New CMS Quality of Life and Environment Interpretive Guidance Effective June 12, 2009

1. New CMS Quality of Life and Environment Interpretive GuidanceEffective June 12, 2009 Carolyn Backes, RN, Continuing Care Program Director, Central New York Regional Office October 9, 2009

2. F172 Access and Visitation Rights • Immediate family and relatives are not subject to visiting hour limitations, unless requested by the resident • 24-hour access to non-relative visitors must also be provided with the consent of the resident • Policy should be accurate to reflect the visiting hours • May need to find another location for visiting if roommate has an issue

3. F172 Access & Visitation Rights • Reasonable Restrictions – imposed by the facility that protect the security of all of the facility's residents • Locking doors at night • Supervised/limited access for visitors that are abusive, committing criminal acts or disruptive or inebriated • Survey question – Do non-relative visitors know they are able to visit 24 hours a day? • How does the facility let everyone know about the visiting hours?

4. F172 Access & Visitation Rights • Facility evaluation for compliance: • Review in resident & family councils – include in letter to families, resident discussion with social worker during routine visits • Discuss with resident and family on admission to determine initial visiting needs • Consider signage that indicates suggested visiting hours with direction for information on making arrangements for additional visiting hours – i.e. “Suggested Visiting Hours are 10:00 am – 8:00 pm. Please see social service for additional visiting needs”

5. F172 Access and VisitationDOH • Surveyors will conduct resident, family & group interviews to determine how the facility ensures 24-hour access to: • State representatives; • US Dept of Health & Human Services (DHHS); • Resident’s physician; • Representatives of the State LTC Ombudsman Program; • Representatives of protection & advocacy agencies for individuals with mental illness or developmental disabilities; • Immediate family or other relatives; and • Other visitors, subject to reasonable restrictions. NYS has issued no citations under F172 over the past 3 years

6. F 175 -Married Couples • The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. • “Does not prohibit the home from accommodating residents who wish to room with a person of their choice.” • Residents can room with another nursing home resident of their choice. • May include mother and son or other family members, two friends of the opposite of same gender or an unmarried couple

7. F175 Married CouplesDOH • Surveyors will be evaluating if the facility has made reasonable accommodations to meet the individual needs and preferences of the resident(s). • Surveyors must also ensure that the facility accommodates resident needs & preferences in a manner that does not endanger the health or safety of individuals or other residents. NYS has issued no citations under F175 over the past 3 yrs.

8. F 241 - Dignity • Grooming residents as they wish to be groomed • Encouraging and assisting resident to dress in clothes other than hospital-type gowns • Use of bibs – not to be used unless it is resident choice • Standing over residents/interactions with other staff when giving care needs to be addressed • Use of signage that may include clinical or personal information • Does not include CDC isolation signs as long as specific infection is not included. • Family insisting on signage needs to be looked at – Why are they insisting?, Is there are care issue? Has the facility tried to work it out with the family?

9. F241 - Dignity • Maintaining resident privacy of body while taken to areas outside of their room, such as bathing such as a bathrobe. • May also consider changing the resident in the bathing area. • Refraining from practices demeaning to residents • Not covering urinary catheter bags • Not providing toileting assistance when requested • Restricting resident from common areas such as the lobby ***Cell phone use by staff needs to be evaluated – Are staff using cell phones while providing care? Are cell phones with cameras permitted?

10. F241 Dignity –Considerations DOH • Was Resident Council approached to discuss limiting resident space for special events &/or for certain times during their day? • Were individual residents interviewed who would be affected by the implementation of these restrictions? • The facility is responsible to provide reasonable accommodations to meet resident’s individual needs & preferences.

11. F241 DignityDOH • The resident has a right to be spoken to respectfully which includes addressing the resident with a name of the resident’s choice, & avoiding use of labels. • The facility should maintain an environment in which there are no signs posted in resident’s rooms or in staff work areas able to be seen by other resident’s and/or visitors that includes confidential or personnel information. • An exception can be made in an individual case if a resident or responsible family member insists on the posting of care information at the bed (e.g. No BPs in the right arm). NYS has issued 71 citations statewide during FFY 2009 under F241

12. F 242 - Self-Determination and Participation • Facility must seek information from the resident/family regarding significant interests and preferences in order to provide assistance to help residents fulfill their choices over aspects of their lives in the facility. • Interview of resident/family on admission by all disciplines regarding preferences/choices – food, bathing schedules, waking and sleep time, activities and incorporating preferences into care plans.

13. F242 Self Determination & Participation DOH • Residents have the right to have a choice over their “schedules”, consistent with their interests, assessments, & plans of care. • These choices include daily waking, eating, bathing, & the time for going to bed at night, etc… • Surveyors will evaluate if resident’s choices to “schedules” are being assessed, addressed, care planned, & implemented to the extent possible.

14. F242 Self Determination & ParticipationDOH • Considerations for Providers & Surveyors • Completion of a comprehensive social history • Balance autonomy and safety • Be proactive. Have healthcare needs been addressed? • Is there evidence of informed decision-making? • Have all disciplines been actively involved in the care planning process? “Negotiated Risk” In FFY 2009 NYS has issued a total of 17 citations under F242

15. F242 – Self Determination and Participation • Facility evaluation for compliance • Review policies and procedures relating to resident assessment and care planning • Use of the MDS for resident’s ability to make choices including actively seeking information from residents/families about interests, preferences and schedule choices. • If resident cannot communicate effectively, use history for schedule changes • Develop communication system for CNAs and other care givers regarding preferences and interests that are not previously known.

16. F242 – Self Determination and Participation • Facility evaluation for compliance continued • In-service staff on policies/procedures relating to self determination and participation. Can be part of culture change training • Consider developing QA tools or adding to existing tools to determine if resident preferences and choices are being adhered to. Identify trends & implement corrective actions • If schedule choice cannot be accommodated, facility should be able to show an assessment of the choices and why they were not able to provide them.

17. F246 – Accommodation of Need • Refers to the facility’s efforts to individualize the resident’s physical environment – bedroom and bathroom, other common use areas • Opening and closing drawers, faucets • Mirrors and toiletry needs are easily within reach • Open and closing doors to bedroom and bathroom • Having assistive devices to use bathroom as independently as possible • Accommodate residents' desire to re-arrange furniture • Communicating with resident’s on eye level, facing resident while talking if resident reads lips • Smoking when the weather is inclement

18. F247 Roommate Notice • Receive notice before the resident’s room or roommate in the facility is changed • To the extent possible, offering choices of rooms if a room change is needed • Discussion of a new roommate as to when the person will be moving in • Assisting a roommate to adjust to the death of a previous roommate in terms of social services and how quickly a new roommate would be placed

19. F247 Roommate NoticeDOH • The facility should be sensitive to the trauma a move or change of roommate causes some residents, and should attempt to be as accommodating as possible. (transfer trauma) • The facility should support a resident whose roommate has passed away by providing a little time to adjust before moving another person into the room, (whenever possible) depending on the resident’s level of connection to the previous roommate. • Key points to consider: • Keep the lines of communication open with residents & families from the time of admission. Be proactive! • Follow up with residents post relocation. Residents may be losing their permanent caregiver(s) and may feel a loss of safety & security. • Remember, family & resident education is crucial. NYS has issued 1 citation under F247 during FFY 2009 but receives multiple inquires regarding the requirement.

20. F247– Roommate Notice • Facility evaluation for compliance • Review policies and procedures for notification of roommate changes and revise to include specific attempts to be as accommodating as possible • Be sure to review policy on admission with residents and families • Document notification of a change in roommate – can be done using a formatted progress note that includes date, notification and resident’s response. Follow-up documentation may be required if resident is apprehensive or upset with change.

21. F252 – Environment • Homelike Environment • Elimination of institutional character - Facility is expected to do as much as possible to become more homelike • Minimize overhead paging • Eliminate use of tray at meals • Minimize use of med carts • Evaluate use of chair and bed alarms • Individualize furniture • Consider smaller nursing stations • Minimizing odors

22. F252 EnvironmentDOH • Intent emphasizes homelike…Guidance provides for enhanced explanation, but no change in the actual intent. • Providers & surveyors should ensure that all equipment is evaluated prior to use to ensure resident health and safety. • DOH has cited & cross-referenced with this F-tag when the facility has failed to: • Evaluate equipment before use to ensure proper working order • Conduct a safety risk assessment (electric lift chairs, appliances) • Failed to assess & correct safety concerns identified with equipment/furnishings. (free-standing closets) NYS has issued a total of 19 citations under F252 during FFY 2009

23. F252 - Environment • Facility evaluation for compliance • Review policies and procedures for resident use of lobby, dining areas when it is not meal time, outdoor patio space. Review policies and procedures on overhead paging, use of alarms, signage. • Areas need to be accessible as part of the resident’s home • Have an ad hoc QA meeting on how your facility can become “less institutionalized” • Evaluate institutionalized practices and make a goal to reduce the frequency and/or type of practice. • Use QOL interviews to determine which areas are problematic for residents • Goal is to strive toward making some of these changes

24. F 256 - Environment: Adequate & DOHComfortable Lighting • Adequate & Comfortable Lighting • Sufficient lighting with minimal glare • Use of daylight as much as possible • Extra lighting such as table and floor lamps • Dimming switches in resident rooms where possible • Use of contrasting color between floor and baseboard • Use of contrasting colored dishware to improve seeing plates and food • Use of way-finding nighttime lighting to assist residents to find the bathroom – red light has been proven effective for night vision NYS has issued 3 citations under F256 during FFY 2009

25. F256 – Environment: Adequate & Comfortable Lighting • Facility evaluation for compliance • Evaluate lighting from observation and interview of residents and staff. • Individualize lighting based on resident need • i.e. – Resident may require additional lighting at bedside for reading • Staff may need to use flashlights or penlights at night when providing care if light is disturbing to roommate • If lighting issues are identified, conduct ad hoc QA meeting to determine what can be done to minimize issue – ie - minimize glare, provide extra task lighting

26. F 371 Sanitary Conditions • Sanitary Conditions • Additional guidance provided clarification allowing residents the right to accept food brought to the facility by any visitor for any resident

27. F371 Sanitary Conditions DOH • Procure food from sources approved or considered satisfactory by Federal, State or local authorities. • Revising a sentence at this Tag to make it clear that this regulation concerns facility procurement and does not limit the rights of residents to accept food from visitors.

28. F371 Sanitary ConditionsDOH • This clarification reflects long-standing DOH policy on this matter. Memos dating back to 1991 identified that this & similar NYS regulations on food from “approved sources” does not apply to items brought into a facility by family or friends. • Providers & surveyors should be cognizant of the potential for food-borne illnesses. • Providers & surveyors should be cognizant of the admission practices. (ie. Kosher facilities) NYS has issued a total of 92 citations under F371 during FFY 2009

29. F 461 - Resident Rooms • Resident Rooms • Window sill height should not exceed 36 inches. No change • As per NYS Code, the window cannot open more than 6 inches • Closet space must allow resident access to reach their hanging clothing whenever they choose. This includes wardrobes being used as closets • Closet space must be separated from roommates clothing

30. F461 Resident RoomsDOH • Bedroom Windows • 36” Window height reflects existing DOH requirements & LSC requirements that have been in effect for all NHs constructed after 1966. • Res Floor at or above Grade • This mirrors a LSC requirement that all NHs have been subject to. • Accessible Clothing • DOH regulations in effect since 1990 have required an adjustable clothes rod in new closets and wardrobes. Regulations regarding Accommodation of Need requires reasonable modifications of the environment to enable resident independence. • Minor physical modifications or the provision of tools may be considered reasonable. • Private Closet Space • NYS has always specified individual closet space and specified the size & most recently the volume

31. F461 Resident Rooms DOH • Resident Call System • NYS has accepted “other electronic systems” for 15+ yrs. • Providers & Surveyors should consider: • Safety factors – Are closets secured? • Is the mechanism of communication systematic & organized? NYS has issued no citations under F461 during FFY 2009

32. F 463 - Resident Call System • Resident Call System • Allows for other electronic systems, such as wireless systems • When determining a deficiency, all parts of the system need to be working and the call bells need to be answered

33. F463 Resident Call Systems DOH • Considerations for Providers & Surveyors regarding resident call systems: • Are wireless devices being utilized appropriately by all staff? • Is there a system of ongoing evaluation to test the functionality of all resident call system types? • Are batteries being checked and changed on a routine basis for wireless system? • Are staff appropriately responding to calls? • When concerns have been identified with current call system, is a back-up plan immediately implemented & communicated to all levels of staff at the time ofimplementation and at the time the standard system is deemed functional? NYS has issued 21 citations under F463 during FFY 2009 including (1) IJ finding

34. Resources http://www.cms.hhs.gov/transmittals/downloads/R48SOMA.pdf http://www.pioneernetwork.net/ http://www.nhqualitycampaign.org/ http://www.medicare.gov/Nursing/Checklist.pdf