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.
