Points to Ponder: Regulations

 By Debbie R. Bera, AC-BC, ADC

I’m sure many of you feel as I do, too many regulations and not enough time to spend with the residents! Lest we forget the reason behind OBRA, it is to protect the rights of persons needing care in the long term care environment. It will protect you and me if we need care in the future, which I find comforting .

Regulations have brought about the need for much more documentation than ever in the history of the profession. Though my least favorite part of my job is documentation, I do have an appreciation for it because it does make you review your program, the resident’s needs. When done with a degree of purposefulness and accuracy it does ultimately provide better care for those living in our homes. I’m sure you would all agree with this after giving it some serious thought. Pre-OBRA, there were some pretty terrible things permissible within long term care settings: quite literally tying people up with restraints, tying wheelchairs to railings to prevent wandering; force feeding residents with syringes to speed up the process, over medicating to prevent unwanted behaviors. These are just some things that I personally experienced when beginning my career in the long term field. Most everything was done for staffs’ convenience with little or no thought or regard to the residents’ desires or needs much less their rights as human beings. One of my very first thoughts, when I started as a nursing assistant was, gosh people treat their dogs better than the people who are living here! And as God is my witness – that is the truth!

We are all aware that there has been a lack of consistency in the regulations and survey process. This is true within states themselves and from state to state. As with anything there is always room for improvement. I do feel that CMS is working to bring about a better system for the delivery of the survey process with the recent and ongoing changes they have made. There continues to be horror stories of surveys from hell (I’ve had them a time or two as well). You do have the right to report these kinds of surveys to the survey team’s superiors and that’s the best you can do in these situations.

Let’s just take some time to reflect and consider some thought-provoking questions regarding regulations.
Would you really want Federal regulations for hours of activities? Think about this question. Many would probably initially respond in the affirmative, feeling that you would gain hours and hence staff. This might be the case, but for some they would likely lose staff because now they would be considered “overstaffed.” Wouldn’t a better approach be to staff according to the needs of the clientele you serve? Higher acuity in cognition and functioning would mean you would staff higher to meet these needs and the opposite would be true for those with less cognitive and physical declines. Wouldn’t this be a much more meaningful and beneficial way of staffing to meet resident needs, regardless of the department within the facility? It certainly seems to make sense to me. So another question than comes to mind – how do we convey this to the powers that be?

Some say activities should be a reimbursable service. Consider this, would making it a reimbursable service negate some professionals serving as Activity Directors (or whatever term you use) from remaining in their positions? Sometimes we have to be careful what we wish for on an immediate basis and consider the long- term outcomes that might result from a certain change. Actually, you can develop restorative programs that are done with activity staff and receive reimbursement for them. (But that is another subject, one in which I have some knowledge of, perhaps another time.)

There are some who would like to see F248 changed, particularly removing state approved course and two years experience in a social or recreational program. Would you really want regulations to specify only one particular program as an option for being qualified as an Activity Director? The word monopoly immediately comes to mind, and usually having a monopoly on something is not best for the consumer. Rather, wouldn’t establishing specific guidelines for course content, no matter who is providing it be a better course of action? Having just two years experience to be qualified to run an activity program in my opinion does not do the profession justice, and almost seems to give the appearance that activities are not as important as other disciplines in long term care. It seems a low requirement for such an important role – but this is just my opinion, what’s yours? One thing is certain; it is difficult to get regulations changed. NAAP has broached this subject with CMS in the past. Maybe you are not aware, but NAAP did have input into the rewrite of F248 and F249 interpretive guidelines back in 2004 until they were published in final stage in 2006. CMS does reach out to NAAP as the recognized National Activity Association and we have a long history of cooperation with CMS.

I’ve touched on a few regulation topics but hopefully have provided some fuel for thought. So where do we go from here? Educate regulators about the Activity Profession? Offer to speak at their conferences and training sessions? Invite them to your conferences and educational opportunities? Expand relationships to other health care organizations (there is clout when branding with “big” names)? Find a common ground with CMS? Form a partnership role instead of an adversarial role?

I think a good place to start is right within your own facilities. Something I learned from my mother is you should always start with your own home to make changes, before you start to change the world. How do you view the survey process when the surveyors walk in? What is your attitude? Don’t you feel you should always be “survey ready?” Shouldn’t you always do things as if the surveyors are in your building? Wouldn’t this be the ultimate in care giving for those who choose your facility for their home? It seems to me it would, and that is the place I would choose to go to if I was in need of long term care! So in closing, would you choose your facility to provide care to you? If not, start now to make the necessary changes so you can answer with a resounding yes! After all, that is the purpose of regulations, to make sure resident needs are met, not to make your life miserable, should be the purpose. Often times simply changing attitudes is all that’s needed to change the world!