Long-Term Care Survey Alert

Is your facility planning on doing something new to improve residents quality of life? If so, your best bet is to work with regulators up front to avoid survey citations and surprises on the back end..

The Centers for Medicare & Medicaid Services provided that valuable advice during its recent Webcast on promoting quality of life in nursing homes, which featured the Pioneer Network (http:/ /cms.internetstreaming.com). The network is a group of providers, consumer advocates, surveyors and others whose aim is to put the "heart and soul" into long-term care practices.

Giving survey agencies a heads up about your plans is important because "facilities may do something new to improve residents quality of life but quality of care somehow slips through the cracks" noted Carmen Bowman, a Colorado surveyor and avid Pioneer Network advocate who spoke during the CMS Webcast. "Remember that one can discover deficient practices with new ways of providing care as well as the old ways," Bowman cautioned.

Regulators can help facilities identify regulations that may get in the way of an innovation. Even though federal regulations dont pose barriers to new practices in nursing facilities, state laws can work against homelike environments or attempts to "Edenize" facilities by bringing pet animals in house.

For example, state regulations may ban microwaves in residents rooms, or dictate a certain water temperature for small dishwashers or clothes washers in resident living areas. Even so, most states will grant variances and waivers and work with providers to support innovative practices.

"Providers can figure out how to do their program within the guidelines," reports Megan Hannan, a trainer with Action Pact in Milwaukee, WI, which works with organizations implementing culture changes to improve resident quality of life.

"The goal isnt to get as many waivers as possible to make a new idea work," Hannan explains. Instead, providers should determine how to structure their plans in ways that will make the state happy.

Meadowlark Hills Retirement Community in Manhattan, KS sidestepped the state-mandated water temperature requirement by installing industry-strength dishwashers in each of its new family-style households for skilled nursing facility residents.

"Stainless steel is in style now and looks nice but we didnt want to risk the water temperature being too low," reports Steve Shields, executive director of the retirement community.

The facility also went with the heavy-duty machines to save labor. "The industrial dishwashers are very fast, which means staff dont have to spend hours in the kitchen and, therefore, have more time for residents," Shields explains.

While you might have leeway with some rules, many fire safety codes are written in stone. For example, facilities cannot have furniture in the halls blocking movement toward exits in case of a fire. So facilities have to figure out how to make their environments more homelike without violating the regs.

"Thats easier to do if you are building out new space for example, you can put in alcoves of seating space that dont impede resident evacuations," says Marie Infante, an attorney with Mintz, Levin, Cohn, Ferris, Glovsky & Popeo in Washington.

Even if youve worked with state regulators in implementing an innovation, dont take for granted that the survey team will be up to speed on your new and improved way of doing things.

Infante has seen facilities make physical plant improvements where they work with state regulators to meet life safety regulations "and then surveyors, who may not know the codes like they should, cite the facility for changes that are already approved." So be prepared to roll out the documentation to show you received a thumbs up on your renovations.

Its best to apprise surveyors of even simple changes like the fact youre disguising or hiding treatment or medication carts, suggests Beth Klitch, principal of Survey Solutions in Columbus, OH. "Otherwise, surveyors might worry your facility doesnt have those things," she notes.

Explain such changes to surveyors within the context of the facilitys philosophy and goals, Klitch advises. Using the above example, the facility staff might say, "Were keeping our med carts locked in the utility room when not in use for safety reasons and also to improve residents quality of life by making the facility less clinical in appearance."

Or say youve renamed your charge nurses "neighborhood coordinators" or dubbed your nursing assistants as "resident assistants" to move away from a medical model of care. "Just tell surveyors who does what and can answer their questions," CMS Bowman advised providers. "And if were asking the wrong staff person, point us in the right direction."

And dont forget to explain innovations to state ombudsmen or adult protective workers who may visit your facility, Klitch adds. Otherwise, they could get confused about what they see and call in the regulators for suspected violations.

In spite of your best explanations, however, some individual "old school" surveyors may still balk at innovations. "They may flip out over innovations, such as new care plan models," Infante warns. "But surveyors authority to cite deficiencies is dictated by the language of the regulations and not by their opinions or what they prefer to see in practice."

As Bowman emphasized in CMS Webcast: "Facilities have the right to explain their new practice, and it is surveyors job to give them that opportunity." Bowman also admonished surveyors to be aware that they will be seeing more innovation. "The time has come," she said.