It doesn’t have to be so Institutional per State and Federal Requirements

Did you know living in a nursing home could and should be terrific by state and federal regulations? I will use federal CMS regulations to make this case. Because most state nursing home regulations as well as state assisted living regulations tend to follow federal, they tend to support a terrific life as well.

What seems to be the enemy is the institutional model/culture/way that we have all inherited but can also reject. Most people are unaware of the many culture change practices implemented over thirty years of an international culture change movement.

One tool that makes this case is the Artifacts of Culture Change which was funded by CMS Division of Nursing Homes and debuted in 2006. Funded by CMP reinvestment funds, an Artifacts of Culture Change 2.0 for Nursing Homes and a first-ever Artifacts of Culture Change for Assisted Living were developed in 2021 and are found at https://www.pioneernetwork.net/artifacts-culture-change/.

Did you know daily life should revolve around the people who live there as individuals? It should be all about them and not about the institution, the institutional schedule or anything for staff convenience:

Tag F600 Abuse
Characteristics placing residents at risk for abuse include:
Policies operate in the interests of the institution rather than residents.

Did you know this means policies should operate in the interests of the people who live there, not the institution?

Did you know this means systems should be flexible honoring those who live there?

Systems should honor each person’s preferences:

Tag F558 The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Tag F636 Comprehensive assessment. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument.

In fact, there are 232 references to meet preferences in CMS regulations and guidance.

Did you know that each individual has the right to choose their own schedules? Again, this means systems should not be rigid, but instead flexible and open:

Tag F561 Self-determination.
Right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part.

Did you know individuals living in nursing homes have the right to make choices about things that are important to them? Anyone living in a nursing home can indicate something is significant to them and that is to be honored. Think of the many examples: sleep until one wakes, eat when one wants to/is hungry, food allergies/sensitivities/preferences are known and followed, desires for volunteering/being connected to family/serving in the community/having a dog or cat or bird are actively supported, individuals are asked every step of the way about their needs, desires, preferences, team members go out of their way to make it “all about me” about each person, unashamedly, with no backlash, rolling of the eyes, etc.:

Tag F561 Self-determination.
Right to make choices about aspects of his or her life in the facility that are significant to the resident.

Did you know each person is to be treated with respect and dignity? An individual is asked first if they want their meds and naturally administered their medications discreetly and privately, not in the middle of the hall. No person is treated less than or like a child. No one is told, “I told you already” or “I took you already (to the bathroom),” belittled or made to feel bad for asking for help:

Tag F550 Resident rights.

The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality.

Did you know each person’s quality of life is to be taken seriously? It is recognized that medical care is only part of life. Each person is known – well known – their interests, skills, talents, gifts even if minimal. If an older person who doesn’t respond much anymore has a beautiful smile, everyone compliments that person and thanks them for it, enhancing their quality of life:

Tag F550 Resident rights.

The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality.

Did you know quality of life is to be a part of every part of life in a nursing home?

Tag 675 Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care

Did you know quality of life is to be taken so seriously that if it is not, it can rise to the level of immediate jeopardy?

Noncompliance at F675 identifies outcomes which rise to the level of immediate jeopardy and reflect an environment of pervasive disregard for the quality of life of the facility’s residents.  This can include the cumulative effect of noncompliance at other regulatory tags on one or more residents.

Did you know that each person’s individuality is to be recognized, each is to be treated in an individualized way, not generic? The institution says to treat everyone the same, no one gets specialized treatment. Because as many have said, if you treat someone special, “they will all want to be treated special.” How did we get here? We are all different and we are to be recognized as different and special and unique as individuals:

Tag F550 Resident rights.
The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality.

Did you know the following requirements take the already mentioned rights up a notch? You, me, a home, a team is to protect and even promote these precious rights which are only a few of them mentioned thus far:

Tag F550 Resident Rights.
The facility must protect and promote the rights of the resident.

 Did you know even legal representatives, which may be family, friends, guardians must also consider the person, their wishes and preferences? Representatives do not have the right to push their preferences onto a person:

Tag F550 Resident Rights. The resident’s wishes and preferences must be considered in the exercise of rights by the representative.

Combine these fantastic regulations with those mentioned in previous articles for providing

• services for each individual to reach their highest practicable physical, mental, psychosocial wellbeing per Tag 655;
• support for the domains of wellbeing: identity, security, autonomy, meaning, connectedness, growth, and joy per Tag 679;
• an environment that de-emphasizes the institutional character of the setting per Tag F584,

and actually many more.

A nursing home or assisted living chooses to comply with the state and/or federal requirements that regulate them, so these should not be surprises.

The institution, the institutional model, institutional culture are not required. The institutional ways have been inherited, they are not required, and you do not have to follow them. You do not have to have an institutional culture and regulations support you in breaking free from it.

Carmen Bowman, MHS, was the first NCCAP Certified Activity Professional to be a state and federal surveyor also working at CMS Central Office Division of Nursing Homes. She calls herself a Regulator turned Educator and her business Edu-Catering: Catering Education for Compliance and Changing Institutional Culture. She teaches how changing institutional culture can be done USING regulations and how to go beyond “activities programming” to giving people back real life.  She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. Join her new blog and consider her new eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC at  www.edu-catering.com. At the Edu-Catering YouTube channel, see how turning rigid schedules into flexible ones creates all the outcomes everyone wants!