The information provided in this overview is taken from a letter to State CMS Survey Agency Directors from the Director of the Survey and Certification Group at CMS. The letter is dated January 23, 2009 and is described as “revised guidance” for long-term care surveyors on F-Tag 309 including a new general investigative protocol and new pain management guidance and investigative protocol.

F-Tag 309 Quality of Care

Definition: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Intent: The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.

What: Recognition and Management of Pain

Who: All residents who have Pain Symptoms, are being Treated for Pain, or who have the Potential for Pain Symptoms Related to Conditions or Treatments

How: In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible should:

  1. Recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated
  2. Evaluate the existing pain and the cause(s)
  3. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current clinical standards of practice, and the resident’s goals and preferences.

“Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain.

Because pain can significantly affect a person’s well-being, it is important that the facility recognize and address pain promptly.”

Key Components of Pain Management mentioned in F-Tag 309:

  • Care Process for Pain Management
  • Assessment
  • Management of Pain
  • Non-Pharmacological Interventions
  • Pharmacological Interventions
  • Monitoring, Reassessment, and Care Plan Revision

Facility Responsibilities

Care Process for Pain Management- For the prevention and management of pain:


  • Assess the potential for pain
  • Recognize the onset or presence of pain
  • Assess identified pain
  • Observe the resident during care, activities, and treatments- this helps not only to detect whether pain is present, but also to potentially identify its location and the limitations pain places on the resident.
  • Monitor for presence of pain and evaluate when there is a change in condition and whenever a new pain or an exacerbation of pain is suspected.


  • Address and treat the underlying causes of the pain, to the extent possible
  • Develop and implement interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both.
  • Consider effective intervention based on:
    • resident’s needs and goals
    • the source(s), type and severity of pain (recognizing that the resident may experience pain from one or more sources either simultaneously or at different times)
    • awareness of the available treatment options
  • Consider sequential trials of various treatment options may be needed to develop the most effective approach.
  • Develop a care plan that is consistent with the resident’s specific conditions, risks, needs, behaviors, preferences and with current standards of practice.
  • Include measurable objectives and timetables with specific interventions in care plan.
  • Identify and use specific strategies for different levels or sources of pain or pain-related symptoms including: Identifying interventions to address the pain based on the resident-specific assessment, a pertinent clinical rationale, and the resident’s goals

Non-pharmacological Interventions

  • Consider non-pharmacologic interventions that may help manage pain effectively when used either independently or in conjunction with pharmacologic agents
  • Non-pharmacologic interventions may include:
    • Altering the environment for comfort by adjusting room temperature, tightening and smoothing linens, use of assistive devices, etc.
    • Physical interventions like ice packs or cold compresses-to reduce swelling and lessen sensation, mild heat-to decrease joint stiffness and increase blood flow to an area, etc.
    • Cognitive/behavioral therapies such as relaxation techniques, reminiscing, music therapy, coping techniques, education about pain, etc.

Pharmacological interventions

  • Develop a pain management plan that is specific to each resident who has pain or who has the potential for pain, such as during a treatment. The pain management plan should consider factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the resident’s desired level of relief and tolerance for adverse consequences.
  • Consider that the resident may accept partial pain relief in order to experience fewer significant adverse consequences (e.g., desire to stay alert instead of experiencing drowsiness/confusion).
  • Work with the resident to identify the most effective and acceptable route for the administration of analgesics, such as orally, topically, by injection, by infusion pump, and/or transdermally.
  • Follow a systematic approach for selecting medications and doses to treat pain.
  • Consider all factors that may influence the selection and dosing of medications including the resident’s medical condition, current medication regimen, nature, severity, and cause of the pain and the course of the illness.

Monitoring, Reassessment and Care Plan Revision

  • Monitor the resident over time this helps identify the extent to which pain is controlled.
  • Identify target signs and symptoms (including verbal reports and non-verbal indicators from the resident) and use standardized assessment tools which can help evaluate the resident’s pain and responses to interventions and determine whether the care plan should be revised.

Effective Data: March 31, 2009

Letter to Surveyors revising guidelines associated with F-Tag 309 and end of life care