CMS SOM App. PP, Tag F699

The facility must ensure that residents who are trauma survivors receive culturally

competent, trauma-informed care in accordance with professional standards of

practice and accounting for residents’ experiences and preferences in order to

eliminate or mitigate triggers that may cause re-traumatization of the resident.

INTENT

The intent of this requirement is to ensure that facilities deliver care and services which,

in addition to meeting professional standards, are delivered using approaches which are

culturally-competent and account for experiences and preferences, and address the needs

of trauma survivors by minimizing triggers and/or re-traumatization.

DEFINITIONS

“Culture” is the conceptual system that structures the way people view the world—it is

the particular set of beliefs, norms, and values that influence ideas about the nature of

relationships, the way people live their lives, and the way people organize their world.

Adopted from Substance Abuse and Mental Health Services Administration. Improving

Cultural Competence.

Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-

4849.

https://store.samhsa.gov/system/files/sma14-4849.pdf

.

“Cultural competency” is a developmental process in which individuals or institutions

achieve increasing levels of awareness, knowledge, and skills along a cultural

competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and

institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in

communities.

US Department of Health and Human Services publication: A Blueprint for Advancing

and Sustaining CLAS Policy and Practice at:

https://thinkculturalhealth.hhs.gov/clas/blueprint#:~:text=A%20Blueprint%20for%20Adv

ancing%20and%20Sustaining%20CLAS%20Policy,culturally%20and%20linguistically

%20appropriate%20services%20within%20your%20organization .

“Trauma” results from an event, series of events, or set of circumstances that is

experienced by an individual as physically or emotionally harmful or life threatening and

that has lasting adverse effects on the individual’s functioning and mental, physical,

social, emotional, or spiritual well-being (“Trauma.” SAMHSA-HRSA Center for

Integrated Health Solutions. Substance Abuse and Mental Health Services

Administration. 30 Nov 2016. Accessed at:

https://www.samhsa.gov/resource/dbhis/samhsas-concept-trauma-guidance-trauma-informed-approach.

“Trauma-informed care” is an approach to delivering care that involves understanding,

recognizing and responding to the effects of all types of trauma. A trauma-informed

approach to care delivery recognizes the widespread impact and signs and symptoms of

trauma in residents, and incorporates knowledge about trauma into care plans, policies,

procedures and practices to avoid re-traumatization. Referred to variably as “trauma-informed care” or “trauma-informed approach.” Adapted from

Concept of Trauma and

Guidance for a Trauma-Informed Approach:

https://store.samhsa.gov/system/files/sma14-4884.pdf

GUIDANCE: §483.25(m)

Background: Increasingly diverse demographics among nursing home residents require

nursing homes to provide culturally competent care. Cultural competency, which

includes language, and cultural preferences, and other cultural aspects such as thoughts,

communications, actions, customs, beliefs, values, and institutions of racial, ethnic,

religious, or social groups, is an important aspect of person-centered care. These elements

influence the beliefs surrounding health, healing, wellness and the delivery of health

services and are critical to reducing health disparities. “Cultural competence has emerged

as an important issue for three practical reasons. First, as the United States becomes more

diverse, practitioners will increasingly see people with a broad range of perspectives on

health, often influenced by their social or cultural backgrounds. Second, research has

shown that provider-patient communication is linked to health outcomes.

31F

1 And third,

two landmark Institute of Medicine (IOM) reports—Crossing the Quality Chasm and

Unequal Treatment—highlight the importance of patient-centered care and cultural

competence in improving quality and eliminating health disparities.

3 2F

2

According to the Substance Abuse and Mental Health Services Administration

(SAMHSA), seventy percent (70%) of adults in the United States have experienced some

type of traumatic event, at least once in their lives. There is a direct correlation between

trauma and physical health conditions such as diabetes, chronic obstructive pulmonary

disease (COPD), heart disease, cancer, and high blood pressure.

While care and services must always be person-centered and honor residents’ choice and

preferences, what is different about providing care and services to a trauma survivor is

that these residents may have lost the ability to trust caregivers, and to feel safe in their

environment. As a result, the principles of trauma-informed care must be addressed and

applied purposefully.

The following principles pertaining to trauma-informed care have been adapted from

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach, located

at

https://store.samhsa.gov/system/files/sma14-4884.pdf

• Safety – Ensuring residents have a sense of emotional and physical safety.

• Trustworthiness and transparency – Efforts to establish a relationship based on

trust, and clear and open communication between the staff and the resident.

• Peer support and mutual self-help – If practicable, it may be appropriate to assist

the resident in locating and arranging to attend support groups which are

organized by qualified professionals. It may be possible for the group to meet in

the facility.

• Collaboration – There is an emphasis on partnering between a resident and/or his

or her representative, and all staff and disciplines involved in the resident’s care in

developing the plan of care. There is recognition that healing happens in

relationships and in the meaningful sharing of power and decision-making.

• Empowerment, voice, and choice – Ensuring that resident’s choice and

preferences are honored and that residents are empowered to be active

participants in their care and decision-making, including recognition of, and

building on resident’s strengths.

Assessment

Facilities should use a multi-pronged approach to identifying a resident’s history of

trauma as well as his or her cultural preferences. This would include asking the resident

about triggers that may be stressors or may prompt recall of a previous traumatic event,

as well as screening and assessment tools such as the Resident Assessment Instrument

(RAI), Admission Assessment, the history and physical, the social history/assessment,

and others. There are many psychosocial screening and assessment tools available

including assessment tools from the United States Department of Veterans Affairs site

PTSD: National Center for PTSD, https://www.ptsd.va.gov/professional/index.asp

.

Trauma

Residents of long-term care facilities may include, but are not limited to, trauma

survivors such as military veterans, survivors of large-scale natural and human-caused

disasters, Holocaust survivors, survivors of physical, sexual, and/or mental abuse (past or

current), or other violent crime, as well as residents with a history of imprisonment,

homelessness, or who have suffered the traumatic loss of a loved one.

The history and physical assessment done by the attending physician can reveal many

clues to a resident’s history of trauma. Scars and other signs of physical trauma should

be explored to determine the cause if the resident is comfortable/agreeable with

discussing them. Numerical tattoos may be an indicator of World War II Holocaust

survivors. Residents with a history of trauma may have diagnoses such as anxiety,

depression, or may have substance abuse issues such as alcoholism, and/or may abuse

prescription medications or street drugs. Evidence of physical and/or psychological

trauma can be revealed during a comprehensive social history or assessment by the social

worker.

Triggers

Facilities must identify triggers which may re-traumatize residents with a history of

trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic

event, even if the stimulus itself is not traumatic or frightening. For many trauma

survivors, the transition to living in an institutional setting (and the associated loss of

independence) can trigger profound re-traumatization. While most triggers are highly

individualized, some common triggers may include:

• Experiencing a lack of privacy or confinement in a crowded or small space;

• Exposure to loud noises, or bright/flashing lights;

• Certain sights, such as objects that are associated with those that used to abuse,

and/or

• Sounds, smells, and even physical touch.

Culture

As mentioned in the Background section above, the increasingly changing demographics

of nursing homes has led to the need to provide culturally competent care. In addition to

racial and ethnic diversity, this also includes religious preference, sexual orientation, and

gender identity.

There are several tools that facilities may use in addition to the Resident Assessment

Instrument (RAI) to assist them in identifying a resident’s cultural preferences. Chapter 3

of the RAI gives guidance on completing Minimum Data Set (MDS) items in section A

that addresses Race, Ethnicity, and Language with which the resident most closely

identifies. These MDS items may be indicators of a resident’s culture and may indicate

further assessment is necessary to determine if there are any cultural preferences which

should be honored while the resident is in the facility. The categories in this

classification are socio-political constructs and should not be interpreted as being

scientific or anthropological in nature. They provide demographic race/ethnicity specific

health trend information. These categories are NOT used to determine eligibility for

participation in any Federal program.

MDS Section A identifies whether the resident wants or needs an interpreter and the

resident’s preferred language. Inability to make needs known and to engage in social

interaction because of a language barrier can result in isolation, depression, and unmet

needs. Language barriers can interfere with accurate assessment.

Facilities must use their Facility Assessment (See F838 for additional guidance related to

Facility Assessment) to identify resident populations having unique cultural

characteristics, such as language (including American Sign Language), religious or

cultural practices, values, and preferences. This facilitates a facility-wide and

department-wide understanding of cultural differences and how to approach the provision

of care and services with dignity and respect for the individual. (Also see, F675, Quality

of Life, for further discussion of the impact of cultural differences on residents and staff.)

NOTE: Facilities are required to communicate effectively, both verbally and in writing,

with residents in a language and manner they can understand. For additional information

see F552, Right to be Informed/Make Treatment Decisions; F572, Notice of Rights and

Rules; and F573, Right to Access/Purchase Copies of Records.

Cultural Competencies

Cultural competencies help staff communicate effectively with residents and their

families and help provide care that is appropriate to the culture and the individual.

Cultural competence (also known as cultural responsiveness, cultural awareness, and

cultural sensitivity) refers to a person’s ability to interact effectively with persons of

cultures different from his/her own. With regard to health care, cultural competence is a

set of behaviors and attitudes held by clinicians that allows them to communicate

effectively with individuals of various cultural backgrounds and to plan for and provide

care that is appropriate to the culture and to the individual.

The following resources are intended for informational purposes only:

• The National Center for Cultural Competence https://nccc.georgetown.edu

• The National Standards for Culturally and Linguistically appropriate Services in

Health and Health Care (developed by the Office of Minority Health in

HHS)https://www.thinkculturalhealth.hhs.gov/clas/blueprint

• Office of Minority Health “Think Cultural Health” website

https://www.thinkculturalhealth.hhs.gov

• Georgetown University publication: Cultural Competence in Health Care: Is it

important for people with chronic conditions

https://hpi.georgetown.edu/agingsociety/pubhtml/cultural/cultural.html

Care Planning to Address Past Trauma

The facility should collaborate with resident trauma survivors, and as appropriate, the

resident’s family, friends, and any other health care professionals (such as psychologists,

mental health professionals) to develop and implement individualized interventions. In

some cases, if a facility has more than one trauma survivor, social services might

consider establishing a support group that is run by a qualified professional, or allowing a

support group to meet in the facility. In situations where a trauma survivor is reluctant to

share his or her history, facilities are still responsible to try to identify triggers which may

re-traumatize the resident, and develop care plan interventions which minimize or

eliminate the effect of the trigger on the resident.

Trigger-specific interventions should identify ways to decrease the resident’s exposure to

triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease

the effect of the trigger on the resident.

Examples of trigger-specific interventions include, but are not limited to the following:

Trigger Intervention

Showers/shower fixtures Provide alternative methods for bathing such as

tubs, sponge bath.

Confinement in small/crowded

spaces

Offer individual or small group activities

Loud noises Decrease/eliminate exposure to loud noises

during holiday celebrations (July 4th, New

Year’s Eve); and/or decrease volume of, or

eliminate overhead paging systems

Removal of clothing Consideration should be given to methods of

assistance given to resident such as:

• Consistent staffing/same-sex care giver

• Removing clothing slowly

• Explanation of what is happening

Exposure to smoke or fire • Remove from areas where smoking is

permitted, or cookouts occur;

• Provide alternative meals inside facility

Additionally, trauma-specific interventions should recognize the interrelation between

trauma and symptoms of trauma such as substance abuse, eating disorders, depression,

and anxiety.

Trauma-specific interventions generally recognize the survivor's need to be respected,

informed, connected, and hopeful regarding their own recovery. Trauma survivors may

need access to support groups either in the facility or in the community, if appropriate

and feasible.

Care Planning to address Cultural Preferences

When a facility admits a resident, it has determined that it can provide the individualized

care and services that resident requires. Facilities must create and sustain an environment

that humanizes and promotes each resident’s well-being and feeling of self-worth and

self-esteem. This requires nursing home leadership to establish a culture that treats each

resident with respect and dignity as an individual, and addresses, supports and/or

enhances his/her feelings of self-worth including personal control over choices and

cultural preferences.

It is important for facilities to be aware of the impact of culture and cultural preferences

on the provision of care and have an understanding of the cultural norms and practices of

the individuals they care for. For example, in some cultures, it may be considered taboo

to direct care at end of life; or in other cultures care must be provided by caregivers of the

same sex as the resident.

In order to provide culturally competent care, staff must understand the cultural

preferences of the individual and how it impacts the delivery of care. A key component

is identifying how to communicate with the resident, in order to be able to identify

physical concerns and issues, and for developing a trusting relationship with staff. For

example, if the resident is non-English speaking, or has limited understanding of English,

the facility should identify how communication will occur with the resident. The care

plan should identify the language spoken and what tools are available to communicate,

whether it be with a communication board or other systems, or through translators. If

communication systems are used, all staff interacting with the resident must know where

those materials are kept, must understand how to use them, and consistently implement

use of those methods. Staff must demonstrate proficiency in communicating with the

resident to assure that critical information can be conveyed, such as a change in

condition, the presence of pain, explanation of routine care, and the ability to refuse care

and services. The facility must provide sufficient guidance for staff, including temporary

staff, on how to communicate and deliver care for the resident. See also §483.10(c)(1),

Resident Rights and §483.21(b)(3)(iii) Comprehensive Person-Centered Care Planning.

There are many aspects of cultural preferences which may impact the delivery of care,

such as:

• Food preparation and choices;

• Clothing preferences such as covering hair or exposed skin;

• Physical contact or provision of care by a person of the opposite sex; or

• Cultural etiquette, such as avoiding eye contact or not raising the voice.

Additionally, facilities should consider:

• Offering activities that are culturally relevant to resident populations within the

facility;

• Group activities with both sexes may not be permitted or appropriate in some

cultures, or the type of programming may be in conflict with his/her cultural

preferences;

• Providing reading materials, movies, newspapers in the resident’s preferred

language may help orient a resident to date, times and events;

• Allowing the performance of religious rites at end of life to the extent possible;

and

• Certain medications, procedures or treatments may be prohibited.

Social services and facility administration may need to evaluate how forms, including

informed consent forms, are provided in the language used by the resident. As mentioned

above, this is a facility-wide opportunity to provide a culturally diverse environment,

respecting and treating each resident with dignity. Assisting the resident and his/her

representative with daily schedules, developed with input by the resident/representative,

ahead of time may alleviate fear and frustration.

Resident-specific approaches must be developed and included in the resident’s care plan.

These interventions must be provided consistently, and supervising staff should monitor

the delivery of care and staff interactions with the resident to assure they are implemented

as written. Using consistent staff, to the extent possible, will assist the resident in feeling

more comfort in the facility. If concerns related to culturally competent and/or trauma-informed care planning are identified, see additional guidance at §483.21(b) in F656.

Monitoring Delivery of Care and Services

As required with any care plan interventions, facilities must monitor the effects of their

approaches to ensure they are implemented as intended, and are having the desired effect

to achieve the measurable objectives and the resident’s goals for care. For residents with

a history of trauma in particular, facilities must evaluate whether the interventions have

been able to mitigate (or reduce) the impact of identified triggers on the resident that may

cause re-traumatization. It is critical to involve the resident and/or his or her family or

representative in this evaluation to ensure clear and open discussion and better understand

if interventions must be modified.

It may be necessary to engage the services of an interpreter to monitor or evaluate the

effect of cultural interventions for non-English speaking residents. As noted above, it is

critical to involve the resident and/or his or her family in evaluating the effectiveness of

cultural interventions in achieving measurable objectives and resident goals.

Surveyors should refer to the following when investigating concerns and citing

noncompliance related to culturally-competent, trauma-informed care:

• F656: For concerns related to development or implementation of culturally

competent and/or trauma-informed care plan interventions;

• F699: For concerns related to outcomes or potential outcomes to the resident

related to culturally-competent and/or trauma-informed care;

• F726: For concerns related to the knowledge, competencies, or skill sets of

nursing staff to provide care or services that are culturally competent and trauma-informed.

• F742: For concerns related to treatment and services for resident with history of

trauma and/or history of post-traumatic stress disorder (PTSD)

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F699, the surveyor's investigation will generally show that the

facility failed to do any one of the following:

• Identify cultural preferences of residents who are trauma survivors;

• Identify a resident’s past history of trauma, and/or triggers which may cause re-traumatization;

• Consistently use approaches that are culturally competent and/or are trauma-informed

INVESTIGATIVE SUMMARY

Use the General Critical Element (CE) Pathway along with the above interpretive

guideline when determining if the facility meets the requirements to provide culturally

competent, trauma-informed care in accordance with professional standards of practice

and accounting for residents’ experiences and preferences in order to eliminate or

mitigate triggers that may cause re-traumatization of the resident.

DEFICIENCY CATEGORIZATION

An example of Severity Level 4 Noncompliance: Immediate Jeopardy to Resident

Health or Safety includes, but is not limited to:

A resident was admitted with a history of sexual abuse by a male and a diagnosis of post-traumatic stress disorder. The resident requested only female staff provide perineal care

due to her severe trauma. A male staff person answered the resident’s call light for

assistance to the bathroom and insisted on performing perineal care as he was the only

staff member available at the time. She refused his assistance and began to get visibly

upset and requested that a female staff member be called in. The resident stated that the

male staff member insisted on performing perineal hygiene after she had toileted despite

the residents past trauma. After returning her to her bed, she was crying and distraught

and stated that she was afraid to request assistance with perineal care as he might return.

She stated she cried all night and that she had profuse sweating, fearing that someone was

outside her door, waiting to come in if she fell asleep. Eventually the resident fell asleep

but awakened screaming, kicking and throwing objects, re-living her previous sexual

assault. She told staff who came into her room that she was fearful for her life, felt dirty

and demeaned, that she wasn’t respected, and there was no reason to go on living.

An example of Severity Level 3 Noncompliance: Actual Harm that is not Immediate

Jeopardy includes, but is not limited to:

Residents were gathered to watch July 4

th fireworks on television. A resident with a

known history of surviving a mass shooting several years ago was placed in the activity

room to watch the fireworks. When the show began, the resident became tearful and

frightened when he heard the sound of the fireworks which resembled the sound of gun

shots. The facility staff noticed that the resident was tearful and appeared frightened.

When asked what was wrong, the resident shared that he was having flashbacks from the

mass shooting he survived years ago. The staff member rubbed the resident’s back and

said “it will be okay \\\\\, the show is only 30 minutes long.” The resident remained in the

activity room for the duration of the fireworks and continued to be tearful. In the

following weeks, the resident decreased his attendance at activities that he previously

enjoyed.

An example of Severity Level 2 Noncompliance: No Actual Harm with potential for

more than minimal harm that is not Immediate Jeopardy includes, but is not limited

to:

Facility staff escorted residents to a local baseball game. One of the residents was a

survivor of a refugee camp and is not comfortable in highly populated areas. Prior to

leaving for the game, facility staff failed to consider the resident’s discomfort with

crowded areas due to his time in a refugee camp. Upon arriving to the baseball game,

there were hundreds of fans that came to watch the game. While watching the game, the

resident informed one of the facility staff members that he was not enjoying himself

because he was feeling anxious in the stadium with so many people around him and often

has panic attacks when he is in crowded areas too long. The facility staff member

immediately escorted the resident out of the stadium and onto the bus where his anxiety

resolved.

An example of Severity Level 1 noncompliance: No actual harm with potential for

minimal harm:

Because of the potential for psychosocial harm, noncompliance at F699 should generally

not be cited at severity level 1.

1 Lurie, N., Jung, M., & Lavizzo-Mourey, R. (2005). Disparities and quality improvement: Federal policy

levers. Health Affairs, 24(2), 354- 364.

2 Betancourt, J. R., Green, A. R., Carillo, J. E., & Park, E. R. (2005). Cultural competence and health care

disparities: Key perspectives and trends. Health Affairs, 24(2), 499-505.