Artifacts of Culture Change Self-Assessment for Nursing Homes

Welcoming is intentional by the community utilizing such methods as a welcoming committee/welcome wagon, resident buddies/mentors, first meals set up with specific individuals who either work and/or live there, an event is held for others to meet the new person, assigned team members meet with the new person, etc.

(Refer to CMS F809 Frequency of meals, Alternate dining times)

(Refer to CMS F809 – Frequency of meals / snacks at bedtime)

Refer to CMS F692 Diet Liberalization, and Dining Practice Standards*: A national task force of clinical standard setting organizations, culture change leaders, and CMS developed evidence-based standards to enhance both nutrition and satisfaction with food and the dining experience. Research has shown that restrictive diets for older individuals in long term care are of little benefit, and in fact can be detrimental. These diets often cause residents to reject their meals, leading to weight loss. Restricting sugar, salt, or fat make little difference in blood sugar, blood pressure, or cholesterol in the older person. Research evidence shows that a liberalized, regular diet for most residents can enhance quality of life as well as contribute to maintenance of physical health. The Pioneer Network developed the Dining Practice Standards Toolkit to assist providers in implementing the Standards. (Both available on Pioneer Network website.)

(Refer to CMS Tag F561 Self-determination, CMS Tag F578 Right to request, refuse or discontinue treatment)

Refer to Dining Practice Standards: Real Food First: The Dining Practice Standards include a section on using real foods instead of and before the addition of artificial dietary supplements Research has shown frequent resident rejection of supplements, with consequent weight loss. Real foods are individualized according to a resident’s abilities to chew and swallow. Examples of real foods are smoothies, shakes, malts and/or protein and fiber powders when extra protein is needed.

(Refer to Dining Practice Standards)

(Refer to CMS F741 Non-pharmacological approaches)

(Refer to CMS F741 Non-pharmacological approaches)

Check "Partially Implemented" if pets only visit and do not live on the premises.

Check "Partially Implemented" if available only in certain neighborhoods.

(Refer to CMS F561 Self-determination)

(Refer to CMS F561 Self-determination)

Care plan refers to the MDS generated care plan document as well as other documents and/or processes used by the community to support sharing of the resident driven comprehensive plan of care. This can include the medication administration record, treatment administration record, a kardex system, getting to know you documents, and should be supported in community policies and procedures.

The Bathing without a Battle book and DVD provide research-based information on proven methods to enhance the bathing experience for those who resist traditional techniques. It contains valuable information on bathing, showering, bed baths, and hair washing methods to accommodate residents’ fears and pain to produce a pleasurable outcome for both residents and team members. (Available on Pioneer Network website.)

(Refer to CMS F561 Self-determination)

(Refer to CMS F561 Self-determination)

(Refer to CMS F561 Self-determination)

(Refer to CMS F803 Menus)

(Refer to CMS F866 QAPI Program)

(Refer to CMS F699 Trauma-informed care)

A life story goes beyond the typical social history, to provide detailed information about what makes this person unique. It goes beyond demographics such as marital status to cover what makes the person special.

(Refer to CMS F656 Comprehensive Care Plan)

(Refer to CMS F688 Mobility, CMS F676 ADL’s: Mobility)

(Refer to CMS F697 Pain management, CMS F741 Non-pharmacological approaches, CMS F679 Activities)

(Refer to CMS F679 Activities)

(Refer to CMS F684 Quality of Care)

(Refer to CMS F553 Right to participate in care planning)

(Refer to CMS F657 Comprehensive Care Plans)

(Refer to F657 Comprehensive Person-Centered Care Plans)

The term "approach" is used as a culture change term instead of "intervention." An intervention in society at large refers to a dire situation for which there must be an intervention. Individualized approaches are actually what has always been meant since the approaches used for one person are different/individualized from the next.

Check Fully Implemented if resident living areas are 16 or fewer residents. Check Partially Implemented if resident living areas are 17 to 24 or if development of smaller living areas is in process. Check Not a Current Practice if resident living areas are more than 25.

Privacy-enhanced, shared rooms have a partial wall between two sides of a shared room, typically floor to ceiling. Sometimes the wall is removable for choice purposes. This gives better privacy than a curtain and two people still typically share one bathroom.

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F558 Accommodation of needs)

(Refer to CMS F558 Accommodation of needs)

(Refer to CMS F558 Accommodation of needs)

(Refer to CMS F584 Environment)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F919 Resident Call System, audible or visual)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F584 Homelike Environment)

(Refer to CMS F583 Privacy)

Locked living areas (secured memory care units) are now viewed as “the hidden restraint” and homes that have unlocked them find that people who are no longer locked in do not have the negative reactions that come when any person is locked up.

(Refer to CMS F686 Skin Integrity)

Instead of referring to admission, being admitted or a “new admit,” culture change/non-institution speak refers to the more natural process, of moving in. Combined with welcoming, the process is intentional about ensuring each person is made to feel comfortable and at home. The move in process takes place over a period of time and is not limited to the day of move-in.

2012 LSC Edition Seating

18.2.3.4 Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2440 mm) in clear and unobstructed width, unless otherwise permitted by one of the following:

(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 18.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 18.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses’ station or similar space.

Annex Material:

A.18.2.3.4(5) The means for affixing the furniture can be achieved with removable brackets to allow cleaning and maintenance. Affixing the furniture to the floor or wall prevents the furniture from moving, so as to maintain a minimum 6 ft (1830 mm) corridor clear width. Affixing the furniture to the floor or wall also provides a sturdiness that allows occupants to safely transfer in and out.

FSC Handbook Commentary:

The provisions of 18/19.2.3.4(5) are new to the 2012 edition of the Code. The material was added to help make the health care occupancy setting, particularly that of nursing homes, more homelike. The provisions reflect the trend of the nursing home industry to move away from institutional models to a new household model. A lengthy corridor that provides no place to sit can make a resident’s travel to the other end of a corridor, as might be done to visit another resident, an arduous task. The provisions of 18/19.2.3.4(5) permit fixed furniture in corridors that are at least 8 ft (2440 mm) wide. Many existing health care occupancies have 8 ft (2440 mm) wide corridors, as they were built to the requirements of this Code applicable to new construction.

(Refer to CMS F584 Safe Environment, comfortable lighting)

(Refer to CMS F604 Respect and dignity, free from physical restraints)

(Refer to CMS F550 Respect and dignity)

(Refer to CMS F584 Comfortable noise level)

According to The Eden Alternative®, “Care partnership implies a balance of care — that opportunities to give as well as receive are abundant and experienced by everyone in the care relationship. Whether two people are friends, neighbors, family members, or client and provider, the relationship is mutual and therefore both people are giving and receiving. Instead of giving care, someone partners in care.” (Refer to The Eden Alternative website “Worlds Make Words” document)

Select "Partially Implemented" if team meetings are held, but less than daily.

A troubleshooter is a team member from any department/team whose role is to ensure things get done for their resident. There are often many things going on with one resident across various departments/teams. For example, a team member from Maintenance, who is the troubleshooter for Mr. P, notes that his request for change in breakfast items has not been fulfilled, his wheelchair wheels squeak, he is missing his winter coat, and has asked for a dentist appointment. The troubleshooter converses with people in the relevant departments/teams to determine status and keep Mr. P informed.

Learning Circles are group meetings in which a topic is posed, and each person speaks in turn with no crosstalk or discussion until the whole group has spoken. This process honors those who are reluctant to speak up and reins in those who can dominate a conversation. Learning Circles were brought to the culture change movement by LaVrene Norton of Action Pact, and more information is available at the Action Pact website and in the Resource Library on the Pioneer Network website.

Select "Partially Implemented" if community meetings are held less often than weekly.

This can occur through participating in events such as state and national culture change conferences and webinars, as well as review of resources. They share information gained team members, residents and families.

(Refer to consistent staffing language at CMS F689 Accidents and F741 Non-pharmacological approaches)

(Refer to consistent staffing language at CMS F689 Accidents and F741 Non-pharmacological approaches)

(Refer to consistent staffing language at CMS F689 Accidents and F741 Non-pharmacological approaches)

This could mean that the home is flexible with accommodating the need for a team member to be able to attend classes during their normal work hours, scholarships, etc.

(Refer to CMS F943 Abuse, Neglect, and Exploitation Training, CMS F947 In-service Training for Nurse Aides, F949 Behavioral Health Training)

Non-institutional language considers the person first, enhances dignity, and is not pejorative or paternalistic. For example, facility becomes home, unit becomes neighborhood, wheelchair-bound becomes person who uses a wheelchair. Pejorative language “we allow our residents to sleep as long as they want” becomes “we support residents to sleep until they wake up.” Pejorative is also teams such as “the girls on 2nd floor,” “the feeders,” “our” residents, and referring to people as room numbers — “112B has her call light on again.” Paternalistic language like, “Are we ready for our shower?” becomes, “What time would you like your shower?” This also includes such terms as “he’s a complainer” and sing-song language used for babies. (Refer to language resources in the Resource Library on Pioneer Network website under the Culture Change Fundamentals category.)