Green House Blog

Partnering with Regulators for a Better Future in Long Term Care

Is there a time where you found institutional rules and practices getting in the way of an Elder’s quality of life? Have you ever wished you could ask CMS a question to gain clarity on how to best serve an Elder while meeting the regulations? If so, stop rubbing that genie bottle because your wish has been granted!

Earlier this morning, deputy division director for the Nursing Homes Division at the Centers for Medicare & Medicaid Services (CMS), Karen Schoeneman ,challenged us all to brainstorm questions we have around culture change.  In her role with CMS, Karen and her team administer the long-term care survey process, the interpretive guidelines and the Quality Indicators Survey process. In addition, Karen and her colleagues commit to publishing a Q&A letter that tackles hot topics in culture change.

As champions of The Green House model and the appreciative inquiry approach, what would you like to see addressed in their next publication? (Don’t worry about Life Safety Code, as that issue is being addressed in a separate response.) We’ll collect all of your thoughts and send them to Karen ASAP!

3 thoughts on “Partnering with Regulators for a Better Future in Long Term Care

  1. As a Recreation Director I have the following observations:

    The new Interpretative guidelines mandating that a “FACILITY” as a whole be responsible for ensuring that all staff be involved in activities (transporting, engagement, leading programs…etc etc.) is just not working. This artificial mandate allows facilities to perpetuate unrealistic and inadequate Recreation staffing ratios. The idea that Recreation Directors can enlist “volunteers” whether they be staff or others is not sustainable. If meaningful small groups , individualized 1:1’s and parallel programming are preferable, within the context of culture change, the Recreation departments need more staff WITHIN their departments!

    Recreation documentation (especially for short termers and the archaic practice of attendance records) needs serious revamping in order to free staff to have their hands on their elders not their charts.

    The punitive and investigatory “gottcha mentality” during the survey process needs to end. It always amazes me that at the “exit meeting”, the citations are explained and that’s it. Surveyors never say what is RIGHT about their findings, what is innovative, what proactive preventative measures they observed. Instead, they dissect interventions that go awry. How’s this for an innovative thought, what about being “collaborative”, instead of punitive. After a survey say, “here’s what we observed that could be improved, made better!”

    All departmental documentation requirements need to be streamlined. Desperately!!!! The notion that “if it wasn’t written down, it didn’t happen” is ludicrous. From just a recreation point of view there are “quality of life” moments, specific to Recreation that are never “documented”. This certainly does not mean that they never happened.

    Although I understand and appreciate the new MDS 3 interviewing process/premise; it is flawed. It has turned out to be MORE time/labor intensive. Questions are ambiguous. Answers often change depending on the “who, when, where” the interviewing is taking place. Hence, a lack of authenticity and deflation of the real purpose.

    Thank you for taking my concerns and observations to CMS. I am a HUGE proponent of culture change. I know it will take time to truly implement. The above are just some of the many stumbling blocks that make the “vision” of culture change unattainable.

  2. As a former Green House Project student intern I am familiar with the Green House model. Currently I work as an RN in a nursing home and am astounded by the amount of paperwork and the laborious process of passing meds to my residents. I am told it is regulation to pour each med, sign it out in MARS, pour the next med, sign it out in MARS and with narcotics, to unlock the narcotic drawer in the med cart, retrieve the narcotic, then re-lock the narcotic drawer, sign out the med in the narcotic book, then sign it out in the MARS, then repeat the process for the next drug or narcotic. Once one resident’s meds are poured, I then lock the med cart, deliver the meds to the individual, return to the cart and start the process over for the next person. If my resident is not awake or is in the shower, I cannot store the poured meds, but must waste them and repour when they are awake. I understand in part the safety reasons for the methodical process and that if it is not done just so when regulators come to observe, the facility suffers a consequence. The Green House model has replaced the institutional med cart with locked medication boxes in each residents’ room. My facility isn’t a Green House but would like to transition more into the “household” model. The med pass is an excruciatingly tedious, labor intensive task that detracts from my being able to deliver individualized patient-focused care. I cannot accept that there is not another way to pour meds that can be both safe and time saving. I would like to know what other alternatives regulations might allow, such as a large container with separate labeled sections for each resident that could be used to store the individually pre-poured meds, so that the time required to do a med pass can be used efficiently while also honoring the unpredictability of resident schedules? I understand the 5 Rights and practice them, however, the required methodology of med pouring takes time and energy away from the desired human to human patient care. I am told it is against regulations to prepour meds and I am unable to accept that as the only option to ensure resident safety. I might have between 16 and 28 patients with two or more med passes. My time is therefore a scarce resource that should be spent on therapeutic interactions with my Elders rather than tediously following the letter of regulatory law. I would like to pour my meds in advance, store them securely and do a med pass that flows according to resident needs, and current regulations as I have understood them do not allow for this.

  3. Karen and the CMS team, MANY thanks for all the work you are doing to make world building a rewarding challenge for all of us. More lives than just mine have been enriched because of your efforts. I am new to the processes of MDS 3.0, MMDSs (here in Maryland), and the many updates (such as Care Plans) that are do on a regular basis.

    Any suggestions you have to coordinate the timing of monthly and quarterly assessments would be greatly appreciated, especially because being able to do them all at once would be beneficial in so many ways.

    Thanks again for your efforts, they are making a difference and a brighter future for all involved.

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