Culture Change Q& A

Clarifications concerning long term care and life safety code (LSC) requirements for Nursing Homes {Questions Regarding Culture Change submitted to and answered by Thomas Hamilton, Director, Center for Medicare and Medicaid Services/Survey and Certification (CMS S&C)}

Question 1: Could the interpretive guidelines explain that handrails are not necessary at the very ends of the hallways on the very small sides of the door? This would allow for filling these unused areas with live plants, for instance, without obstructing egress, and handrails would still be available up to the end of each hallway.

Answer 1: The purpose of the handrail requirements at Tag F468 is to assist residents with ambulation and/or wheelchair navigation. They are a safety device as well as a mobility enhancer for those residents who need assistance. The survey team onsite would need to observe the responses of residents to the placement of objects that block the portion of the handrails that is at the end of a hallway. They would also interview residents to gain their opinion as to whether the objects are interfering with their independence in navigating to the places they wish to go.

Question 2: If a hallway is wider that the required 8 feet, can chairs, benches, or plants occasionally be placed in the hall, and allow the handrails not to be useable in those areas.

Answer 2:

The answer is similar to the above answer. Surveyors would observe and interview residents to determine if the loss if the use of handrail by placing objects in front of them is hampering their independence and mobility.

Questions 3: Could the resident call system (F463) regulation that requires calls to be able to be received at the nurses' station be change to include as well the nurses work areas and direct care workers? Many homes moving away from the institutional model are replacing nurses'stations with normal kitchens, living room, and dining room areas, and using the systems whereby resident calls connect directly to care givers' radio/pagers. Because it is harder to change the text of regulation could the phrase "at the nurses' station" be removed from the following sentence in the interpretive Guidelines: "the intent of this requirement is that residents, when in their room and toilet and bathing areas, have a means to directly come contact staff at the nurses' station."

Answer 3: We agree that it is desirable for resident and /or their caregivers or visitors to be able to quickly contact nursing staff when they need help. The use if modern pager/telephone systems which route resident calls to caregivers in a specified order is a satisfactory way to meet the intent of the requirement at F463. We will make a change in the Interpretive Guideline to reflect this position.

Question 4: Would CMS consider adding to the posting requirements at Tag F 156 (42 CFR 483.10 9b) (10), text similar to that stated in the Tag F 167 about posting of survey results, "... or a notice of the availability." Although this may just be trading one posting for several, some homes really want the create a homely environment without so many postings and many homes are placing postings into a photo album or binder to minimize the institutional look of so many postings.

Answer 4: The purpose of the posting requirement at both F156 and F 167 is for resident and any other interested parties to be able to know the information exists, and to easily locate and read the information without needing to ask for it. What you request above, namely, one posting that advises the public of what information itself is in public and easily accessible such as in a lobby areas in a marked (titled) notebook or album. This includes the following information:

"A posting of names , addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit,(F156)

"Written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits." (F156) and

"The facility must make the results available for examination in a place readily accessible to resident and must post a notice of their availability"(F167)

Question 5: Does the 8 feet requirement (at LSC Tag K39) continue to be necessary since evacuations are no longer done via wheeling a person out of the building in a bed? Could 6 feet meet the requirement? If 6 feet sufficed, this would again refer back to our question regarding the requirement for handrails when something else such as a bench might take up the other 2 feet.

Answer 5: The 8 foot corridor width is a requirement of the Life Safety Code(LSC). Corridors remain a route to use in internal movement of residents in and emergency situation to areas of safety in different parts of the facility. This movement may be by beds, gurney, or other methods which may require the full width of the corridor. We do not believe it would be in the best interests of the residents to reduce the level of safety in a facility.

Question 6: Tag F 368 (Frequency of Meals): You request a clarification that the regulation language at this Tag that "each Resident received and the facility provides at least three meals daily" does not require the resident to actually eat the food for the facility to be in compliance. You also asked for clarification about the regulatory language specifying that there must be no more that 14 hours between supper and breakfast (or 16 hours if a resident group agrees and a nourishing snack is provided). You state that some believe this language means all of the residents must actually eat promptly by the 14th hour, which makes it difficult for the facility to honor a specific residents's request to refue a night snack and then sleep late.

Answer 6: The regulation language is in place to prevent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses until residents receive their next meal. The language was not intended to diminish the right of any resident to refuse any particular meal or snack, nor to dimiinish the right of a resident over their sleeping and waking time. These rights are described at Tag F242 Self-determination and Participation. You are correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered. If surveyors encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue only if the resident(s) complains about the food items provided. If a resident is sleeping late and misses breakfast, surveyors would want to know if the facility has anyting for the resident to eat when they awaken (such as continental breakfast items)if they desire any food before lunch time begins.

Question 7: F370 (Approved Food Sources): You ask if the regulatory language at the Tag that the facility must procure food from approved sources prohibits residents from any of the following: 1) growing their own garden produce and eating it; 2)eating fish they have caught on a fishing trip; or 3) eating food brought to them by their own family or friends.

Answer 7: The regulatory language at this Tag is in place to prohibit a facility from procuring their food supply from questionable sources, in order to keep residents safe. It would be problematic if the faciltiy is serving food to all residents from the sources you list, since the facility woudl not be abel to verify that the food they are providing is safe. The regulation isnot intende todiminnish the rights of specific residents it eat food in any of the circumstances you mention. In those cases, the facility is notprocuring food. the residents are making their own choices to eat what they desire to eat. This would also be the case of a resident ordered a pizza, attended a ball game and bought a hot dog, or any similarcircumstance. The right to make these choices is also part of the regulatory language at F242, that the resident has the tight to, "make choices about aspects of his or her life in the facility that are important to the resident." This is akey right that we believe is also an important contributing factor to a resident's quality of life.

Question 8: Tag F354 (Registered Nurse): "Can the traditional DON role be shared with several registered nurses with each nurse responsible for one or more households or clusters?"

Answer 8: The interpretive guidelines (i.e., Guidance to Surveyors) already contain this language: " the facility is required to desidgnate an RN to werve as DON on a full time basis. This requirement can be met when RNs share the postion. If RNs share the DON position, the total hours per week must equal 40. Facility staff must understand the shared responsibilities." Thus, the position cna be shared; however, a comprehensive set of duties and respoonsibilities of a DON is not specified in the regulation s of interpretive guidelines. We interpret this role to encompass not only general supervision of nursiing care for the facility, but oversight of nursing policiies and procedures, overall responsibility for hiring/firing of nursing staff, ensuring sufficient nursing staff 9F353), ensuring proficiency of nurseaides (F498), active participation in the the quality assurance committee (see Tag F520), and responsibility to receive and act on communications from the pharmacy consultant about medication problems (Tags F429 and F430). A faciliity that desires to have various people share the DON postion would need to consider how these DON duties will be fulfilled in a shared position. As long as these duties are fulfilled, we would consider the facility in compliance with F354, whether or not the position is being shared.

Question 9: Tag F521 (Quality Assessment and Assurance): You ask whether the regulatory responsiblity for this committee to "meet" can be fulfilled of the physician member is not physically present, but is participating through alternate means, "such as conference calls or reading minutes/issues and giving input."

Answer 9: Yes, participation can be achieved through means of telephone conferencing, however, we do not accept the alternative of the physician merely reading documents before or after the meeting. We believe the purpose of the meeting is to provide a forum for discussion of issues and plans, which cannot be adequately fulfilled if the physician is merely reading and commenting on documents, since this does not allow for the interchange of ideas.