New Guidelines For New York Nursing Home Surveyors

The Long-Term Care Community Coalition (LTCCC) passed on the information below. The LTCCC is a non-profit group dedicated to improving long-term care through research, education and advocacy. Please visit their website and consider joining the group.

In April, CMS issued new interpretive guidelines for state surveyors to help them assess nursing home compliance with the Nursing Home Reform Law (OBRA ’87), which requires that residents be provided with the care necessary to enable them to achieve their highest practicable physical, social and emotional well-being. Though these requirements are all essential components of our national minimum standards for nursing homes, from a consumer perspective they are generally considered to be largely absent from survey and oversight processes. The institutional nature of most nursing homes, high incidence of pressure sores and widespread use of physical and chemical restraints are all evidence that nursing homes have been permitted to operate with virtual disregard for what the law requires.

The new guidelines, which go into effect on June 17, give surveyors detailed information on how to assess nursing homes specifically in terms of quality of life and environment. Following are some examples of guidelines relating to dignity and autonomy from the advance copy of the guidelines:

1) Grooming residents as they wish to be groomed (e.g., maintaining the resident’s personal preferences regarding hair length/style, facial hair for men, removal of facial hair for women, and clothing style);

2) Encouraging and assisting residents to dress in their own clothes appropriate to the time of day and individual preferences rather than hospital-type gowns;

3) Promoting resident independence and dignity in dining such as avoidance of:

4) Day-to-day use of plastic cutlery and paper/plastic dishware;

5) Bibs (also known as clothing protectors) instead of napkins (except by resident choice);

6) Staff standing over residents while assisting them to eat;

7) Staff interacting/conversing only with each other rather than with residents, while assisting residents;

8) Respecting residents’ private space and property (e.g., not changing radio or television station without resident’s permission, knocking on doors and requesting permission to enter, closing doors as requested by the resident, not moving or inspecting resident’s personal possessions without permission);

9) Respecting residents by speaking respectfully, addressing the resident with a name of the resident’s choice, avoiding use of labels for residents such as “feeders,” not excluding residents from conversations or discussing residents in community settings in which others can overhear private information;

10) Residents have the right to have a choice over their schedules, consistent with their interests, assessments, and plans of care. Choice over “schedules” includes (but is not limited to) choices over the schedules that are important to the resident, such as daily waking, eating, bathing, and the time for going to bed at night. Residents have the right to choose health care schedules consistent with their interests and preferences, and the facility should gather this information in order to be proactive in assisting residents to fulfill their choices. For example, if a resident mentions that her therapy is scheduled at the time of her favorite television program, the facility should accommodate the resident to the extent that it can.

11) If the resident refuses a bath because he or she prefers a shower or a different bathing method such as in-bed bathing, prefers it at a different time of day or on a different day, does not feel well that day, is uneasy about the aide assigned to help or is worried about falling, the staff member should make the necessary adjustments realizing the resident is not refusing to be clean but refusing the bath under the circumstance provided. The facility staff should meet with the resident to make adjustments in the care plan to accommodate his or her preferences.

12) The food procurement requirements for facilities are not intended to restrict resident choice. All residents have the right to accept food brought to the facility by any visitor(s) for any resident.

13) Procedure [for Surveyor to Follow]: For a sampled resident, use resident and family interviews as well as information from the Resident Assessment Instrument (RAI) to consider the resident’s former life style and personal choices made while in the facility to obtain a picture of the resident’s individual needs and preferences.

14) Throughout the survey, observe: Do staff show respect for residents? When staff interact with a resident, do staff pay attention to the resident as an individual? Do staff respond in a timely manner to the resident’s requests for assistance? Do they explain to the resident what care they are doing or where they are taking the resident? Do staff groom residents as they wish to be groomed?

15) In group activities, do staff members focus attention on the group of residents? Or, do staff members appear distracted when they interact with residents? For example, do they continue to talk with each other while doing a “task” for a resident(s) as if the resident were not present?

16) Determine if staff members respond in a dignified manner to residents with cognitive impairments, such as not contradicting what residents are saying, and addressing what residents are trying to express (the agenda) behind their behavior. For example, a resident with dementia may be attempting to exit the building in the afternoon, but the actual intent is a desire to meet her children at the school bus, as she did when a young mother. Allowing the behavior under supervision such as walking with the resident without challenging or disputing the resident’s intent and conversing with the resident about the desire (tell me about your children) may assist the behavior to dissipate, and the staff member can then invite the resident to come along to have a drink or snack or participate in a task or activity.

Website Resources:

NEW CMS GUIDELINES CALL FOR HOMELIKE ENVIRONMENT IN NURSING HOMES, Centers for Medicare and Medicaid Services, April 10, 2009.

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