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Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidelines. Part 1: Making Changes and Adapting the Physical Environment Barbara Frank B & F Consulting

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creating home the new quality of life revisions to the ltc surveyor guidelines

Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidelines

Part 1: Making Changes and Adapting the Physical Environment

Barbara Frank

B & F Consulting


Developments in the Field of Long-Term Care that Contributed to OBRA ’87, Culture Change, and to continued development of our understanding of good practice

obra 87

OBRA 87:

Each facility must provide

care and services to:

“attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.”

physical mental and psychosocial well being

Physical, mental, and psychosocial well-being

Quality of Care +Quality of Life


Quality of Care vs. Quality of Life


Health Promotion

New Practice

Institutional Care

Individualized Care

Old Practice

Risk Prevention

B&F Consulting


2004-05, CMS funded QIO pilot, Improving the Nursing Home Culture, staffed by Quality Partners of Rhode Island, in which 254 nursing homes in 21 states, individualized care, significantly reduced turnover and improved clinical outcomes.


CMS Surveyor Training Series

  • “From Institutional to Individualized Care”
  • Part 1: Individualizing Care (Mornings, Alarms)
  • Part 2: Transforming Systems (Nights, Meals, Consistent Assignment, Quality Care Implications)
  • Part 3: Case Studies (Mornings, Meals, Med Pass, Medical Perspective)
  • Part 4: How of Change (Inclusive Leadership, Consistent Assignment, Staff Stability)

Videotapes can be purchased from:

from institutional to individualized care
From Institutional to Individualized Care

Also available from

National Technical Information Services

5285 Port Royal Road, Rm. 1008, Sills Bldg. Springfield VA 22161

Phone: (703) 605-6186

additional resources
Additional Resources
  • RI Dept. of Health Individualized Care Pilot
    • Quality Partners of Rhode Island
    • HATCh – Change Ideas
    • Individualized Care Curriculum

How of Change

  • Quality, the result, is a function of quality, the process
  • A people paradigm: Cannot continuously improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships

Covey, 1991


Key Systems to Individualize Care

Collaborative problem-solving within and across departments: ask “how can we get this done?”

Inter-shift Communication

So Staff have 24/7 view of residents

Start of Shift Rounds

So Staff Work Together, Share Information

Consistent Assignment

So Staff Know Residents Individually

f242 self determination and participation1
F242 Self-Determination and Participation
  • Rights to make choices over:
    • Activities
    • Schedules
    • Health care
    • Interactions with members of the community
    • Aspects of his or her life that are significant to the resident
  • Choices over schedules is specified to include schedules of waking, eating, bathing, and going to bed at night, as well as health care schedules
gathering and using information
Gathering and Using Information
  • Facility must:
    • Actively seek information
    • Be “pro-active” in assisting residents to fulfill their choices
    • Make residents’ choices known to caregivers
where is info on residents choices
Where is Info on Residents’ Choices?
  • Resident, and family/friends
  • MDS
  • Social Work Assessment
  • Social History

You have the information in hand, but do you have it in the hands of those who need it?

just in time communication
“Just-in-time” communication
  • Flow of info – First 24 hours is key
    • Who needs what information by when?
    • Is there coordination between Social Worker and hands-on care-givers?
    • Start-of-shift stand-up
    • Shift-to-shift hand-offs
    • Hand-offs to Weekend Staff

To honor residents’ choices, you need to know residents well individually. To know residents well individually, you need to use consistent assignment of staff.

basics for consistent assignment
Basics for Consistent Assignment
  • Fair distribution of work
  • Matches work for residents and staff
  • Adjust as needed
  • Include nurses, housekeeping, others
  • Resource: Consistent Assignment Change Idea at (HATCh)
the how of change
The “How” of Change
  • Personalize/See Through Residents’ Eyes
    • What do you need for a good start to your day? (a good night’s sleep, when do you like to eat what, what’s a good bathing experience for you?)
    • What happens when you don’t get it?

Ask residents:

What was your morning routine before you lived here?

how of change continued
How of Change, continued
  • 2. Compare to what is currently happening. Keep what works. Examine what doesn’t:
    • How does it work now?
    • When we individualize now, how do we do it?
    • What are the obstacles and considerations?
individualizing mornings obstacles and considerations
Individualizing Mornings:Obstacles and Considerations
  • Breakfast times and central delivery
    • Early risers’ coffee – breakfast cart, carafe
    • Late risers’ breakfast – decentralize food supplies and equipment
    • Breakfast buffets
  • Clinical and Operational Benefits
    • Less agitation, better appetite, less plate waste

“My name is Ilda Ford. I am 95 years old. I have been eating my eggs soft side up most of my life and I am not dead yet”

resources for individualized mornings
Resources for Individualized Mornings
  • From Institutional to Individualized Care (FIIC) Parts 1 and 2
  • Culture Change: A Case Study, available thru your QIO or with FIIC Part 1
  • QPRI Change Idea: Waking and Sleeping
individualizing food not just meals
Individualizing Food (not just meals)
  • What do you like to eat, when?
  • Breakfast foods available – time and place
  • Staff access to sandwich foods and soups
  • Microwaves, coffee pots, Forman Grill
  • In-room refrigerators
  • Late night snacks
  • Resource: FIIC 2 & 3; Change Idea on Dining

A pantry where residents and their families can get anything they want, that’s stocked with the foods they like

individualize the med pass
Individualize the Med Pass
  • Individualize schedule
    • “upon rising” and “before going to sleep”
    • Before meal/after meal
  • Benefits: Opens schedule, frees up nurses
  • Resources:
    • FIIC, Part 3
    • Pioneer Network Newsletter, Summer 2008
individualized bathing
Individualized Bathing
  • Dignity – Webinar Part 2
  • Bath, shower, bed bath, wash-up
  • Time of day and Frequency – Opening rising and bed times, opens possibilities for evening bath, morning shower.
  • Methods Resource:

How of Change, continued

3. Bring people together to figure out how to make changes.

  • What issues do they see?
  • Encourage open dialogue and debate.
  • Use concerns as “to-do” list
include people affected by change
Include People Affected by Change
  • Individualized Mornings:
    • Residents and their families
    • CNAs and nurses working nights and days
    • Housekeeping
    • Maintenance (floor cleaning)
    • Food services
    • Therapies (esp. important for short-term rehab)
    • Medical Director (for med pass and diet Q’s)
how of change continued1
How of Change, continued

4. Pilot changes

    • Start with easy changes that are building blocks (one care area, coffee cart, residents who can easily tell you)
    • Evaluate impact on residents and staff (weight loss, agitation levels, staff time, med pass)
    • Adjust operations and evaluate again
    • Learn and spread
  • Resource: FIIC Part 4
  • Residents’ choices can change
  • Residents may have special needs on a given day
  • Residents have adapted to your schedule. You’ll have to make sure they know that they can have their own schedule without losing out on meals, appointments
individual routines improve outcomes
Individual Routines Improve Outcomes
  • Better Sleep – Better Mood
  • Better Healing
  • Improved Appetite
  • Reduced Agitation; Less Depression
  • Fewer Falls; Better Balance and Mobility
  • Fewer Pressure Ulcers
  • Better transition home from sub-acute care
accommodation of needs tips
Accommodation of Needs Tips
  • About relationship of person to environment
  • Consistent assignment is key
  • Use red flags like falls (do root cause analysis)
  • Special focus when a resident moves in
  • Interdisciplinary collaboration
creating home the new quality of life revisions to the ltc surveyor guidance

Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidance

Part 2: Feeling at Home




Lived Space



Safety Predictability


Judith Carboni, 1987



  • Non-Personhood
  • Disconnectedness
  • Meaningless Space
  • Without boundaries
  • Powerless/Dependence
  • Insecurity/Uncertainty
  • Placelessness

Judith Carboni, 1987

home homelessness continuum
Home – Homelessness Continuum


Severely damaged and tenuous relationship between person and environment

Damaged relationship between person and environment

Weakened, impaired relationship between individual and environment


Strong, intimate, fluid relationship with the environment

Judith T. Carboni, 1987

feeling at home

Feeling at Home:

A strong, intimate, fluid relationship between the individual and their environment


Health Promotion


Institutional Care



Risk Prevention

B&F Consulting 2006


For more information, contact:

Barbara Frank

B & F Consulting