< Culture Change

Making Sense of Regulations

There are many reasons to resist change. But while we may be able to overcome fears, break habits and embrace new behaviors, state and federal regulations still often leave us scratching our heads. Part of the struggle with regulations is not having good or full information about them and how they work in light of culture change practices. With funding from the Hulda B. and Maurice L. Rothschild Foundation, researchers at the University of Minnesota School of Public Health have undertaken the immense job of compiling all state and federal regulations on one easy-to-use website - NH Regulations Plus. As the site itself says, "This searchable website will serve as a one-stop location to examine and compare the content of state regulations related to nursing homes, the processes of regulation and exceptions to regulations within a state, recent state changes, innovative nursing-home designs and programs that were accomplished within existing regulations, and innovative state regulatory initiative."

Regulations are designed to ensure a safe environment for residents as well as quality and consistency of care. For decades, regulations were met with paper compliance. However, OBRA '87 changed the focus to success in outcomes and maintenance of the highest level of well-being for residents. Still, the culture change movement struggles to blend innovation and compliance. So often "regulations" are cited as the reason for resistance to culture change. "Oh, we can't do that. It's against regulations." However, few really know just what their state regulations allow, permit or forbid. Many of the "regulations" blamed for blocking progress are created from nursing home staff word-of-mouth, not by state regulators.

According to Dr. Rosalie A. Kane, co-project director for NH Regulations Plus, federal regulations are fairly brief and general. It is at the state level that things get more specific and varied. The website offers pdf downloads of the full federal regulations. But, it is where the site offers views of regulations by state and topic that its purpose as a guide for innovations is most clear.

Through conferences, literature and visits to culture change nursing homes, there is much information to inspire changes in one's own facility. However, because all states are different, facilities must check their own state's regulations to see that they are in compliance before adopting these new practices. In the regulations by state section, users can view specific states' full nursing home regulations with a state-specific table of contents, and can link directly to each state's laws and regulatory agency. Recently, links to state rules for licensure of nursing-home administrators have been added to the state pages, which are a space for inclusion of any specific initiatives or applicable regulations in a state. In Florida, for example, the state page takes users to "Regulations for Restaurants" that are applicable in nursing homes.

In the regulations by topic section, a user can choose a topic such as "Quality of Life" or "Nursing Services," where he or she will view Federal requirements on this topic and related subtopics, a listing of states with their additional requirements concerning the topic and a comparison of state regulations as they pertain to culture change and innovation. The page includes a narrative about how States differ on each dimension, backed up with supporting links to specific states and regulations on the site. In this way, a user can easily verify the specific language of a regulation and view the ways other states address the regulation and its effect on culture change.

Broad topics such as "Physical Environments" are broken down into sub-categories as detailed as bedrooms, toilet rooms, call systems, and the like, and a section on "New Construction" offers state-by-state information about application processes and the state's stance on matters dear to culture change such as kitchens and neighborhood design. Throughout the narratives, users will note italicized sections labeled "NHPlusComments." Here, Drs. Kane and Cutler insert their own editorial thoughts about how a particular provision may affect culture changes positively or negatively, or highlight some inconsistencies or anomalies related to a particular regulation.

As of January, 2007, the section entitled "Art of the Possible" has yet to take shape because the information posted on it will come from folks working in culture change facilities. Kane, along with her co-director of the project, Dr. Lois J. Cutler, are seeking input from facilities that have used creative physical design, unusual staffing programs and unique problem-solving practices that promote privacy, community, resident autonomy and quality of life. The hope is that stories of their successes will help other facilities struggling to balance safety with innovation.

Topics including culture change, quality of care, quality of life, regulatory process, residents' rights, staff deployment and training and technology will be covered in "Art of the Possible."

Even though they have not yet been chronicled on the site, the dialog and subsequent resolutions between culture change facilities and regulators that the creators of the site are hoping for is already taking place.

Federal regulations say nothing about nurses' stations. However, according to Kane, "States address it big time. And states that give it a lot of attention can interfere with the move to [the] neighborhood [model]."

Some states require the nurses' station to be attached to the floor, some that from the nurses' station you can see the doorway of every room that station supervises, and others require no more than a specific distance between station and resident rooms. Theoretically, if a facility was building households but the regulations concerning the nurses' station in its state were interfering with the development of a physical environment that resembled home more than institution, the facility could go to NH Regulations Plus and view other states' requirements for nurses' stations and surveillance. Citing the regulations of other states that allow electronic surveillance may help to get regulations changed in the facility's home state.

The "Regulatory Process" section is also still in development. In this section, users will be able to find information about the process of changing regulations and in making exceptions or waivers to existing regulations. A Florida facility recently went through an example of such a challenge to accommodate residents' requests to have their beds against a wall on one side.

According to Cathy Lieblich, a coordinator of the Florida Pioneers Network, the Pioneers worked in coalition with the facility to get an amendment passed in state legislature to allow beds against the wall as long as there is documentation in the care plan. The amendment reads:

"Residents or their representatives shall be able to request a change in the placement of the bed in their room, provided that at admission they are presented with a room that meets the requirements of the Florida Building Code." (requiring beds to be 3 feet away from the wall on both sides) "The location of a bed may be changed if the requested placement does not infringe on the resident's roommate or interfere with the resident's care or safety as determined by the care planning team in accordance with facility policies and procedures. In addition, the bed placement may not be used as a restraint. Each facility shall maintain a log of resident rooms with beds that are not in strict compliance with the Florida Building Code in order for such log to be used by surveyors and nurse monitors during inspections and visits. Any resident or resident representative who requests that a bed be moved shall sign a statement indicating that they understand the room will not be in compliance with the Florida Building Code, but they would prefer to exercise their right to self-determination. The statement must be retained as part of the resident's care plan. Any facility that offers this option shall notify the agency of this practice by submitting a letter signed by the nursing home administrator of record and a copy of the facility's policies and procedures."

This is a great example of facilities working with regulations to ensure the highest quality of life and care of the residents and of the type of action the NH Regulations Plus website hopes to inspire and support.

A second stage planning grant from the Rothschild Foundation beginning in January 2007, will allow the researchers to contemplate the regulations as a whole, pinpoint areas of relevance to culture change with additional NHRegsComments, engage with other leaders in the field and, using the website as a resource, to scrutinize how regulatory distinctions might impede or facilitate such goals as universal front-line workers or neighborhood designs. The ultimate goal for this phase of the project is twofold: to determine how to sustain, update and use the resource, and to conduct projects to identify exemplary models of regulation on specific topics for nursing homes and by extension to assisted living which is now entirely regulated by states.

While NH Regulations Plus is a work in progress, the information already available is vast. The attention to detail and organization by its creators has brought clarity and easy access to its content. Even while giving a tour of the site, Kane notices a small glitch in layout and makes a note to change it. The enormity of the task was a bit daunting but she says, "Now that we've gained momentum it's working out better." Good news for a project that will always be growing and changing as nursing homes' and regulators' experiences grow and change.