CMS Tag F741 Non-pharmacological Approaches – Adjusting environment to be more homelike: De-emphasizing the institutional character of the setting

CMS Tag 741 includes a long list of examples of individualized, non-pharmacological approaches to help meet behavioral health needs. We will be reviewing all of them. Food preferences, exercise, pain relief, individualizing sleep, dining, bathroom routines, preferred lighting and comfortable sound levels have been discussed in previous articles and now we highlight:

• Adjusting the environment to be more individually preferred and homelike….

CMS uses the term homelike since 1987 and CMS’ definition is incredible.

CMS Tag F584 Safe, Clean, Comfortable Homelike Environment

DEFINITIONS §483.10(i)

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. A determination of “homelike” should include the resident’s opinion of the living environment.

De-emphasize the institutional character of the setting; did you know that is in CMS regulation?  There is so much i could say about that but for this article I would like to focus on CMS’ own examples in its own Guidance for Tag F584.

GUIDANCE §483.10(i) 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. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible.

Some practices that can be eliminated to decrease the institutional character of the environment include, but are not limited to, the following:

• Overhead paging and piped-in music throughout the building.
• Meal service using trays (some residents may wish to eat certain meals on trays).
• Institutional signs labeling work rooms/closets visible to residents and public.
• Medication or treatment carts (some store medications in locked areas in resident rooms or in secured carts that appear like furniture).
• The widespread and long-term use of audible chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic.
• Furniture that does not reflect a homelike environment or is uncomfortable; the absence of window treatments or drapes; the lack of textures or the absence of bedspreads or personal items in rooms or on walls.
• Large, centrally located nursing/care team stations, including those with barriers (such as Plexiglas) that prevent the staff from interacting with residents.

Let’s take these one at a time.

Eliminate Overhead Paging

Not using overhead paging is considered a culture change practice as evidenced in the original and Artifacts of Culture Change 2.0:

Artifact 70. Team members communicate with each other without using overhead paging.

Artifact 82. Except for emergencies, the overhead paging system has been turned off. This includes not paging over speaker phones. (Refer to CMS F584 Homelike Environment)

Many communities stopped using overhead paging even before our ability to easily text or call one another nowadays. People describe it as quiet and normal as we don’t have overhead paging in our homes. People also say they would never go back to using such an institutional noisy practice.

Eliminate Piped in Music

Piped in music traditionally has been found to be confusing to some and annoying to others depending upon cognition and hearing abilities. Then again, some communities maybe decide to play music at times. I know of several who play a song at strategic times to encourage movement/dancing for increased individualized movement; one of a 12 part series I teach called Proactive Practices to Prevent Falls. If you don’t move it… you lose it.

Eliminate Meal Service using Trays

Hopefully most communities no longer use trays. At the least we promote removing food from a tray. This is another culture change practice.

Artifact 75. In dining rooms, meals are not eaten on trays. Food is removed from any tray used for transport. (Refer to CMS F584 Homelike Environment)

I do see a preponderance of food delivered on trays again and would encourage homes to get back to point of service delivery instead. Even more efficient than steam tables are hot food carts. The SuzyQ Cart is designed to be brought table to table, people can see and smell their choices. Food is hotter and choice is maximized. When people choose, money is saved from less waste, and many communities turn around and share remaining food with team members.

Eliminate Bed and Chair Alarms

Eliminating bed and chair alarms has become the norm thankfully. Get this, I co-authored a book called Eliminating Alarms and Preventing Falls by Engaging with Life. Because so many have eliminated alarms, the title is sort of outdated. But that was the goal. And if you are still using them check this out too, subtitle of the book is Alarms: The New Deficient Practice as alarms can be deficient at about 7 CMS regulations.

Eliminate Over-Labeling of Rooms

Where this comes from is the institutional practice of the over-labeling of rooms. Dining Room or Living Room seem obvious and not what we do in our homes. Somes rooms are required to be labeled such as those with hazardous materials but not usually every single room.

Eliminate Medication and Treatment Carts

Many culture change homes eliminate the institutional icon, the med/treatment cart. Some moved to dresser looking carts, better yet some created double-locked med drawers and cabinets in rooms. This has long been considered a culture change practice.

Artifact 59. The home has eliminated, or never used, medication carts. (Refer to CMS F584 Homelike Environment)

Furniture, Window Treatments, Textures, Bedspreads and Personal Items

Institutional furniture is usually uncomfortable. I have seen teams dedicated to this issue purposefully put chairs of various kinds and various heights in homes so that people have choice of furniture that fits their body, isn’t that fantastic? I have also seen organizations welcome people to bring their own furniture and bedspreads from home. Yes, really. Did you know you could too? The key is committing to using the flame-retardant sprays keeping up with the manufacturer’s directions such as once every six months. Often a person’s bedspread these days is already flame-retardant I have also seen the same organization actually, offer choice to people moving into a room for their preferred color scheme of paint and drapes, etc.

Does it make anyone else sad or is it just me that people are often advised not to bring personal items as they may get lost or stolen? One remedy I have seen work well for this is to offer of a locked curio cabinet. People should have their personal items, their artifacts, their antiques, their handmade items, their favorite things around them.  Would you agree?

Last but not least, everyone should also have their personalized wall. Many people have a wall that shows who they are with pictures, diplomas, certificates, awards and other special identifiers of their life.  Each individual should have their own wall, or walls, that really depict who they are. I recommend making this more of an expectation of people particularly family members to please help you to learn this person quickly. They know their mom or dad their whole life; you are just starting to get to know them. Encourage, even insist, there be all sorts of photos of their life perhaps even labeled to help you much quicker get to know this new-to-you individual. A premise of the culture change movement is to help people feel well known we call it being well known.  Notice how this regulation supports it. Think of how it helps the person as well to have their lifetime memories around them such as Rose from the Titanic even on the ship when she was older.

Eliminate Nursing Stations

Many culture change homes intentionally take out nursing stations as they too are an institutional icon.

Artifact 59. The home has eliminated, or never used, medication carts. (Refer to CMS F584 Homelike Environment)

Please remove those especially with barriers such as Plexiglas that prevent team members from interacting with those who live and stay there and need the human connection. I actually have photos of people whose home it is involved with demolition day! In the same space normal tables and chairs and desks are added. Always think normal. Rampant Normalcy is a goal of the culture change movement. Tucking medical records away into a normal cabinet also does wonders to de-institutionalize and create home.

In an upcoming articles we will consider the shift from using the term homelike to avoiding that term and instead focusing on home. Using the word home is powerful and then working hard to make sure it is real home is even better.

But for now let’s celebrate the wonderful definition CMS has given us here and permission to deinstitutionalize the institutional character of the setting. Does your entire team, community, organization, company know this is actually within CMS regulations?!

Carmen Bowman, MHS, Regulator turned Educator of Edu-Catering: Catering Education for Compliance and Changing Institutional Culture is an activities/engagement/community life, regulatory compliance and culture change consultant.   She is a co-developer of the Artifacts of Culture Change original and 2.0 and Assisted Living versions. She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. At www.edu-catering.com join The Be Encouraged Blog, Become a Leader of Normal Life with the eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC and share with your team the eBook Individualizing Medication Administration using Regulations. At the Edu-Catering YouTube channel, see documentaries that highlight changed cultures.