The new CMS “homelike environment survey guidelines” F252

What can I say?   These changes will significantly alter how a facility looks and operates!  I am still thinking through the implications of these changes and how they will impact the care providers, the manufacturers who service the industry and the products that HealthCare Source represents.   

One customer has already commented that they felt mitigated by the length of time that it will take for these guidelines to take hold.  I explained that, operationally this is true, but HealthCare Source looks at the guidelines from a “capital equipment perspective” with purchases having a useful life of 10 years or more.  If you are spending capital dollars TODAY then you need to at least take these guidelines into account, even if you say NO to implementing them. 

My initial reaction is that some of the guideline changes have real merit.  Some of the guideline changes are going to be difficult for the industry to address.  And at least one of the guideline changes MUST have been written by some Senator’s “idiot love child”, because no one with intimate knowledge the industry would initiate a guideline like this.  This one guideline, if interpreted and implemented as written, with no further thought, has the potential to return a disaster on the scale of New York’s 1911 Triangle Factory debacle. 

I “betcha” you want to know which I think it is! 

Before we go there, I can’t just let the industry “off the hook” in this matter.  These guidelines are printed for comment in advance of adoption.  Why are we dealing with these issues after they have already been implemented and why are they such a surprise to everyone I talk to about them?  The most common response I have gotten from industry professionals is; “They can’t do that!”.   

Back to the business at hand!   Let’s start with the short list of what items the guideline RECOMMENDS be “banned” from the long term care environment. 

• Banned - Overhead paging and piped in music.  
• Good call!  No one cares to know that the Administrator has a phone call and no one “lives” in an elevator.  
• Besides that, the person who is assigned to pick the playlist generally has terrible taste in music. 
• Banned - Meal service on trays in the dining room.  
• Good call!  It’s tough enough for some residents to maintain an “interest in food” without making the servings look like “fast food”.   
• Banned – Institutional signage labeling workrooms and closets. 
• Hmmm.  There are areas that need signs, either to keep people out or to get people in.  One good example is a public restroom.

• Banned  - Medication Carts.  
• Another Hmmm.  I can clearly see the objection to the “monster” medication carts that serve 50 residents, weigh hundreds of pounds and block the hallways … but facilities are not required to use those carts except for the fact that this may be the type of cart that is provided to facilities by their pharmacy at no charge.  
• Is this a really a legitimate regulatory change or is it an obtuse way for CMS to address what some consider an ongoing “Safe Harbors” violation?  The guidelines recommend that “medications could be stored in the resident room” instead of in carts, but they do not address how the facility should deal with narcotics or refrigerated medications in this situation.  
• If this guideline is implemented, a facility will need to completely alter how they address med storage and med delivery.  Double hmmm.

•  Banned – Audible Alarms and Call Systems.  
• A double good call.  See my previous posting addressing wireless call systems. 

• Banned – Mass purchased furniture.  
• Are you kidding me???  On the surface this looks …. OK.  And then you start thinking about the ramifications, and I am not talking about the design issues, those points can be addressed by a professional designer! I am talking about both Residents and Operators bringing toxic, flammable junk furniture into the health care environment.  
• Has no one read about off shore furniture that contains dangerous levels of formaldehyde gasses? … this guideline could place that dangerous furniture right under resident’s noses!

• And this same guideline is asking that we use “home like” curtains and bedspreads.  Well I’ve got news for you, this stuff along with “furniture from home”, BURNS! This CMS guideline could turn the Skilled Nursing environment into a fire trap.  Did ANYONE talk to a Fire Marshall about this guideline?

• YES! We want to provide a “home like” environment, but at what cost?  The Skilled Nursing environment IS an institution and it is the job of the care giver and CMS to keep residents safe inside this institution.  “Home like” should be an IMAGE, not a function.  If this guideline is misunderstood and misapplied by a “well meaning” caregiver, the resident safety net will break down.   

• California, fortunately, has a number of environmental regulations that conflict with THIS CMS guideline.  CA TB 133 flammability standards, CARB toxic emission standards and other fire safety regulations are in effect in this market.  Other states may not have this protection in place. 

• Banned – Large centrally located nurse stations. 

• Hmmm.  This guideline may be putting the “COMPUTER CART before the horse”.  On the surface I think this guideline will be a good idea but a lot of things need to happen before it will work.  These include the implementation of MDS 3.0 and mobile assessment, RUGS IV, full computer automation in the facility, the installation of a facility wide wireless, encrypted, internet connection and the acquisition of a “work station on wheels” for each nurse.  
• Oh yeah, and some place to store the workstations and re-charge them when not in use. 

Please read these guidelines to see if you agree or disagree with me.  I look forward to your comments!   

Here is the guideline … Chapter and Verse:


F252 
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09) 
§483.15(h) - Environment 
The facility must provide-- 
§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; 

Interpretive Guidelines: §483.15(h)(1) 
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment. 
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of: 

Overhead paging and piped-in music throughout the building; 

Meal service in the dining room using trays (some residents may wish to eat certain meals in their rooms on trays); 

Institutional signage labeling work rooms/closets in areas visible to residents and the public; 

Medication carts (some innovative facilities store medications in locked areas in resident rooms); 

The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network; 

Mass purchased furniture, drapes and bedspreads that all look alike throughout the building (some innovators invite the placement of some residents’ furniture in common areas); and 

Large, centrally located nursing/care team stations. 

Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them.