Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
Key: Residents are ‘People First’. All information in this chart that is not quoting an actual rule uses the terms “people, persons, etc.
Note: Not every item below needs to be addressed in your first plan. Consider testing one, two or three strategies and check the
results. Use a life satisfaction survey to learn if changes are accepted by the people living in or visiting the nursing home.
Federal Regulation
F-150 Exercise of Rights
The resident has a right to a dignified
existence, self-determination, and
communication with and access to persons and
services inside and outside the facility.
A facility must protect and promote the rights
of each resident.
F-154 Resident Rights: Understand Total
Health Status
The resident has the right to be fully informed
in language that he or she can understand of
his or her total health status, including but not
limited to, his other medical condition.
The resident has the right to be fully informed
in advance about care and treatment and of any
changes in that care or treatment that may
affect the resident's well-being.
F-155 Resident Rights: Refusing Treatment
The resident has the right to refuse treatment,
to refuse to participate in experimental
research, and to formulate an advance
directive…
Examples
What My Home Might Plan To Do
 Enable people to self-administer
medications if they want to and if the care
planning team determines it is safe for
them to do so.
 Build relationships with people, their
families and physicians to help understand
each person as individuals and provide
care in accordance with their preferences
and values.
 Provide information on the person's
medical conditions in a language he/she
can understand and that is free of technical
jargon.
 Use care planning conferences as teaching
opportunities and develop “I” care plans in
place of traditional care plans. (Quality
Partners of Rhode Island, 2005)
 Understand that cultural and spiritual
practices may impact treatment decisions.
 Determine exactly what a person is
refusing and why.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 1 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-164 Resident Rights: Privacy and
Confidentiality
The resident has the right to personal privacy
and confidentiality of his or her personal and
clinical records.
(1) Personal privacy includes
accommodations, medical treatment, written
and telephone communications, personal care,
visits, and meetings of family and resident
groups, but this does not require the facility to
provide a private room for each resident;
(2) Except as provided in paragraph (e)(3) of
this section, the resident may approve or refuse
the release of personal and clinical records to
any individual outside the facility;
(3) The resident’s right to refuse release of
personal and clinical records does not apply
when-(i) The resident is transferred to another
health care institution; or
(ii) Record release is required by law.
F-165 Resident Rights: Voicing Grievances
The resident has the right to voice grievances
without discrimination or reprisal. Such
grievances include those with respect to
treatment which has been furnished as well
that which has not been furnished.
 Teach staff that only those directly
involved in providing treatments,
delivering care, or to whom the person has
given consent, can be present during
delivery of care.
 Ensure people are granted privacy when
using the bathroom and in other activities
of personal hygiene.
 Empower people to feel comfortable with
voicing their concerns to the ombudsman,
staff members and family members to find
a solution to their complaint.
 Empower community and neighborhood
groups to help resolve conflicts,
grievances, and complaints, thus keeping
problems close to their source.
 Empower members of committees and
groups to provide information on the
'heartbeat' of the home.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 2 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-240 Quality of Life
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.
F-241 Dignity
The facility must promote care for residents in
a manner and in an environment that maintains
or enhances each resident's dignity and respect
in full recognition of his or her individuality.
 Furnish the home with personal items
(e.g., pictures, furnishings) that belong to
the people living there. Interview family
members or friends when a person cannot
communicate. Organize fundraisers to
enhance the comforts of people with
limited resources. Provide familiar
surroundings for the major cultural groups
represented in the home.
 Offer parties, dinners and life celebrations
to encourage socialization of people and
their families.
 Provide spiritual opportunities common to
the people living in the home, such as
speakers, meditation groups, yoga,
religious services and music.
 Consider inviting a local boy/girl scout
troop to help with a community-style
volunteer project. Other groups are
elementary and secondary schools, YMCA
or garden club to help with projects and
activities that would be fun and interesting
for people living in the home.
 Although tasks (such as bathing) are
important, maintaining the person's dignity
means allowing him/her to refuse a task or
establish a routine of personal choice when
possible.
 Get the person’s permission before
changing radio or television stations.
 Get the person’s consent to move or
inspect personal possessions.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 3 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-248 Activities
The facility must provide for an ongoing
program of activities designed to meet, in
accordance with the comprehensive
assessment, the interests and the physical,
mental, and psychosocial well-being of each
resident.
CMS Interpretive Guideline: Non-traditional
Approaches to Activities. Surveyors need to be
aware that some facilities may take a nontraditional approach to activities. In
neighborhoods/households, all staff may be trained
as nurse aides and are responsible to provide
activities, and activities may resemble those of a
private home. Residents, staff, and families may
interact in ways that reflect daily life, instead of in
formal activities programs. Residents may be more
involved in the ongoing activities in their living
area, such as care-planned approaches including
chores, preparing foods, meeting with other
residents to choose spontaneous activities, and
leading an activity. It has been reported that some
culture changed homes might not have a traditional
activities calendar, and instead focus on community
life to include activities. Instead of an "activities
director," some homes have a Community Life
Coordinator, a Community Developer, or other title
for the individual directing the activities program.
 Incorporate each person’s lifelong interests
into the available activity options.
 Design programs that reflect schedules,
choices and rights of individuals.
 Consider both genders, all age groups, and
various cultures and faiths in designing
activities.
 Periodically walk around the home,
observing what people are, and are not,
doing.
Ask yourself: Did the person choose what they
are doing; or did staff make the choice?
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 4 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-252 Safe, Clean, Comfortable, Homelike
Environment
The facility must provide a safe, clean,
comfortable and homelike environment,
allowing the resident to use his or her personal
belongings to the extent possible.
 A "homelike environment" is one that
plays down the institutional quality of the
setting, to the extent possible, and allows
the person to use those personal
belongings that support a homelike
environment. A homelike setting
recognizes the unique and independent
nature of people, provides an opportunity
for self-expression, and encourages
connections with the past and family. The
goal of "homelike" is that the nursing
home provides surroundings as close to a
private home as possible. This idea
includes getting rid of unpleasant odors,
and institutional practices as much as
possible.
Examples of ‘institutional’ living are:
 Overhead paging or piped-in music
throughout the building;
 Meal service in the dining room using
trays (some people may wish to eat some
meals in their rooms on trays);
 Signs that label work rooms/closets in
areas seen by people and the public;
 Medication carts in hallways;
 Widespread use of chair and bed alarms
which people living in the home can hear,
instead of limited use for selected people
intended for a diagnostic purpose or
according to the care plan. Unexpected
noise can startle people and limit normal
repositioning movements.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 5 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-309 Quality of Care
Each resident must receive and the facility
must provide the necessary care and services
to attain or maintain the highest practicable
physical, mental, and psychosocial well-being,
in accordance with the comprehensive
assessment and plan of care.
F-314 Pressure Ulcers
Based on the comprehensive assessment of a
resident, the facility must ensure that (1) a
resident who enters the facility without
pressure sores does not develop pressure sores
unless the individual's clinical condition
demonstrates that they were unavoidable; and
(2) a resident having pressure sores receives
necessary treatment and services to promote
healing, prevent infection and prevent new
sores from developing.
F-315 Urinary Incontinence
Based on the resident's comprehensive
assessment, the facility must ensure that (1) a
resident who enters the facility without an
indwelling catheter is not catheterized unless
the resident's clinical condition demonstrates
that catheterization was necessary; and (2) a
resident who is incontinent of bladder receives
appropriate treatment and services to prevent
urinary tract infections and to restore as much
normal bladder function as possible.
 Ensure that assessments are accurate, and
care plans are individualized and
consistently followed.
 Develop procedures to ensure that all staff
can recognize and report changes in
condition.
 Manage a person’s pain to ensure quality
of life.
 Offer and provide necessary pain
medication before dressing changes and
wound care.
 Offer emotional support to people with
pressure ulcers or other wounds, as
changes in body integrity can impact selfesteem.
 Respect each person’s need for dignity by
providing services to improve urinary
function.
 Provide emotional support to people with
catheters to prevent decline in the person’s
self-esteem.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 6 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-327 Hydration
The facility must provide each resident with
sufficient fluid intake to maintain proper
hydration and health.
F-363 Standard Menus and
Nutritional Adequacy
Menus must meet the nutritional needs of
residents in accordance with the recommended
dietary allowances of the Food and Nutrition
Board of the National Research Council,
National Academy of Sciences; be prepared in
advance; and be followed.
 Provide beverage stations, water pitchers
with a covered glass within each person’s
reach, hydration cart, etc.
 Document a person’s fluid preferences and
routines, and encourage staff to follow this
pattern to enhance successful hydration.
 Involve people in the decision-making
process of their nutritional care plan.
 Use resident council meetings to discuss
menus and meal planning with people.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 7 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-364 Food
Each resident receives and the facility provides
food prepared by methods that conserve
nutritive value, flavor, and appearance; and
food that is palatable, attractive, and at the
proper temperature.
 Train kitchen staff on cooking methods
that enhance palatability.
 Observe during meals whether food is
palatable and attractive.
Remember: ‘proper temperature’ is only
tested by surveyors when the food leaves the
stove or is holding on a buffet table!
Family-style service at the table is NOT a
violation of F-364. However, it is
appropriate to remove leftovers to chill or
throw out as soon as people are finished
eating.
CMS Interpretive Guideline: The intent of this
regulation is to assure that the nutritive value of
food is not compromised and destroyed because of
prolonged food storage, light, and air exposure;
prolonged cooking of foods in a large volume of
water and prolong holding on steam table, and the
addition of baking soda. Food should be palatable,
attractive, and at the proper temperature as
determined by the type of food to ensure resident's
satisfaction. Refer to §483.15(e) and/or
§483.15(a).
Guidelines: §483.35(d)(1)
"Food-palatability" refers to the taste and/or flavor
of the food.
"Food attractiveness" refers to the appearance of
the food when served to residents.
Procedures: §483.35(d)(1)
Evidence for palatability and attractiveness of food,
from day to day and meal to meal, may be
strengthened through sources such as: additional
observation, resident and staff interviews, and
review of resident council minutes. Review
nutritional adequacy in §483.25(i)(l).
Probes: §483.35(d)(1)(2)
Does food have a distinctly appetizing aroma and
appearance, which is varied in color and texture?
Is food generally well seasoned (use of spices,
herbs, etc.) and acceptable to residents?
Conserves nutritive value:
Is food prepared in a way to preserve vitamins?
Method of storage and preparation should cause
minimum loss of nutrients.
Food temperature:
Is food served at preferable temperature (hot foods
are served hot and cold foods are served cold) as
discerned by the resident and customary practice?
Not to be confused with the proper holding
Texas Department of Aging and Disability Services,
temperature.
Center for Policy and Innovation - September 2011
Page 8 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
F-368 Frequency of Meals
(1) Each resident receives and the facility
provides at least three meals daily, at regular
times comparable to normal mealtimes in the
community. (2) There must be no more than
14 hours between a substantial evening meal
and breakfast the following day, except as
provided in (4) below. (3) The facility must
offer snacks at bedtime daily. (4) When a
nourishing snack is provided at bedtime, up to
16 hours may elapse between a substantial
evening meal and breakfast the following day
if a resident group agrees to this meal span,
and a nourishing snack is served.
F-490 Administration
A facility must be administered in a manner
that enables it to use its resources effectively
and efficiently to attain or maintain the highest
practicable physical, mental, and psychosocial
well-being of each resident.
F-517 Disaster and
Emergency Preparedness
The facility must have detailed written plans
and procedures to meet all potential
emergencies and disasters, such as fire, severe
weather, and missing residents.
 Use neighborhood meetings to identify the
best meal times in each neighborhood.
 Recognize individual preferences
regarding waking up or sleeping in.
 Continental breakfast served from 6:00 to
9:00 AM, hotel style.
 Promote creativity amongst people, staff
and families.
 Support the formation of groups.
 Consider establishing a Culture Change
committee, inviting both professional and
hourly staff, as well as people living in the
home and council membership to
participate. What would this group suggest
as a first step in change?
 Develop plans based on each person's
abilities and limitations.
 Use community meetings to teach and
review preparation plans and procedures.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
Page 9 of 11
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
A New Vision for America’s Nursing Homes
 Nursing homes are pleasant and desirable places to live and to work.
 A core principle of the nursing home is to honor resident wishes and choices. Food preferences, activities,
other wishes, and special needs of each resident are a top priority of all staff.
 Each staff member understands the care plans for his or her assigned residents, including the reason for each
intervention documented in the care plan.
 Physical and chemical restraints are rarely used and only for medically appropriate reasons.
 Facility-acquired pressure ulcers are rare. All pressure ulcers are treated appropriately using current
evidence-based practices.
 Staff identify and evaluate undesired outcomes and events and respond appropriately.
 All staff participate in scheduling, making assignments, and determining how assigned tasks are to be
accomplished.
 Resident and staff measures of quality and satisfaction demonstrate that a commitment to quality is effective
and sustainable.
 Staff turnover is low; nursing home staff members are prized and heavily recruited by hospitals and other
providers.
Taken from the Delmarva Foundation presentation, "Nursing Home Culture Change."
Delmarva Foundation is the Quality Improvement Organization for the State of Maryland.
Visit them at: http://www.mdqio.org/index.html
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
11
Page 10 of
Planning Tool for a Person-Directed Life-Style in __________________________________________________ Nursing Home
(Facility Name)
Plan, Do, Study, Act (PDSA)
One means of implementing change is through using the PDSA cycle:
Identify what changes need to
be made and either implement
the data or repeat the cycle with
changes to the objective or plan.
4. ACT
3. STUDY
1. PLAN
Create your objective, formulate
questions and predictions, and
develop a plan to carry out the
cycle (who, what, where, when).
2. DO
Complete the analysis of data,
compare data to the predictions,
and summarize what was
learned.
Carry out the plan, document
problems and unexpected
observations, and begin to
analyze the data.
Source: Institute for Healthcare Improvement, Boston, Massachusetts, http://www.ihi.org/IHI/.
Texas Department of Aging and Disability Services, Center for Policy and Innovation - September 2011
11
Page 11 of