Long-Term Care Survey Alert

If you're not at least climbing on the bandwagon, here's how to get a leg up -- fast.

Looking for a blueprint of dos and don'ts for creating a homey environment that will earn passing marks from surveyors grading your culture change efforts? The recent revisions to survey guidance for F252 (environment) may provide just the ticket.

The guidance, which went into effect on June 17, identifies several "good practices" that the Centers for Medicare & Medicaid Services believes can decrease the "institutional character" of nursing homes. These include eliminating a few common features that have been part and parcel of most nursing homes, which were, after all, built on the medical model. The list includes the following, among others:

• "Large, centrally located nursing/ care team stations."

• Medication carts. ("Some innovative facilities store medications in locked areas in resident rooms," CMS states.)

• "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," CMS notes.)

Your first step in risk-managing this new area of survey scrutiny: Be prepared to pull out the written guidance if surveyors start threatening to write you up for having med carts or nursing stations, etc.

The survey guidance notes that "a nursing facility is not considered non-compliant if it still has some of these institutional features, but the facility is expected to do all it can within fiscal constraints to provide an environment that enhances quality of life for residents, in accordance with resident preferences."

Surveyor training on the guidance is very important, stresses

Evvie Munley, a policy analyst with the American Association of Homes & Services for the Aging. "Facilities are at different points on the culture change journey and some of the recommended modifications to the physical environment ... will take time, particularly in older structures," Munley points out.

Facilities can make significant inroads on their journey toward culture change, however, by implementing these strategies, many of which don't carry hefty price tags.

1. Focus on how the facility feels to residents. The guidance notes that a home environment involves "striving for person-centered care, including individualization, relationships, and making the resident feel welcome and comfortable."

And "simply making a commitment to honoring resident preferences for things like sleep and wake times and when they get their meals can make a huge difference," observes Rena Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor for the American Association of Nurse Assessment Coordinators. "Each resident should have a preference list for sleep time, meal times, bathing, etc.," she says.

"Even facilities that aren't the most exciting structures have found ways to personalize the environment," says Mary Jane Koren, MD, MPH, assistant VP of the Frail Elders Program with The Commonwealth Fund in New York City. They do so by allowing residents to bring in their personal possessions, and by creating an identity for the residents within the facility -- "that is giving them a role," says Koren. "The Eden alternative, for example, has a Web site with ideas for doing that, as does the Pioneer Network" (www.edenalt.org and www.pioneernetwork.net).

"Letting residents help plan activities they would like and letting them help care for plants and animals gives them a sense of dignity because they are making a contribution," adds Koren (see the case study on p. 62).

At the same time, avoid a cookiecutter approach. Someone in a rehab unit who wants to learn to use an artificial limb in two weeks and go home may not care about personalizing his environment, notes DianaWaugh, RN, BSN, a consultant in Waterville, Ohio. But make sure you've assessed and documented that to be the case.

fruit. For example, get rid of institutional-style dining areas where residents eat from trays, as well as overhead paging and piped-in music--the guidance specifically includes both of these on its ditch list.

Also revisit widespread and long-term use of audible (to the resident) bed and chair alarms, which the survey guidance notes can be problematic for residents. Consultant Diane Atchinson, RN-C, MSN, ANP, is finding that surveyors are already beginning to view the personal alarms as inconsistent with culture change.

Exception: Using a personal alarm temporarily to monitor someone who has fallen until the care team can get a revised care plan into place might be OK, says Atchinson, owner and President of DPA Associates Inc. in Kansas City, Mo.

"The alarm can also provide data on when someone tends to get up to establish a pattern" for care planning.

3. Designate teams to plan for future changes. The teams can brainstorm ways to make initial, smaller changes, Shephard suggests. "For example, how much will it cost to put locked boxes in rooms for the  medications in lieu of having medication carts?" The team can then identify more moderate changes, and also longer range ones requiring more investment, she adds.

Tip: Facilities can take steps to make the bathing area look like a bathing area, notes Cheryl Boldt, RN, a consultant in Omaha, Neb. "Some facilities have gone the whole route of creating a spa-like ambiance with aromatherapy, but you can do simple things like hanging towels on racks, and putting pictures on the walls."