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New Interpretive Guidance for quality of life, environment tags

June 1, 2009
by Carmen S. Bowman, MHS, ACC
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The Center for Medicare & Medicaid Services (CMS) released new Interpretive Guidance for several quality of life and environment tags on April 10. These changes grew from the “Creating Home” national symposium cosponsored by CMS and the Pioneer Network in April 2008. At this national symposium, many changes to the interpretive guidelines were identified by stakeholders. CMS has taken these recommendations seriously and changed the interpretive guidelines. Hopefully, changes to regulations will be made by CMS as well. Here is a rundown of the most recent CMS Interpretive Guidance changes.

F172 Access and Visitation Rights-Visitors must have 24-hour access to residents with “reasonable restrictions” defined as anyone who might affect the security of all residents.

F175 Married Couples-A resident may choose to room with another nursing home resident of his or her choice.

F241 Dignity-We still have many undignified practices in the more typical nursing homes. Therefore, CMS has added examples to the interpretive guidelines including:

  • Eliminating such practices as using bibs (also known as clothing protectors) and instead offering cloth napkins

  • Having staff sit rather than stand when helping residents to eat

  • Identifying that staff should be interacting/conversing with residents rather than with each other while assisting residents

  • Speaking to residents respectfully; avoiding use of labels for residents such as “feeders”

  • Grooming residents as they wish to be groomed; cleaning residents' faces, hands, and clothing after they are soiled

At the 2008 Pioneer Network Conference, Past President Sue Misorski challenged us to think about what a dignified existence means. As she said, what residents want more than anything else is to get to the bathroom when they need to. This is such a basic human right. I know we can get this handled.

CMS refers to toileting again in an example of undignified care of refusing to comply with a resident's request for toileting assistance during mealtimes, and restricting residents from use of common areas open to the general public such as lobbies and restrooms. It is dehumanizing to restrict residents from using restrooms, closer to where they dine, which are open to the public but not to residents. Huh? I can recall when African-Americans could not use restrooms open to the public. Is this what we want for our elders?

F242 Self-Determination and Participation-Many of us refer to this regulation as “choices” because it states that the resident has the right to … make choices (emphasis added) about aspects of his or her life in the facility that are significant to the resident. What is new is identifying that this includes actively seeking information from the resident regarding significant interests and preferences in order to provide necessary assistance to help residents fulfill their choices over their lives. Wow, actively seeking is definitely new. Also new are these fabulous changes:

Residents have the right to have a choice over their schedules, consistent with their interests and assessments. Choice over “schedules” includes daily waking, eating, bathing, and going to bed at night. Residents have the right to choose healthcare schedules consistent with their interests and preferences, and the home should gather this information in order to be proactive in assisting residents to fulfill their choices.

In addition, during resident and family interviews, surveyors are to determine what time the resident awakens and goes to sleep, and whether this is the resident's preferred time. They will also determine whether the facility is honoring the resident's preferences regarding the timing (morning, afternoon, evening, and how many times a week) for bathing and also the method (shower, bath, in-bed bathing). They will obtain further information as necessary from observations and staff interviews. If the resident is unaware of the right to make such choices, determine whether the home has actively sought information from the resident and/or family (for a resident unable to express choices) regarding preferences and whether these choices were relayed to caregivers. This is your opportunity to lead in honoring resident preferences.

F246 Accommodation of Needs-CMS now states this requirement refers to the resident's physical environment and added requirements for adaptations to bedrooms and bathrooms to ensure each resident can (if they are able) open and close drawers (special drawer pulls) and bedroom and bathroom doors (push/pull handles), turn faucets on and off (lever handles), and see her/himself in a mirror (tilt mirrors). Residents should be able to rise from living room furniture including different sizes and types of furniture with appropriate seat height, depth, firmness, and arms that assist residents into a standing position. It is time to individualize physical surroundings just as you do in your home. In addition, CMS wisely adds here that reasonably sufficient electric outlets should be provided to accommodate the resident's need to safely use her/his electronic personal items. It is important to recognize that residents will be bringing more and more items that need to be plugged in to their new home.