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Promising Practices in Dining and the Environment

The CMS Interpretive Guidelines and Creating Home

A Safe, Clean, Homelike Environment

Below is the full text of the CMS Interpretive Guidelines changes for the tags related to dining.

The CMS Tag Revisions are in red italics.
Portions of new text related to Promising Practices in dining are bookended with these symbols.

The CMS interpretive Guidelines beyond dining can be accessed at: 
June 12, 2009 CMS Interpretive Guidelines.

§483.15(h) F-252 Environment

The facility must provide--

§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;

Interpretive Guidelines: §483.15(h)(1)

For purposes of this requirement, "environment" refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.   A determination of "homelike" should include the resident's opinion of the living environment.

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 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 good practices that serve to decrease the institutional character of the environment include the elimination of:

  • Overhead paging and piped-in music throughout the building;

  • Meal service in the dining room using trays (some residents may wish to eat certain meals in their rooms on trays);

  • Institutional signage labeling work rooms/closets in areas visible to residents and the public;

  • Medication carts (some innovative facilities store medications in locked areas in resident rooms); 

  • The widespread and long-term use of audible (to the resident) 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. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, "From Institutionalized to Individualized Care," Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network;

  • Mass purchased furniture, drapes and bedspreads that all look alike throughout the building (some innovators invite the placement of some residents' furniture in common areas); and

  • Large, centrally located nursing/care team stations. 

Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them. A nursing facility is not considered non-compliant if it still has some of these institutional features, but the facility is expected to do all it can within fiscal constraints to provide an environment that enhances quality of life for residents, in accordance with resident preferences.

A "homelike" or homey environment is not achieved simply through enhancements to the physical environment. It concerns striving for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable.

In a facility in which most residents come for a short-term stay, the "good practices" listed in this section are just as important as in a facility with a majority of long term care residents. A resident in the facility for a short-term stay would not typically move her/his bedroom furniture into the room, but may desire to bring a television, chair or other personal belongings to have while staying in the facility.

Although the regulatory language at this tag refers to "safe," "clean," "comfortable," and "homelike," for consistency, the following specific F- tags should be used for certain issues of safety and cleanliness:

  • For issues of safety of the environment, presence of hazards and hazardous practices, use §483.25(h), Accidents, Tag F - 323;

  • For issues of fire danger, use §483.70(a) Life Safety from Fire, Tag F - 454;

  • For issues of cleanliness and maintenance of common living areas frequented by residents, use §483.15(h)(2), Housekeeping and Maintenance, Tag F - 254;

  • For issues of cleanliness of areas of the facility used by staff only (e.g., break room, medication room, laundry, kitchen, etc.) or the public only (e.g., parking lot), use §483.70(h), Tag F - 465 Other Environmental Conditions; and

  • Although this Tag can be used for issues of general comfortableness of the environment such as furniture, there are more specific Tags to use for the following issues:
  • For issues of uncomfortable lighting, use §483.15(h)(5), Tag F - 256 Adequate and Comfortable Lighting;

  • For issues of uncomfortable temperature, use §483.15(h)(6), Tag F - 257 Comfortable and Safe Temperature Levels; and

  • For issues of uncomfortable noise levels, use §483.15(h)(7), Tag F - 258 Comfortable Sound Levels.

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