CMS Tag F741 Non-pharmacological Approaches – Individualizing Dining Routines

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 and individualizing sleep routines have been discussed in previous articles and now highlight:

• Individualizing sleep and dining routines, as well as schedules to use the bathroom…

A famous quote from the culture change movement is “No longer are the needs of the institution to come before the needs of the individual” by Wendy Lustbader an original pioneer of the Pioneer Network. Did you also know regulations ask for this?

It is good for all professionals to know that schedules in a LTC home should be per those who live there.

CMS Tag 561 Self-determination, Guidance states:

Facilities must not develop a schedule for care, such as waking or bathing schedules, for staff convenience and without the input of the residents.

CMS Tag 600 re: Abuse states: Characteristics placing residents at risk for abuse [part a longer list]:

Policies operate in the interests of the institution rather than residents.

Did you also know there are 232 CMS references to preferences? Let that sink in. Let your whole team know as it is a game changer…

232 CMS REFERENCES TO PREFERENCES

How many people prefer to sleep until they wake up (expanded in last article)? How many prefer to eat when they want to? Does your team know? Does your team ask? How many people living in LTC homes are even asked if they are hungry? That is a sobering question.

Open dining times of at least 2 hours per meal is a culture change practice that turns the rigid meal schedule into a flexible one. Open dining beautifully serves the people who live … and sleep … and eat … in the home… their home.  Open mealtimes support natural awakening and being well rested. Regulations actually support open dining times yet many do not realize it.

CMS Tag F809 Frequency of Meals states:

There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

Sadly, many of us learned this as the 14-hour rule. We should have learned it as the 16-hour rule. Plus, most homes already naturally offer nourishing snacks and bedtime. And what group of people living in an LTC home wouldn’t support more choice? Here is how it shakes out. Consider breakfast from 6:00 am to 9 am, lunch 11 am to 1 pm and dinner 4:30 pm to 6:30 pm. From 6:30 pm to 6:00 am is only 11.5 hours! Better than even the 14 hours.

And here is what most people don’t think about. Your home will be MORE compliant with the several regulation requirements to honor choice… more compliant than ever before:

• Residents have the right to choice of schedules, CMS Tag F561.
• Policies operate in the interests of the institution rather than residents, Tag 600 Abuse.
• Right to accommodation of needs and preferences, CMS Tag 558.
• Residents have the same rights as any US citizen, CMS Tag 550.

Many homes already have open dining times without realizing it. If breakfast is at 7:00 am, could I get breakfast at 8:00 am in the home where you serve? I certainly hope so. This becomes a way to step into open dining easily. Instead of stating that breakfast is at 7:00 am, state breakfast is served from 7:00 am to 8:00 am. That is the key and then work together as a proactive team to keep widening the timeframes.

Think of the benefits particularly right here in considering a person’s day after a good night’s sleep. People who are well rested are more alert. People who are more alert eat better. One home experienced NO WEIGHT LOSS for the first time in seven years thanks to not waking, serving food when one wants – essentially 24-hour open dining – and no longer acting like individuals were doing something wrong when asking for food outside of meals. Westward Heights Care Center team in Lander, Wyoming realized it’s their home, their food and asked, What are we doing? They can eat what they want when they want. And all is better.

Opening up dining times is a blessing for all. In 2001 I got to visit Crestview in Bethany, Missouri where administrator Eric Haider and team were one of the first nursing homes and assisted livings to provide open dining times. The exact times listed above in fact. In one of the hallways at 11:45 am a woman named Wyla told Eric that she just woke up and was ready for breakfast. Even my institutional brain back then said to myself, Oh I bet she is confused, she already had breakfast and she means she is ready for lunch…. Then, we walked into the dining room, and I overheard Eric tell two servers “Wyla just woke up and is ready for breakfast.” That was a first for me. Later the director of nursing added that Wyla no longer had any so-called behaviors either. Of course not.

And there we have it, open up dining times makes person-directed, individualized dining routines possible and is truly a non-pharmacological approach helping those who live and eat in LTC homes to be supported, avoiding unnecessary medications or chemical restraints. It is exciting to truly meet individuals’ routines, choices and to support people to be well rested.

I end with a famous quote from the CMS broadcast From Institutional to Individualized Care Series in 2007 “Clinical benefits, just by going by the residents’ schedule, have resulted in better sleep, nutrition, moods and other outcomes.”

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 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.