These are the new guidance requirements for surveyors as set forth by the Centers for Medicare and Medicaid Services (CMS).  These updates are to be utilized when regulators across the country survey facilities.

To go directly to the updated CMS Guidance, cick here.

Effective Date June 12, 09
F 172  Access and Visitation 

1. Really a choice issue
2. Adds guidance that facilities must provide 24-hour access to any visitor who is visiting with consent of resident.
3. “Reasonable restrictions” regulatory language is defined as those restrictions that keep the home’s residents safe
1. Keeping home locked at night
2. Restricting persons who are disruptive or inebriated, found to be committing criminal acts, abusive, exploitive or coercive to a resident
3. Providing alternate locations for visits (other than bedroom) in order to minimize disruptions to roommate

F 175 Married Couples

1. Really a choice issue
2. Permissive sentence added that this regulation does not prohibit the home from accommodating residents who wish to room with a person of their choice.
3. Refers surveyors to F 242 Self-Determination and Participation for right to make choices.

F 241 Dignity 
The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.

1. Grooming as residents wish to be groomed 
2. Clean faces, hands and clothing → Activities of Daily Living Tags
3. Encourage and assist residents to wear their own clothing rather than hospital-type gowns
4. Privacy of body including sufficiently covered such as with a robe while transporting or clothes changed in bathing room
5. Respecting residents’ space, not changing radio or TV station to suit staff, knocking, keeping belongings where resident likes them

Promoting dignity in dining by eliminating such practices as:

1. bibs (also known as clothing protectors) and instead offering cloth napkins,
2. Staff sit rather than stand when assisting residents to eat
3. Staff interact/converse with residents rather than only with each other while assisting residents
4. Avoiding labels such as “feeders”

Refraining from practices demeaning to residents such as:

1. refusing to comply with a resident’s request for toileting assistance during meal times, and
2. restricting residents from using common areas open to the general public such as restrooms

F 242 Self-Determination and Participation
The resident has the right to:
1) Choose activities, schedules, and health care consistent with his/her interests, assessments and plans of care;
2) Interact with members of the community both inside and outside the facility; and
3) Make choices about aspects of his or her life that are significant to the resident.

1. actively seeking preferences, choice over schedules important to the resident i.e. waking, eating, bathing, retiring,
2. if resident is unaware of the right to make such choices , surveyors need to determine if home has actively sought resident preference information and if that information has been shared with caregivers

F 246 Accommodation of Needs
A personalized homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression and encourages links with their past and family members

1. ADA recommends seating at 17.5 – 18.5” but too high for shorter people. 
2. Brawley: hip joints can be shattered when rising from inappropriate chair, and difficult to rise from seat that is too deep. 
3. CMS interpretive guidance for Tag F 323 Accidents - mentions furniture that is not appropriate for a resident (e.g. chairs or beds that are too low…) as an example of potential hazards.

F 247 Notice Before Room or Roommate Change
Right to receive notice before the resident’s room or roommate in the facility is changed.

1. Guidance added to encourage home to be sensitive to resident needs when moving to a new room or getting a new roommate
2. Grieving? Spouse? Social services needed?
3. No relationship is different.
4. Meeting each other, seeing room, etc.

F 252 Safe, Clean, Comfortable, Homelike  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. “Homelike” and “resident” was landmarked in 1987 and we keep moving toward creating home.

Policies should not only ‘allow’ residents and family members to personalize spaces but also should strongly encourage them to do so.” Maggie Calkins, PhD.

Home has no rule prohibiting, and residents are welcome, to decorate their rooms any way they wish including using nails, tape, screws, etc. 

“We recommend you emphasize to residents and families the importance of bringing residents’ personal belongings.  Often, family members consider dispersing the loved one’s belongings before moving the elder to a nursing home.  Encourage them instead to bring meaningful artifacts to help complete the elder’s new home.”   LaVrene Norton and Steve Shields In Pursuit of the Sunbeam

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
 Examples of good practices that de-emphasize institutional character include the elimination of:

1. overhead paging
2. piped in music
3. audible alarms

F 255 Private Closet Space
Included residents being able to access the items in their closets (wheelchair height)

F 256 Adequate and Comfortable Lighting

1. Sufficient lighting, elimination of glare from shiny flooring and unshielded windows, even light, day light, during nighttime residents need to be able to navigate home, dimming switches, contrast colors
2. CMS Quality of Life study average = blindness rating in current institutional nursing homes
3. Non-glare floor wax (“Satin”), linoleum, Pergo, carpet are some examples

F 371 Sanitary Conditions

1. Unsafe food sources: Nursing homes are not permitted to use home-prepared or home-preserved (e.g. canned, pickled) food for service to residents.
2. Note: The food procurement requirements are not intended to restrict resident choice.  All residents have the right to accept food brought to the facility from any visitor(s) for any resident.

F 461 Resident Rooms

1. References Life Safety Code 2000 edition
2. Speaks to homelike environment and, brings language of now deleted Tag F 255 here
1. “The facility must provide each resident with individualized closet space in his/her bedroom with clothes racks and shelves accessible to the resident.”

F 463 Resident Call System
Intent
The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means of directly contacting staff at the nurses’ station.  This communication may be through audible or visual signals and may include wireless systems

1. The nurses’ station must be equipped to receive resident calls through a communication system from:
   
   – Resident rooms; and
   – Toilet and bathing facilities.
   – Interpretive Guidelines already refer to ability to use“wireless systems.”
   – Recognizes decentralized staff work areas and direct communication electronic systems
   – Needs  to be functioning
   – Staff are answering resident calls
   – Some homes turning off the sound has created many benefits for those that live and work there

NOTE:  For those that need/want/feel more comfortable with audible can provide a bell, telephone numbers, etc

As an aside, there exists a regulatory requirement that requires that residents are asked their ideas concerning proposed policy and operational decisions of the facility  F 243/244. This also ties into person-centered care and while it has not been amended, it deserves attention as it relates to culture change initiatives and individualized care.

Changes to Life Safety Code
New safety code revisions will be incorporated into the 2012 edition of the NFPA 101 Life Safety Code. These changes include four proposals that will help foster a more comfortable, home-like environment. Learn more here.