F695 Respiratory care, including tracheostomy care and tracheal suctioning, is one of the top 10 areas cited most often in nursing homes. This regulation states that the facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. This week’s blog examines key considerations for compliance with F695.

Changes in the respiratory system that are associated with age may lead to the development of and/or difficulties in treating diseases that affect the respiratory system. These changes may also affect therapies and interventions. The Minimum Data Set (MDS) has identified the most frequent respiratory diseases and syndromes that a resident may have been admitted with or acquired after admission to a nursing home to include pneumonia, asthma, chronic obstructive pulmonary disease (COPD), chronic lung disease, respiratory failure, and shortness of breath (dyspnea) with exertion, or when sitting at rest. In addition, this can include residents who have been admitted with or previously had acute respiratory distress syndrome (ARDS), lung cancer, obstructive sleep apnea, or a history of tuberculosis.

Your facility must determine, based on your facility assessment, the resident population, diagnoses, staffing, resources, and staff skills and knowledge, whether it has the capability and capacity to provide the required respiratory care and/or services for a resident who has a respiratory diagnosis or syndrome. Before admitting a resident who needs respiratory care services,  it is imperative that the facility is staffed with the minimum amount of certified professional staff and employees who have been taught and are knowledgeable in respiratory care. The facility must also assure that resident care policies and procedures for respiratory care and services are developed, according to professional standards of practice, prior to admission of a resident requiring specific types of respiratory care and services.  To cite deficient practice at F695, the examination conducted by the surveyor will generally prove that the facility failed to do one or more of the following:

  • Provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care, and/or suctioning; or
  • Provide necessary respiratory care consistent with professional standards of practice, the resident’s care plan, goals, and preferences.

 How is your facility performing? A broad topic indeed, respiratory care and services do not only pertain to trachs and suctioning. Do you serve residents receiving oxygen, BiPAP, or CPAP therapy? How about aerosol drug delivery and appropriate respiratory assessment?  The Respiratory Care Critical Element (CE) Pathway, along with the interpretive guidance found in SOM Appendix PP, is instrumental when determining whether or not your facility is providing the necessary care and services as ordered to meet residents’ needs. The guidance shall be utilized by surveyors as a broad source of information regarding the professional standards of practice about the delivery of care in accordance with this tag.

You will also need to determine whether or not your facility has conducted an assessment and developed an individualized care plan based on professional standards of practice and provided by qualified, competent staff. This can be identified by reviewing individual comprehensive assessments, comprehensive care plans, and orders. During this review you should determine the degree to which the facility has implemented interventions in accordance with the resident’s needs, goals for care, and professional standards of practice, in a manner that is consistent across all shifts. The observations and interviews that need to be conducted to substantiate any concerns that have been identified will be guided by this information.

The staff should document the assessment and monitoring of the resident’s respiratory condition in accordance with the current professional standards of practice. This should include the resident’s response to any therapy that is provided as well as any changes in the resident’s respiratory condition. Documentation should include, as required, the following components, depending on the type of respiratory services the resident receives, the physician’s orders, and the individualized respiratory care plan:

  • Vital signs, including the respiratory rate;
  • Chest movement and respiratory effort, and the identification of abnormal breath sounds;
  • Signs of dyspnea, cyanosis, coughing, whether position affects breathing, characteristics of sputum, signs of potential infection, or the presence of behavioral changes that may reflect hypoxia including anxiety, apprehension, level of consciousness; and
  • Instructions for the resident on how to participate/assist in the respiratory treatments as appropriate.

Join Proactive on September 9, 2022 – Analysis of top 10 citations in the nation: F695 Respiratory/Trach Care and Suctioning for a deep dive review of Survey Procedures related to this topic, as well as examples of IJ citations and recommended action steps to avoid the same or similar issues. Learn more and register at: Survey Success! Avoiding Top Citations – Proactive Medical Review



Written By: Jessica Cairns, RN, RAC-CT, CMAC

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