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The Basics of Promising Practices

CMS Interpretive Guidelines

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The Essence of the CMS Regulations

The issuance of 42 CFR, Part 483 compelled many nursing homes to identify and correct deficient care practices and to meet minimal dignity and respect standards as well as focus on improving clinical practice outcomes.  Gradually, CMS began to further explore and define the culture of nursing homes and a deeper meaning of ''choice" and of "home."  In 2006 and 2007, CMS created a four part satellite broadcast series "From Institutional to Individualized Care." The broadcast series set the stage for the first-ever national symposium on Culture Change co-sponsored by CMS and Pioneer Network: Creating Home in the Nursing Home: A National Symposium on Culture Change and the Physical Environment Requirements. The results of this symposium promoted person-centered living environments and produced a set of recommendations to update and clarify certain CMS regulations.

Effective June 12, 2009, CMS released revisions to eleven Interpretive Guidelines (Nursing Homes-Issuance of Revisions to Interpretive Guidance Part of Appendix PP, State Operations Manual located at: June 12 2009 CMS Interpretive Guidelines).  This issuance was a major initiative for CMS to redefine nursing home culture, by revising guidelines that specifically relate to person-centered care, needs and preferences. The revisions include both environmental and systemic nursing home components, and require institutionalized nursing homes that have not yet adopted person-directed practices to create the look and feel of a real home in which dignity and respect are presumed and are further promoted by striving to accommodate individual resident choices and needs.  Providers and regulators alike are re-considering the meaning of self-determination and of home and choice, originally intended in OBRA '87.

Providers are re-inventing how to provide nursing home care, how to create home and how to accommodate choice.  In recent years, both as a result of regulatory requirements and market driven pressures, new care models have emerged.  The concept of person-centered care is at the core of all of these models.  All have the same goal of focusing on how to accommodate resident individualism and self-determination as it intersects with regulatory standards and operational implementation challenges.

At the core of the changes to the Interpretive Guidelines are F- 241 Dignity, F- 242 Self-Determination and Participation, and F- 252 Safe, Clean, Comfortable and Homelike Environment.  These three F-Tags hugely impact resident care practices in so many areas that it helps to think of them as the foundation of many other F-Tags. For practical purposes, we can think of F- 241 (Dignity) as the "I have a right" regulation, F- 242 (Self-Determination) as the "I can determine my activities, health care and schedule according to my needs and preferences" regulation and F- 252 (Home) as the "I want my room and space to accommodate my individual needs and desires" regulation.

F - 241, F - 242, F - 252, essentially say: "I should be treated in a dignified and respectful fashion at all times, in accordance with my personal preferences and choices and I should be able to live in a space that accommodates my level of need and function as well as my lifestyle preferences."  Traditionally, nursing homes have focused on accommodating basic dignity but the institutional structure and provider concerns about resident safety, legal ramifications, and cost have limited resident choices over daily life and daily pleasures.  The intent of the revisions, as pertains to Promising Practices, is intended to maximize dignity and choice throughout the dining experience.

 Click here to learn more
about F- 241 Dignity
and Promising Practices
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about F- 242 Self-Determination
and Participation

and Promising Practices
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about F- 252 Safe,
Clean, Comfortable and
Homelike Environment

and Promising Practices

In addition to F-241, F-242, and F-252, the June 12 2009 CMS Interpretive Guidelines revisions also pertain to the following F-Tags. All referenced F-Tags largely pertain to either environmental or operational changes that are ultimately drivers of enhancing resident dignity, choice and home. Click on each F-Tag below to learn more about how they relate to Promising Practices.

The CMS Interpretive Guidelines beyond Promising Practices can be accessed at:
June 12 2009 CMS Interpretive Guidelines

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