observed a psychosocial
outcome.
Would this result in a deficiency?
Before the Psychosocial Outcome Severity
guide is used, there must first be a deficient
practice which results in a deficiency being
cited
84
Example (continued)




The survey team would utilize investigative skills of
observation, interview and record review to
determine if a deficient practice exists
The survey team would assess if the facility had
provided grief counseling and psychosocial support
for the resident
The survey team would observe staff interactions
with the resident
The survey team would interview the resident or
resident’s family and staff
85
Example (continued)


If the facility had identified, assessed,
developed interventions, implemented
interventions, and re-assessed for positive
results, no deficiency would be cited
If the facility failed to meet the psychosocial
needs of the resident, a deficient practice
would be identified.


Appropriate F tag selected
Psychosocial Outcome Severity Guide utilized
86
The End
Rebecca L. Hall
rhall4@elmore.rr.com
(334) 462-2672
(334) 567-0800
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