Creating Home:

The New Quality of Life Revisions to LTC Surveyor Guidance

Questions and Answers for Session Two
June 17 & 18

Feeling At Home

Q: What is your view on DPOA's limiting visitors? Do you believe they can do that?
A.There is not a single "one size fits all" answer to this complex question. The key for the nursing home is to individualize, to know their residents and their families so they can appropriately respond to these issues on an individual basis.

Q: I have seen that in F241-Procedure 483.15(a) there is a reference to a Resident Assessment Instrument. Where may I obtain a copy of this Instrument?
A. The Resident Assessment Instrument (RAI) is the overarching name for all parts of the assessment process, including the Minimum Data Set (MDS) and other required portions such as triggers, RAPs, etc.

Q: How should a facility consider visiting areas that allow residents/visitors to smoke? Several of these areas are not as secure as inside the building.
A. This is another issue in which the key is to individualize, depending on the structure of the nursing home, nature of their inside and outside smoking areas, whether they are fenced, what kind of neighborhood area surrounds the home, etc. Each nursing home already has policies governing smoking if they allow smoking at all (homes have the right to go "smoke-free") and policies governing visitors.

Q: Can facilities have "public restrooms" locked - thereby preventing residents from using them in common areas?
A. The goal of the guidance revision is to create a dignified and homelike atmosphere for residents. Nursing homes should take a look at their policy to lock lobby restrooms to determine why they do so and what is the effect on residents.

Q: Have the critical pathways for the QIS manual been revised to include the new guidelines?
A. Not yet, but we are beginning to work on that. The QIS is currently in the stage of being programmed into the CMS data system and we need to allow the programmers to finish their work before making further content changes to the QIS protocols. Surveyors are being trained on the new guidance and will take it into account during both the QIS and the Traditional survey processes.

Q: Any suggestions for behavior residents who are not willing to accept any roommate at all even with prior notifications and meetings?
A. Surveyors will take into account the particular circumstances of the resident in question when evaluating compliance with the notice before room or roommate change regulation. The optimal solution for a particular resident is a matter for the interdisciplinary team to develop.

Q: When considering the use hairnets for staff, shouldn't creating a homelike environment be considered? Using hairnets in individual neighborhoods seems to be contrary to a homelike environment.
A: Hair restraint does not automatically translate to hairnets. Hair should be retrained in a manner that reduces the risk for it to fall into food being prepared. Also this restriction is for kitchen (food preparation areas) and not dining rooms or other eating areas where restraints are not required.

Q: We have a resident who lives in our ALC. He has an Oriental rug in his room that has a very strong odor. You mentioned eliminating odors in the environment, how would you suggest handling this situation? Thank you!
A. This is better handled by the interdisciplinary team than by CMS.

Q: In regards to the visiting hours what if visitors want to stay the night? How do we handle that situation?
A. There is not a "one size fits all" answer for this question. Most homes do not have quarters for visitors. The home should look at its visiting policies and determine how they will respond to this situation.

Q: What if the visitor wants to spend the night?
A. Covered above.

Q: Will life safety change their regulations to allow for families to bring in their own furniture?
A. The Life Safety Code permits residents to bring in upholstered furniture and mattresses provided that a smoke detector is installed in the room or the facility is fully sprinklered. NFPA 101, Life Safety Code, 2000 edition.

Q: What about signs on a residents door notifying staff and visitors of infection precautions?
A. Signs on doors are still very controversial however there should be some method of communicating to the other residents and guest that precautions are necessary before entering a room with "transmission based (isolation) precautions" in place. One alternative is the have a sign which simply informs the visitor or quest to visit the nurse before entering the room.

Q: If your community has a religious affiliation that does not allow for unmarried couples to share a room, can we make this part of our policies?
A. Yes, if this policy is made clear to residents prior to their decision to move in to the home.

Q: Can pictures still be displayed in resident rooms to indicate certain things? Example a picture of a bed stands for the resident is on a turn schedule. A star may mean this resident is at fall risk, etc.
A. Care signs for staff posted on walls of bedrooms is an institutional practice that detracts from the homelike character of the room. Almost always, these signs can be placed out of sight such as inside the closet, or staff can carry care information cards with them. Some homes are using symbols instead of words or pictures, but often residents get to know what these symbols mean and will tell surveyors they are upset at being "marked" with some classification (a star, leaf, etc.). The home should look at its practice and determine an optimal means by which their care staff can receive the information they need without diminishing dignity to residents.

Q: Does the nourishment room on a unit need to have a door on it or can it be open to allow accessibility to residents?
A. There is no federal requirement for a "nourishment room" nor any federal guidance on how it is configured. The home should assess its residents, the room, and the intention of the room to determine the answer to this question.

Q: Diners such as Wow Wingery provide paper towels on a stand up dispenser on each table. Is that an acceptable alternative instead of regular napkins?
A. This is ok if this is part of the culture of the community in which the nursing home is located.

Q: Are residents allowed to keep items out on the bathroom counter to be more accessible or does it have to be contained in a bag or in a container?
A. There is no federal requirement preventing toiletries from being accessible to residents. The key is for the home to individualize; it may not be appropriate to do this in every resident room.

Q: When does a resident have the right to refuse a room change?
A. Residents do not have the right to refuse room changes.

Q: What if a resident continues to refuse a roommate in their room, but refuses to pay for a private space? What should be in place to show that you have tried to accommodate the resident as best as possible?
A. Residents do not have the right to refuse to allow a roommate to be placed in their room. This is a matter best handled and documented by the interdisciplinary team.

Q: A number of issues raised today have been implemented as a result of DOH demands or as a result of codes which govern environment ie. call systems -- how do we do both: change yet meet the other codes not mentioned today?
A. Each home must work in the context of its State laws. Surveyors will be knowledgeable about both State and federal requirements.

Q: Is posting symbols on the door plate by the resident's name, for example, lift stickers, fall risk stickers, gait belt usage stickers, a violation of resident dignity?
A. Answered above.

Q: What to the regs say regarding residents having "jobs" at the facility, such as putting up door tags for admission?
A. This is covered at F169, 483.10(h) Work, which says that residents have the right to "perform services for the facility," whether paid or as a volunteer. This regulation has been in place since 1990.

Session One Questions and Answers
LTC Surveyor Guidance Webinar Home