Other Regulatory Resources

It is clear that better education is the key to marrying culture change and regulations. Here are some resources that may help bridge the gap for regulators and nursing home staff. We've included some Action Pact learning tools as well as other websites with helpful information and stories.


Don't Blame OBRA: The Regulations Aren't in the Way

by Karen Schoeneman


From the website of Almost Home, a feature length documentary chronicling a year in the life of residents and staff at St. John's retirement community as the facility and those who live and work there undergo culture change from a medical model to a social model. This story is one of several posted on the site covering many aspects of culture change. There is also an eight minute video clip from the movie about St. John's state survey and how the staff and regulators balance quality of care with quality of life.


American Health Care Association


This link lists states and has a link to each state's regulations. Simple, to the point and handy.


From the home page: "AHCA represents the long-term care community to the nation at large - to government, business leaders, and the general public. It also serves as a force for change within the long term care field, providing information, education, and administrative tools that enhance quality at every level."




From the U.S. Department of Health and Human Services, this is where you can get the word right from the horse's mouth. While this page is designed for people with Medicare, it offers a nice description of the regulation's process and role. This might be a good place to start when having a discussion about regulations so that everyone is coming from the same place of this shared knowledge instead of holding misconceptions or misinformation.


The Pioneer Network


The Pioneer Network offers some articles on different aspects of regulations, an introduction of the website that compares state regulations in nursing homes compiled by the University of Minnesota (described in detail in the first of our trilogy of web stories on regulations) and a a six minute video clip featuring a discussion between Karen Schoeneman of the CMS Division of Nursing Homes and Thomas Hamilton, Director of the Survey and Certification Group at CMS. They discuss how person-directed care is consistent with existing federal regulations.


Centers for Medicare and Medicaid Services


A pdf of the December 21, 2006 CMS memo of "Details for Nursing Home Culture Change Regulatory Compliance Questions and Answers." It includes:


  • Responses we have made to inquiries concerning compliance with the long-term care health and life safety code requirements in nursing homes that are changing their cultures and adopting new practices;
  • Summarizes questions and answers from a June, 2006 CMS Pic-Tel conference with leaders of the Green House Project (Attachment A); and
  • Provides information about an upcoming series of 4 CMS culture change satellite webcasts (Attachment B).


This is exactly the kind of dialogue and education that will help bridge the information gap between culture change homes and regulators.


Regulatory Support for Culture Change:

How OBRA '87 Regulations Support Culture Change
by Carmen S. Bowman.
Published by Action Pact, Inc.


This workbook gives a detailed overview of regulatory support for culture change. Author Carmen S. Bowman, a former state surveyor, speaks the language of F-tags and discusses compliance issues in dining, resident choice, physician orders, wireless call systems, animals, med carts, consistent staffing, cross-training, self-directed work teams, homey environments, care planning, waivers and variances. She provides clear explanations and recommends practices to assure quality.


Here is an excerpt from the workbook on the Quality of Life tag:


    "Tag F240: A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.

    This regulation obviously supports culture change. The whole culture change movement is about just this. Notice the regulation refers to Œeach' resident's quality of life. Over and over, OBRA '87 re-focuses us on the individuality of each resident. This is, of course, how it should be and isn't it great that it is written directly into regulation? How in defines quality of life foe him or herself is usually different that how the next person defines it, although common themes tend to be independence, freedom and choice. Truly finding tout what quality of life is for each person living in your care is not doubt a Herculean task. However, discovering what quality of life entails for each person and helping them fulfill it brings meaning and purpose to staff's work life."


Appendices include letters from CMS addressing several culture change questions, changes in SNF payment regulations to include innovations, and the use of Civil Monetary penalty monies. Suggested activities throughout the book will help teams to objectively look at regulatory compliance and support of culture change in their organization.


Household Matters Kit

(Policies & Procedures and QI sections)
Click here to order the Kit from Meadowlark Hills, or feel free to email us for more detailed information on the Kit's contents.

The Household Matters Kit was produced by Action Pact and supported by the Commonwealth Fund, the Kansas Department on Aging and the Sunflower Foundation. In addition to other resources for use in implementing the Household Model, the kit includes CD-ROMs of quality improvement measurement system and policies and procedures for the Household Model to be used as a resource on a computer or printout. The federal regulations based manual offers policies and procedures for organizational, administrative, human resources, leadership, development, clinical, programmatic, environmental and support departments.


Nursing homes that have used these sections of the tool kit have shared their experiences with us:


"We are building one of the first household-model SNFs in North Carolina right now. We had to meet with the construction section of our state regulator in August and I was nervous about the household kitchens. The toolkit really helped us. It had just come out and I was able to pull up the household kitchen P&Ps and tweak them over a weekend. They looked great and gave me the deeper understanding I needed to have an informed conversation with regulators. They have the thoroughness the state was looking for in terms of operations and safety."


    - Bev Cowdrick, AVP, Administrator at Huntersville Oaks of the Carolinas Healthcare System


"We used the P&P from the toolkit as a source for revising our existing policies so that they would reflect our households. The P&P section gave us a good place the start. We have used the laundry, housekeeping and dietary ones the most as those are the areas that we had strictly departmental policies before. We expect our next survey any time and I know they will ask for our policy for residents helping in the dining room and/or what our policy is for doing personal laundry in the households. We now have them covered. The tool kit was a great resource as we could "cut and paste" to individualize them for our facility without having to start from scratch."


    - Marilyn Oelfke, RN, Senior Director of Long-term Care Services at Perham Memorial Hospital and Home, Perham, MN

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