Changing the Physical Environment of Nursing...

Changing the Physical Environment of Nursing Homes

PREPARED BY

JANUARY 2012

FUNDED BY

Addressing State Regulatory Hurdles

P R E PA R E D B Y C H I PA R T N E R S | F U N D E D B Y T H E C A L I F O R N I A H E A LT H C A R E F O U N D AT I O N

CONTENTSIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Philosophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Green House® / Small House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Household Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Federal – Center for Medicare & Medicaid Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Federal Support for Green House® and Culture Change Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

California Regulatory Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

OfficeofStatewideHealthPlanningandDevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CaliforniaDepartmentofPublicHealth–LicensingandCertification . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

TheCaliforniaNursingHomeLandscapeandRegulatoryProgress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

OSHPDandL&C–ProcessandApproach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

The Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Nurses’Station,StaffOfficesandSpaceNeeds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Resident Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

The Hearth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

StateLegislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

LessonsLearnedfromThreeStates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

KeyLessons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

The Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

KeyLessons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

KeyLessons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

The Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

California Green House® Projects Pending in California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Mt.SanAntonioGardens(Pomona,CA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

MercyRetirementandCareCenter(Oakland,CA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

History of Environmental Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

C H A N G I N G T H E P H Y S I C A L E N V I R O N M E N T O F N U R S I N G H O M E S : A D D R E S S I N G S TAT E R E G U L AT O R Y H U R D L E S

Traditional nursing homes don’t look much like a home.

They closely resemble the institutional hospital setting,

as indeed that was their model. However, a hospital

is not designed to be a home, but rather a place where

one stays temporarily in order to get acute medical care

for the short term. This has been the most common

model for nursing home construction since the 1950s.

“There is no theoretical underpinning for designing nursing

homes in this manner — no theory that dictates that this is

supportive of either good care or positive quality of life”

(Calkins, 2005).1


INTRODUCTION

The purpose of this Issue Brief is to explore the regulatory issues and challenges inherent in the development of small home models like Green House® 2 . It is hoped that the development ofalternativemodelswillencouragethespread of culture change, enhance the physical environment of the nursing home, facilitate a higher quality of life and provide the setting for a higher quality of care in nursing homes . While many providers are desirous of environmental change, the regulatory environment and licensing process often provide a myriad of regulatory challenges . This briefwillexaminehowthoseregulatoryissueshavebeenovercome in other states, explore changes that are in process in California and seektobring“lessonslearned”fromotherstatesto California .

The creation of a more home-like physical environment is one of the hallmarks of culture change in nursing homes, and facilities that have implemented culture change practices haveshownanincreasedqualityofcare.3 Whilehighqualitycarecancertainlybeprovidedin an older, more conventional style nursing

home, full implementation of resident-centered care practices often requires physical changes includingprivateroomswithprivatebathrooms,and smaller self-contained residences that are designedlikehomeswithworkingkitchensandconsistentstaffing.Itisanticipated(anddemonstratedinearlyresearch)thatthese homes may:

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Provide a more meaningful experience fortheresidentswithhigher quality of life and social participation

Allowresidentsto maximize their functional capacity becauseofthesmaller scale of the environment and freedom from institutional routines

Encourage family memberstoparticipatemore actively,

contributingtogreatersatisfaction for elders and families

Provideconsistentstaffingthatallowsdirectcarestafftoknowtheresidentsbetter,tohaveagreatersenseoftheirabilitytopositivelyaffectresidents’livesandtoexperienceincreasedjobsatisfaction and productivity

This brief will examine how those regulatory

issues have been overcome in other

states, explore changes that are in process in California and seek to bring “lessons learned”

from other states to California.


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ThE PhIlOSOPhY

It is important to examine the philosophy underwhichnursinghomeregulationsarebothpromulgated and enforced and to understand the processbywhichthoseregulationsareadaptedtokeeppacewiththechangingcultureoflong-termcare.DiscussionswithregulatorystaffinCaliforniaatboththeOfficeofStatewideHealthPlanningandDevelopment(OSHPD)andCaliforniaDepartmentofPublicHealthLicensingandCertification(L&C)suggestthattheirforemostconcernissafetyand,whiletheyacknowledgetheresidentialnatureofskillednursingfacilities,theyalsoacknowledgethatthemodelwasoriginallyconceptualizedtobehospital-like.Assuch,theyviewnursinghomesprimarilyashealthcarefacilitiesfirstandresidences second .

In1964,whenMedicaidwascreated,unlicensed,unregulated and unsupervised facilities for frail seniorswererampantandqualityofcareinthesefacilitieswasoftenquestionable,ifnotblatantlypoor . Medicaid created an entitlement program that licensed nursing facilities and provided a levelofreimbursementforthosewithlimitedfinancialresource.Thephysicalstructureand the regulatory structure of the nursing home mirroredthehospitalwithnursingstations,double-loadedcorridors,pre-platedmealsservedon trays, overhead paging, medication carts and amodelthatwasdesignedfor“efficient”deliveryof health care services . That initial focus on health careandthequalityofthatcarehelpedtobringsomestructureandqualitytowhathadbeenanunlicensed and unregulated environment .

Whiletherehasbeensubstantialchangeoverthelast50yearsinhowandwherehealthcareisdelivered,verylittlehaschangedaboutthe

physical environment of the vast majority of nursing homes in this country . The trappings ofthehospitalandindustrialefficiency—medcarts, overhead paging, shared rooms and nursing stations—arestillthestandardfor95percent of the nursing homes in the country .

Today, culture change proponents suggest that nursinghomesshouldbefirstandforemostaresidenceand,withinthatresidence,qualityhealth care is delivered and quality of life is supported.Additionally,carepracticeoverthattimehaschangeddramatically.Long-termcaredoesnothavetobedeliveredinaninstitutionalsettinginordertobehighqualityandmany frail,nursinghome-eligibleindividualsarereceivinghighqualitycareintheirownhomes.Today,qualityoflifeisnowacknowledgedto beasimportantasqualityofcare.In1987, theOmnibusBudgetReconciliationAct(OBRA)codifiedinFederallawthatresidentsinnursingfacilities have the right to live in the least restrictiveenvironmentpossible,thattheyhavethe right to control their care and that they haveasayintheenvironmentinwhichthatcare isdelivered.Institutionalizationwasnolonger the legal standard . Yet many of the vestiges of the institutional environment still exist in state nursing home regulations .

It is the intent of this document to examine the waysinwhichmanyprovidersandregulatorsthroughout the country have implemented environmentalmodificationsthatallownursinghomes to create more residential environments, likeGreenHouse®,andhowtheregulatoryagenciesinthosestateshavebothresponded to and facilitated changes . It is also hoped that thisdocumentwillassistinbringingthose“lessonslearned”toCalifornia.


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BACKGROUND

GREEN hOUSE®/Small house

Licensedasaskillednursingfacility,theGreen House®smallhomemodelgoesbeyond“home-like”towhattrulyfeelslike“home” through fundamental changes to architecture, organizational structure and philosophy of care . Key aspects of the model are:

Each facility is a series of self-contained residences, each designed like a private homewhilemeetinginstitutionalhealthcare construction standards . Multiple Green House® homes on a campus aredesigned,likearesidentialsub- division, to make a community and provide economies of scale . With a maximum of 10 to 12 elders per home, eachresidenthasaprivatebedroomandbathroom.Thecommonspaceinthehouse,referredtoasthe“hearth,”includes a living area, a single dining tablethataccommodatesalloftheresidents(andstaff)formealsandanopen kitchen .

Green House® home implementations range in size from one home on a long-termcarecampustoaneighborhoodof16homes.A24-homehigh-riseprojecthasbeendevelopedinanurbansetting.Multiple homes on a single campus are licensedandcertifiedasasingleskillednursing home provider .

The Green House ® project is implemented

all at one time, in a carefully crafted method designed to

support initial success as well as long-term

sustainability.

Speciallytrainedworkers(withcoretrainingascertifiednursingassistants)staff each residence as a self-managed workteamprovidingpersonalcare,activities, meal preparation and service, light housekeeping and laundry .

Partneringwiththedirectcarestaff is a clinical support team of licensed nurses, therapists, medical director, aswellassocialservices,activities and dietary specialists .

Unlike most culture change models, the Green House® project is implemented all at one time, in a carefully crafted method designed to support initialsuccessaswellaslong-termsustainability.While this Issue Brief highlights Green House® as an example of the type of positive change happening in nursing homes across the country, providersarealsomakingbothphysicalandoperational changes to existing facilities in order to make them more home-like and creating other types of small home models .


household ModelThereareanumberofchangestonationalandstatecodesthatacknowledgethemovementfrom the nursing home as a large institutional environment to the creation of smaller house- holdswithinthenursinghome.Ahousehold isaplacewhereasmallgroupofresidents livethatistheirhome.Itincludesakitchen(withawidevarietyoffoodaccessibletoresidents24/7includingbreakfast-to-orderanduponrequest),a dining room and a living room . It encompasses renovationstoanexistingbuilding,newconstructionofhouseholdswithinabuildingorsingle households in the form of cottages, houses andsimilarstructures.Alongwiththesephysicalcomponents households are committed to:

Cross-functioning staff, permanently assignedtoahousehold(consistentassignment).

Integrated organizational functions rather than oversight provided through separate departmental services . Staff reports to the household instead of up a departmental chain of command .

Trueresident-directedcarewhere the rhythm of each individual’s life isdictatedbyhisorherowndesires.

Agenuinesenseofcommunitywheretheflowofhouseholdlifeisintentionallyshapedanddesignedbythelifepursuitsof those living in the household . Allresidentshaveopportunitiestoparticipate in the daily life of the household in the manner and to the extent they choose .

Self-ledworkteamsofstaffthatmovealongacontinuumofempowerment and team autonomy .4

There are a number of changes to national and state codes that

acknowledge the movement from the nursing home as a large institutional environment to the creation of smaller households within the nursing home.

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REGUlATIONS

Federal, state, local, and life safety code regulations dictate the physical environment of a nursing home . Culture change innovators report that regulations at each of these levels can hampertheirabilitytomakechangesthatwouldcreate a more home-like environment . Thus, manyproviders,whowishtopursueinnovativeideas,becomediscouragedbyrequirementstheybelievetobeunreasonableand/orbyconcernsthatwhattheybuildcouldsubsequentlybefoundtobeoutofcompliance.

Federal — Centers for Medicare & Medicaid ServicesThenursinghomeregulatorystructurebeginswithregulationspromulgatedattheFederallevelandenforcedbyCentersforMedicare&MedicareServices(CMS).5 CMS is the component of the Federalgovernment’sDepartmentofHealthandHuman Services that oversees the Medicare and Medicaidprograms.AlargeportionofMedicareand Medicaid dollars is used each year to cover nursing home care and services for the elderly anddisabled.Stategovernmentsoverseethelicensing of nursing homes and have a contract

withCMStomonitorthosenursinghomesthatwanttobeeligibletoprovidecaretoMedicareandMedicaidbeneficiaries.CMShascreated a minimum set of health and safety standards, butstatesmaypassandenforceregulations that are more restrictive .

While the majority of the nursing home regulations in Title 42 are focused on the delivery of services, CMS also requires nursing homes to conformtothe2000editionoftheLifeSafetyCode(LSC).TheLSCisasetoffireprotectionrequirementsdesignedtoprovideareasonabledegreeofsafetyfromfire,smokeandpanic.TheLSCisapublicationoftheNationalFireProtectionAgency(NFPA).Aswaiversareanimportant vehicle to create change at the state level,itisimportanttoacknowledgethatCMSalsohastherighttograntwaiverstothecode:“Afterconsiderationofstatesurveyagencyfindings, CMSmaywaivespecificprovisionsoftheNFPALifeSafetyCodewhich,ifrigidlyapplied,wouldresultinunreasonablehardshipuponthefacility,butonlyifthewavierdoesnotadverselyaffectthehealthandsafetyofthepatients.”6

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Federal Support for Green house® and the Culture Change MovementCMShasbeenexceptionallysupportiveoftheculturechangemovementandtheGreenHouse® model in particular:

APRil 2006: CMSreleasedtheArtifactsofCultureChange,atoolforproviderstoassessthereadiness,implementationandsustainabilityofperson-directedcare.TheArtifactstoolfillsthepurposeofcollectingthemajorconcretechangeshomesmadetocareandworkplacepractices, policies and schedules, increased resident autonomy, and improved environment .

DECEmbER 2006: CMS sent a letter to allStateSurveyAgencyDirectorsclarifying compliance withthelong-termhealthandLSCrequirementsinnursinghomesthatarechangingtheirculturesandadoptingnewpractices.

FEbRuARy 2007:CMSrespondedtoaninquirybytheMississippiSenateandHousedelegationsregarding the Green House® Project.LeslieNorwalk,ActingAdministratorofCMSstatedthatCMSissupportiveoftheculturechangemovementand“believe[s]theseinnovationsmore fully implement the Nursing Home ReformprovisionsoftheOmnibusBudgetReconciliationActof1987,fromwhichournursinghomeregulationsarederived.” Additionally,CMSoffereditscontributiontothemovementbystating,“Itisourgoal tohaveStateagenciesassistinnovativeprovidersindetermininghowchangesthey wishtomaketoimprovethelivesoftheirresidentscanbecompliantwiththeFederalregulationsthatprotectallresidents.”

APRil 2008:CMScosponsoredwithPioneerNetworkanationalsymposium,“CreatingHomeintheNursingHomeI:ANationalSymposiumonCultureChangeandtheEnvironmentRequirements”topromotediscussion,dispelbarriersandcoordinateactionthatsupportsculturechangeinnursinghomeenvironments.Thesymposiumandfollow-upeffortsdiscussedindetailatCreatingHomeSymposiumweregroundbreakingeffortstobroadenanddeependiscussionofthelinkagesbetweenperson-directedimplementationandtheregulatory environment .

JuNE 2009:CMSreleasedrevisionstoelevenInterpretiveGuidelinestoredefinenursinghomeculturebyrevisingguidelinesthatspecificallyrelatedtoperson-centeredcare,needsandpreferences.Therevisionsincludebothenvironmentalandsystemicnursinghomecomponents and require institutionalized nursing homes that have not yet adopted person-directednursingpracticestocreatethelookandfeelofarealhomeinwhichdignityandrespectarepresumedandarefurtherpromotedbystrivingtoaccommodateindividualresident choices and needs .

mAy 2010:CMSpartneredwiththePioneerNetworktosponsoranonlinesymposiumentitled“CreatingHomeintheNursingHomeII:ANationalSymposiumonCultureChangeand theFoodandDiningRequirements.”Thesymposiumaddresseddininginitiativesthatpromote culture change in nursing homes and explored the potential and perceived regulatorybarrierstomakingsuchtransformations.

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California Regulatory StructureIn order to understand how California differs from other states, it is important to understand the process that an applicant must go through to construct, renovate and license a skilled nursing facility. There are three key approvals needed for both major renovations to nursing homes to implement the household model, or create Green House® homes in California:

1) OfficeofStatewideHealthPlanning andDevelopment(OSHPD),

2) CaliforniaDepartmentofPublicHealthOfficeofLicensingandCertification(L&C),and

3) CaliforniaStateFireMarshall(fire and panic safety)

Office of Statewide Health Planning and DevelopmentOSHPDisoneof13departmentswithintheCaliforniaHealthandHumanServicesAgency.OSHPD’sFacilitiesDevelopmentDivision(FDD)reviews and inspects health facility construction projects.FDDisresponsibleforapprovingandoverseeing all aspects of general acute care hospital, psychiatric hospital, skilled nursing home and intermediate care facility construction in California under Title 247 of the California Code of Regulations (CCR). This responsibility includes: establishing building standards which govern construction of these types of facilities; reviewingtheplansandspecificationsfornewconstruction, alteration, renovation or additions to health facilities; and, observing construction in progress to ensure compliance with the approved plansandspecifications.FDDisalsoaregulatoryagency authorized to develop building standards

adoptedintheCaliforniaBuildingStandardsCode for hospitals and skilled nursing facilities, as well as correctional treatment centers and licensed clinics.

CCR Title 24 is reserved for state regulations that govern the design and construction of buildings, associated facilities [skilled nursing] and equipment. These regulations are also known as building standards. Cities and counties may adopt ordinances making more restrictive requirements than provided by CCR Title 24, because of local climatic, geological or topographicalconditions.Additionally,citiesand counties may adopt ordinances requiring firesuppressionsprinklersystemsandotherfireprotections that are more restrictive than the adoptionsinCCRTitle24bytheOfficeoftheStateFireMarshal.

California Department of Public Health — Licensing and CertificationHealth care facilities in California are licensed, regulated,inspected,and/orcertifiedbytheCaliforniaDepartmentofPublicHealthLicensingandCertificationProgram(L&C)underCCRTitle 228andtheU.S.DepartmentofHealthandHumanServices’CMS.Theseagencieshave separate — yet sometimes overlapping — jurisdictions.L&Cisresponsibleforensuringhealth care facilities comply with state laws andregulations.Inaddition,L&CcooperateswithCMStoensurethatfacilitiesacceptingMedicareandMedi-Cal(inCalifornia,MedicaidisreferredtoasMedi-Cal)paymentsmeetFederalrequirements.9L&Calsooverseesthecertificationof nurse assistants, home health aides and the licensing of nursing home administrators.

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The California Nursing home landscape and Regulatory ProgressCalifornia has approximately 1,296 nursing facilities,thevastmajority(1,244)inurbansettingsandthevastmajorityforprofit(80percent).Mosthomesarefreestanding—only160arehospital-basednursingfacilities.10 California’s nursing home supply and utilization ratesarebelowthenationalaverage.Thestatehas123,920nursinghomebeds—32forevery1,000peopleage65+.Thisislowerthanthenationalaverageof46bedsforthisagegroup.Forthe85+population,thebedsupply isequallylow.California’sratioof241bedsper1,000age85+istheninthlowestinthenationand30percentbelowthenationalaverageof345 .11 California’s nursing home occupancy rate isequaltothenationalaverage(86percent).

The majority of nursing homes in California are30to40yearsold,arebuiltaccordingtothetraditionalinstitutionalmodel(hospital-like),many are in need of some level of renovation, whileothersarehopelesslyoutdated.Providers’abilitytomakerenovationstooutdatedfacilitiesand/ormakestructuralmodificationstofacilitateculturechangeischallengedbyCalifornia’shigher than average construction costs and California’sbudgetarychallenges.ThisbudgetaryshortfallcreatestwochallengesforCalifornia’snursinghomes:1)theGovernorhasimposeda ten percent reduction in Medi-Cal payment ratesfornursinghomesand2)therehasbeenasignificantreductioninfundingforhomeandcommunity-basedservices,whichmayincreasethenumberofMedi-Calrecipientsinnursinghomes . With a Medi-Cal per diem shortfall of $3 .34 per resident per day12(beforethecurrenttenpercentreduction),anincreaseinMedi-Calresidentsaccessingnursinghomeswillcertainlycontributetoalessrobustfinancial

picture for nursing homes throughout the State . Theselowmarginsandunstablefinancialscenariosmakenursinghomeownersmoreriskadverseandlesswillingtomakeenvironmentalchanges,particularlysubstantialchangeslikeGreen House®.Whilethefinancialpictureischallenging,itmaybeexacerbatedbydemandfor long-term care services in the coming decade, bothinstitutionalandhomeandcommunity-based,whichwillreachunprecedentedlevels inCaliforniadrivenbythehighgrowthrate of the 65+ population .

8

2000

2010

2020

2030

2040

2050

0� 2,000� 4,000� 6,000� 8,000� 10,000� 12,000

65 to 74 75 to 84 85+

California’s Aging Population, 2000–2050Projected* number of residents, by age groupIn thousands

*Datafor2010to2050areprojections.

Chart source: State Population Projections and PopulationProjectionsProgram.PopulationDivision:StateofCalifornia,DepartmentofFinance,Race/EthnicPopulationwithAgeandSexDetail,2000–2050.Sacramento,CA,2007.


Positive Changes in the California EnvironmentWhilemostprovidersinCaliforniahavebeenhesitanttotakeonthechallengeofthesenewmodels,Mt.SanAntonioGardens(Gardens) in Pomona and Mercy Retirement and Care Center(Mercy)inOaklandaremovingthroughtheprocessofdeveloping(Gardens)orevaluating(Mercy)howtheGreenHouse®modelcanbeimplemented given California’s regulatory environment . The process of change in the vastmajorityofstateshasbegunwitha nursinghomeproviderswillingtoseekwaiversorchangeswithinthestateregulatorystructureto implement a more person-centered physical environment .

Whilethesetwoprovidersworkthroughtheregulatory issues, some changes have made that path easier to travel:

OSHPDhasapprovedregulationsthat pavethewayforamorehome-likemodel withregulationsthatdefine“households.” These regulations provide a platform for futurechangesthatfurtherdefinethesmall home/household model .

CADPHLicensingandCertificationheld educational sessions for its senior leadership focused on the Green House® model and the implications for operations .

The Green House® Replication Initiative has targeted California as a key state for replication .

The California State Senate Select CommitteeonAgingheldhearingstoclarifythebarrierstocreationofGreenHouse® homes in California .

TheCareDeliveryandDesignImprovementCommittee(CDDIC)13 hascreatedasubcommitteetoexaminethe issues around changing the physical structureofnursinghomesandwillmake recommendations for changes and provide technical guidance to providers as they seek to make changes .

Anall-dayconference(Changingthe Physical Environment of Nursing Homes: AddressingStateRegulatoryHurdles)coordinatedbyChiPartnersandfundedbytheCaliforniaHealthCareFoundationbroughttogetherproviders,regulators and interested parties to examine“lessonslearned”fromotherstatesandseekcollaborativesolutionsfor California .

Providers’ ability to make renovations to

outdated facilities and/or make structural

modifications to facilitate culture change

is challenged by ... higher than average

construction costs and budgetary challenges.

9


OSHPD and L&C — Process and ApproachCreating a new nursing facility or making substantial renovations to an existing facility begins at the local planning department for the jurisdiction in which the facility will reside. Once the applicant gains some understanding of the local issues and requirements, they approach OSHPD. OSHPD enforces Title 24 of the CCR and that regulatory structure preempts the local building department for the enforcement of all building codes. It is important that the applicant’s architect have familiarity working with OSHPD and designing skilled nursing facilities. The process can be complex as the construction of a health care facility can be very different from construction of other building types. While it is assumed that the applicant will be in contact with L&C early in the process, when OSHPD begins work on a project, it provides L&C with a letter alerting them to the project. At least at the Sacramento level, it appears that OSHPD and L&C have a good working relationship. Staff acknowledged challenges and disconnects between the regulatory structures of Title 22 and Title 24, but they work to eliminate or ameliorate these challenges on a project-by-project basis.

Both OSHPD and L&C are working under somewhat challenging staffing conditions. While the required furloughs for staff that were in place during California’s budget crisis have been replaced by a defined number of personal leave days per year, this still reduces staff’s ability to meet its workload. Additionally, there has been a 15 percent reduction in the work force for OSHPD, and a 25 percent vacancy in staff positions at L&C. During these challenging times, the amount of work has not lessened and both organizations have had to do “more with less.” Additionally, many of the more experienced staff

have left both organizations, resulting in a reduction in the quality of the work that is being com- pleted and longer timelines to complete that work.

OSHPD works under CCR Title 24 and L&C works under CCR Title 22. While both codes are part of the California Code of Regulations, the process for altering the two titles is quite different. OSHPD is able to alter Title 24 with a process that takes approximately 18 months, while alterations to the Title 22 of the L&C code may take over a decade.14 OSHPD’s process for altering the code allows it to keep more up to date on changes in the field as demonstrated by the current code changes (revisions) that have created a “household model”15 for skilled nursing facilities that seeks to acknowledge the industry’s move to a more residential model of care. L&C’s process does not allow it to keep up with changes in health care practice, resulting in a set of regulations that are out of date, particularly in light of changes in the industry as a result of the culture change movement.

While program flexibility can work

well to institute change, program flexibility

for one project does not guarantee that same program

flexibility for another project.

10


WhileTitle22hasnotbeenupdatedinyears,staffatL&ChasmadeeffortstobothunderstandandembraceculturechangeandnewmodelslikeGreen House®.UnderTitle22,L&Cdoeshavetheoptiontoallow“programflexibility”:“Allskillednursingfacilitiesshallmaintaincompliancewiththe licensing requirements . These requirements donotprohibittheuseofalternateconcepts,methods, procedures, techniques, equipment, personnelqualificationsortheconductingof pilot projects, provided such exceptions are carriedoutwiththeprovisionsforsafeandadequatecareandwiththepriorwrittenapproval of the department . Such approval shall provide for the terms and conditions under whichtheexceptionisgranted.AwrittenrequestandsubstantiatingevidencesupportingtherequestshallbesubmittedbytheapplicantorlicenseetotheDepartment.”16 While program flexibilitycanworkwelltoinstitutechange,programflexibilityforoneprojectdoesnotguaranteethatsameprogramflexibilityforanother project .

WhileTitle22andTitle24bothgovernskillednursing facilities, the Titles are very different in theirapproach.Title24isallaboutconstructionandphysicalstructuresafety,whileTitle22focusesonservices,thestaffingofthefacilityandthe provision of health care . There are very clear disconnectsbetweenthetwoTitles.

TheOfficeoftheStateFireMarshallhastheresponsibilityforproposingthefireandpanicsafety requirements in Title 24 for skilled nursing facilities, though they tend to take guidance from

thedecisionsmadebyOSHPDthroughtheirenforcement actions . Much of the regulatory structure of the International Building Code (andTitle24)isbasedontheNationalFireProtectionAssociation101LSC.Additionally,there is a great deal of autonomy given to the localfireinspectors,whichcanposechallenges to applicants .

California has an additional layer of regulatory approval not found in other states, approval from theCaliforniaDepartmentofPublicHealth,DepartmentofEnvironmentalHealthforthedesign and construction of the dietary component (kitchen).17 While small homes and Green House® aredesignedwiththekitchentoberesidentialinnature,ithasbeendeterminedthattheyfallunder the regulations for retail food facilities (restaurants).ThoughitappearsthatthisissuehasbeenresolvedinthecaseofMt.SanAntonioGardens, it may present challenges to others in the future .18

In July of 2011, the California Building StandardsCommissionapprovedOSHPD’schanges to the Building Standards for Skilled Nursing and Intermediate Care Facilities that createanewcategorywithinChapter12–InteriorEnvironmentcalled“1225.5.2HouseholdModel.”TheseHouseholdModelregulationsaremeant to encompass many of the culture change principlesespousedbyGreenHouse® and other small home developers . These draft regulations willtakeeffectin2012,butprovidersliketheGardens and Mercy may cite them as alternate designcriterianow.

11


ThE ISSUES

While some regulators have simply struggled withthephilosophicalnatureofsmallhomes(staffingmodel,roleofclinicalsupportteam,servicemodel,etc.),mosthavehadspecificissueswiththefollowing:

Kitchen

The residential scale and character

of the [small home] kitchen resembles

the kitchen that residents had in their

own homes, thus making them feel at

home. The kitchen is usually the most

utilized room in one’s home both to pre-

pare meals and to eat and as a gather-

ing place so an open residential looking

kitchen is an important way to “create

home” for residents. The food can be

prepared in full view (and smell) of

residents, staff and visitors resulting

in an increased appetite and interest in

this important aspect of everyday life.

Some residents, depending on cogni-

tion and physical frailty level, may be

able to participate in food preparation

activities with the staff.19

InmostofthestateswhereGreenHouse® (orsmallhomes)haseitherbeenadoptedorcontemplated, the kitchen is at the heart of most of the regulatory challenges . In California and inmostotherstates,thosewholicenseskillednursingviewthekitchenasthegreatestthreatto safety in the nursing home . It is the single placewhere“fire”isneeded,toleratedandtightlycontrolled.Additionally,thekitchenbringsupoperational issues of food safety, infection control andthesafetyofresidentsaroundfireandheat.

Historically,nursinghomeshavebeenallowedtohave“warmingkitchens,”outsideofthecommercialkitchen,withnon-commercialappliancesthatallowthefacilitytoheatpre-prepared food or for limited cooking . The cooking doneinthistypeofwarmingkitchenisoftenreferred to as an activity and the kitchen as an activity center rather than a true kitchen bytheFireMarshal.Thesewarmingkitchensare usually not licensed kitchens and, as such, the facility needs to also have a fully licensed commercial kitchen to prepare and serve daily meals .

The licensing challenges around the kitchen is directedatthosefacilitieswherethekitchenisusedtopreparemealsonadailybasis.Fullyfunctional kitchens are crucial to the Green House® and small home models, as they are used to prepare all the meals for the house and are an important area for resident engagement and

12


activity.Basedonthespecificstateregulatoryenvironment, Green House® has crafted measures to lessen the risk including using induction cook tops(stovetopsthatdonotgethotbecauseheatis transferred from the element directly to the potorpan)andgasshut-offvalveswhencookingappliancesarenotinuse.Additionallystoveguardscanbeavailabletobeplacedonthetop of the stove if staff needs to leave the kitchen whilefoodiscooking.Retractablegatescanprevent entry into the kitchen if necessary, and lockedcabinetsanddrawerskeepchemicalsandsharp utensils out of reach . These precautions are a means of preventing potential accidents andeliminatinghazardswhilemakingitpossibleto live in a home instead of an institution .20 To meet the evolving interpretation of current institutional life safety and related codes, Green House®homesarenowbuiltwithfireshutters(orasimilardevice)tofullyseparatethe open plan kitchen in case of an emergency . AllnewGreenHouse® homes also include a commercialhoodwithfullfiresuppressionsystemsabovethestove.

Generally any time this full-service kitchen hasanopencookingappliance,additionalfiresuppressionsystems(Type1commercialhood)and/or physical separation of this appliance from exits is needed . Currently a task force from the

PioneerNetworkhasreceivedapprovalfromNFPAforthefollowingchangestotheregulationsfor kitchens:

Kitchenswillbepermittedtobeopentoother spaces and the corridor as long as theymeetallofthefollowingcriteria:

—Mayuseeitherresidentialorcommercial stoves or cooktops .

—Kitchencannotservemorethan 30 residents .

—Kitchenmustbewithinasmokecompartment21 and must only serve residents in that smoke compartment . Abuildingwithmultiplesmokecompartments may have an open kitchen in each smoke compartment .

—Thesmokecompartmentwhere thekitchenislocated,whetherinaneworexistingbuilding,mustbefully sprinkled .

—Arangehoodmustbeprovidedwithafiresuppressionsystem,greaseclean-outcapabilityanda500cfmfan.

—Hoodsmaybeventedtotheexteriororre-circulating,butdoesnot need to meet full commercial hood requirements .

—Localsmokealarmsthatarenot tiedintothefirealarmsystem maybeprovidedintheareaoftheopen kitchen .

13


Nurses’ Stations, Staff Offices and Space Needs

Asnursinghomeswerepatternedafterhospitals,nurses’ stations in nursing facilities are similar to nurses’ stations in hospitals . They are often located at the entry to the nursing facility and are thefirstthingthatoneseesasonewalksthroughthe door . The nurses’ station simply reinforces the concept that this is an institution, not a home .

In most nursing homes, nurses’ stations are the control center for the nursing facility . The physicalstructureofthestationisoftenabarrierthat separates staff from residents and, in some facilities, that station is so high that residents in wheelchairscannotseeoverit.Requirementsfornurses’ stations fall under state regulations, asthereisnoFederalrequirement.Assuch,somestatesrequirenurses’stations,whileothersdo not . Select state regulations require that the nursesbeabletoseedowneachhallfromthenurses’ station even though nurses are not sitting atanurses’stationatalltimes—themajority oftheirtimeshouldbeincaregiving.

Green House® homes and many small home modelsremovethenurses’station,allowingnursestositatthediningroomtableorinthelivingroomwhiletheydocharting.Thisallowsforinteractionwithresidentsandadditionalobservationandmonitoringofresidentconditions.Thisalsoreducesthebarrierbetween

residentsandstaffcreatedbytheimposingnurses’ station . In the Green House® model, nursestravelbetweenhousesand are not embeddedineachhouse,furtherreducingtheneedforadefined“station”forthem.

Somestateshavestruggledwiththeremovalof the nurses’ station and still require some semblanceofastation,albeitoftenonlyadesk . Ohio has softened language in its state regulations that require a nurse area rather than anurses’station.SeveralstateswhereGreenHouse® hasbeenadoptedrequirea“room”wherenursescansafelystorefilesandhaveprivatemeetingswithfamilyandresidents.Assomestateregulationsalsorequiredefinedspacefordietary,administration,socialworkandothers,this space may also serve that function .

Inthetraditionalnursinghomewith60+bedsand often over 100 staff, there are space needs that don’t manifest themselves in small homes like Green House® homes.Plumbingregulationsoftenrequiremaleandfemalebathroomsforthepublicandseparatebathroomsforstaff.Whileaunisexbathroomtoaccommodatestaffmaybeallowedbycodesdependingonthenumberofstaff, separate facilities accommodating staff are necessary for appropriate infection control . State regulationsoftencallfordefinedofficespacefordietaryandadministrativestafftobelocatedwithinthedietaryservicespace.IntheGreenHouse® model, these staff are housed outside ofthehomeandsodon’tneedspacewithinthehome itself .

14


havingawallononeside.IntheGreenHouse®, theresidentroomsopenontoaneight-foot-widecorridorwhichsurroundstheopenheartharea.Thiscausesthatopenspace(eight-footcorridor)tobemuchlargerthanwhatwouldnormallybedesignedinaresidentialhome,forcingthisinstitutional feature even in the small home model .

The hearth

Althoughthehearth,whichincludesafireplace,is the heart of the Green House®, there are a numberofstateswheretheFireMarshallandtheregulatoryauthoritieswillnotallowthathearthtoproduceheat.Whilethereareanumberof issues here, the fact that resident rooms open ontothehearthareaseemstobeattheheartoftheissue,thoughtherearestateswheretheconceptofhavingafireplaceinanursinghomeis simply not code compliant . In many states, Californiaincluded,therecannotbeafireplacein the common area open to resident rooms, yetthereareanumberofnursinghomesinCaliforniawithfireplaces.

CurrentlyataskforcefromthePioneerNetworkhasreceivedapprovalfromNFPAforthefollowingchangestotheregulationsforfireplaces:

Allowsgasorelectricfireplacestobeused in smoke compartments that containsleepingrooms,butnotwithinindividual sleeping rooms . Controls must belockedandasealedglassfrontmustbeprovidedtopreventanyonefromthrowingobjectsintotheflames.

15

Resident Rooms

“It’s the same deal over and over again

of having old regulatory language

and needing to decide how it relates to

something new that was not thought of

when it was written. For example, our

Federal regulation that bedrooms must

have direct access to an exit corridor

was developed to eliminate the practice

of having one bedroom located behind

another, which is a fire safety issue

that was encountered in old buildings

that were turned into nursing homes

long ago. Now the issue is resurfacing

in Green Houses® that are built to look

like homes and do not wish to have the

institutional look of a corridor.” 22

There is another regulatory issue that has come upwiththedesignofGreenHouses® regarding thearrangementofbedroomsaroundthecentrallivingspaceandwhetherthebedroomshavedirect access to an exit corridor as required byCMSregulation23 . Currently, CMS has no authority under current regulations to approve a variation to this requirement . This requirement grewoutoftheold-stylenursinghomewhereyouoften had to pass from one room and into another to reach the corridor . States have gotten around thisissuebyconsideringacorridorasonly


oklahoma

Arkansas

STATE lEGISlATION

While many states have granted individual waivers(alternatemeansofcompliance)thatmake the Green House® /small home model possible,otherstateswantingtocreateamore

permanent environment for the this model and encourage its spread, have passed legislation to amend statute or regulatory language . If Green House®andsmallhomemodelsaregoingtogrowexponentially,thislegislativestrategywillbeimportant .

InMarch2007,ArkansasHouseBills1363and1364weresignedintolaw.TheyprovideArkansas’OfficeofLong-TermCaretheabilitytoprovidesupport,staffingflexibilityandspecializedreimbursementstoorganizationsinterestedincreating a Green House® projectorimplementinganEdenAlternativeprogram.HouseBill 1363amendsArkansas’Long-TermCareTrustFund,anaccountfundedbynursing

home’scivilmonetarypenalties,toallowtheDirectoroftheOfficeofLong-TermCaretousefundsfrom the trust to create programs supporting Green House®projectsorEdenAlternativePrograms.DiscussionswiththeOfficeofLong-TermCareindicatethatplanninggrantsforGreenHouse® adopters areonesuchprogram.HouseBill1364amendsArkansas’CoderelatingtonursinghomestaffingstandardstoallowtheOfficeofLong-TermCaretocreateseparatestaffingstandardsandreimburse- ment categories for Green House® projectsorEdenAlternativehomesasdeterminednecessary.

In2007,GovernorBradHenrysignedHouseBill1510,whichhelpedtobringtheGreenHouse® Project to Oklahoma . The legislation gave the CommissionerofHealththeabilitytowaivecertainprovisionsoftheOklahomaNursingHomeCareActifnecessarytorestore“individualstoa self-contained residence in the community that is designed like a private

homeandhousesnomorethan10individuals.”WhiletheGreenHouse® Project does not typically need waiverstooperateunderstateguidelines,theaddedflexibilityisanexcellenttooltohaveavailable.

In2007,WyomingadoptedtheLong-TermCareChoicesAct(SF89).TheActcoversseveralitemsrelatingtolong-termcare,includingcreatingan“alternativeeldercarehome”category(modeledontheGreenHouse® Project principles)andafeasibilitygranttofundtheexplorationofoneAlternativeElderCareHome.TheElderCareHomemustprovidea“residentialhomeenvironment”toMedicaidsupportedresidents,includingprivatebedroomsand

baths,aden,anopenkitchen(implied),anofficeforanurse,openaccesstoallareasofthehouseandasecuredpatioduringwakinghours,overheadlifts,arestraint-freeenvironment,andself-managedworkteamsofdirectcareandnursingstaff.

InJuly2006,Section116ofChapter139oftheActsof2006becamelawinMassachusetts,providingaCertificateofNeedfor100newskillednursingbedstobedevelopedusingtheGreenHouse® modelofcarebyChelseaJewishNursingHome.Thisisthefirstapprovalfornewnursingbeds tobegrantedinthestateinthepast10years.

16

Wyoming

massachusetts


lESSONS lEARNED FROM ThREE STATES

Thefollowingthreestates(Arkansas,MichiganandTennessee)haveallimplementedGreenHouse® and other small home models . Each has taken a different path to implementation, though therearecommonthemesthatcanbedrawnfromall of the states:

1 . It is important to have a highly placed and committed advocate within the State regulatory structure. Green House® has struggledinthosestateswithoutastateadvocateandflourishedinstateswherethereisanadvocateatthe“director”level . Many of these advocates have beguntheirculturechangejourney withtheEdenAlternative.

2 . “You have to see it.” A common theme is that providers and regulators must see a Green House® in action, talk to staff andinteractwithresidentstotrulyunderstand the process and appreciate the outcomes . Regulators and providers from these three states all visited Green Houses® prior to making any changes .

3 . Those states (providers and regulators) that were committed to and active in theEdenAlternativewerealsoearlyproponents of the Green House® model .

4 . States with a dynamic regulatory process – one that is updated regularly to keep pacewithchangesinlong-termcare–aremuchbetterpositionedtoadoptsmall home models and implement elements of person-centered care .

5 . States that carve out or create a “small home” sectionwithintheregulatorystructurearebetterpositionedtoencouragethegrowth ofsmallhomeswithintheirstate. TheuseofwaiversandAlternativeMeansofCompliance(AMC) is a disincentive to some providers and creates a level of uncertainty around thelongevityofthewaiver.

6 . States don’t create change without the encouragement of committed providers. Selectmembersoftheskillednursingprovider community and the state trade associations representing skilled nursing and state culture change coalitions arecrucialto“pushing”statesto make change .

7 . In many states, incremental change has been a successful path to full implementation of models like Green House® . Once again, operational changes originallypromulgatedbytheEdenAlternativehaveledtomoresubstantialchanges that have opened the door to small home models .

17


Key lessons

ArkansashadacommittedindividualwithinintheOfficeofLong-Term Carewhoservedasanadvocate and facilitator .

Rather than change existing regulation, thestatesimplyaddednewsectionsto the regulatory structure that acknowledgedGreenHouse® and small home models .

Therewasenoughsupportat the legislative level to create statutory change .

CivilMonetaryPenalty(CMP)fundswereusedtooffsetdevelopmentcosts tocreatenewfacilities.

EnhancedMedicaidreimbursementincented providers to engage in culturechangeandnewmodelslike Green House® .

The Process

Arkansas’routetoGreenHouse®beganwiththeestablishmentofaffordableassistedlivingas a more person-centered alternative to skilled nursing care . The process to create a regulatory frameworkforALhelpedregulatorsintheArkansasDepartmentofHumanServices24

toseethebenefitsofamorehome-like, non-institutionalmodelofcare.Additionally, thesameorganizationthatworkedonthe state’sassistedlivingprogram(ComingHomeProgram)andestablisheditscredibilitythroughthatworkalsoworkedwiththeStatetoestablishGreen House®.BothprogramswerefundedthroughtheRobertWoodJohnsonFoundation.

Arkansas’skillednursingregulationswerewrittenin1984,aresomeofthemosthighlyprescriptiveinthecountryandhadnotbeensignificantlyalteredsincetheirinception. Aswritten,theyhinderedanystateorproviderefforts at culture change, and their prescriptive nature precluded the creation of small home models like Green House®.Anyattempttocompletelyrewritetheseregulationswould haveencounteredsignificantoppositionfrom the industry .

Aswithotherstatesthathadsuccessfullyimplemented the Green House®model,therewasanadvocatewithinthestatehierarchy,CarolShockley,theDirectoroftheOfficeofLong-TermCareattheDepartmentofHumanServices. Ms.Shockleyhadbeenimpressedwiththe EdenAlternativeandtakentheEdentraining.Shesubsequentlytraveledwithmembersof herstafftovisitthefirstGreenHouses® in Tupelo, MS . While desirous of creating an environmentinArkansasthatwouldallowGreenHouse® toflourish,sheknewthatacompleterewriteofthenursinghomeregulationstoallowforGreenHouse®wouldbechallengingand,possibly,unsuccessful.ToinstitutetheGreen House® modelinArkansasrequiredbothstatutory and regulatory changes . The statutory changewouldallowfacilitiestouseuniversalworkers(Shahbaz/CNAs)andtheregulatorychangewouldcreatetwonewsectionsinthe

18

Arkansas


currentregulations(Section700–GreenHouse® andSection800–HomeStyle)thatallowedselectproviderstoadoptthisnewmodel.

ThenewregulationsforGreenHouse® homes arebriefandplacetheresponsibilityofvettingnewprojectswiththeGreenHouse® staff . Under“Designation,”GreenHouse® staff must approvenewprojectsandthoseprojectsmustremainingoodstandingwiththeGreenHouse® organizationtocontinuetobeingoodstandingwiththestate.

700 GREEN hOUSE® Facilities25

701 Intent

Green House® facilities are an attempt

to enhance residents’ quality of life

through the use of a non-institutional

facility model resulting in a residential-

style physical plant and specific prin-

ciples of staff interaction. The Green

House® model utilizes small, freestand-

ing, self-contained homes surrounding

or adjacent to a central administra-

tion unit, each housing between ten

(10) and twelve (12) private rooms,

each with full bathrooms. The resi-

dents’ rooms are constructed around a

central, communal, family-style open

space that includes a hearth, dining

area and residential-style kitchen.

All residents’ room entrances are visible

from the central communal area. Each

home is built to blend architecturally

with neighboring homes. The intent

of these regulations is to create a frame-

work that encourages the construc-

tion and operation of Green House®

facilities.

702 Designation

To be designated by the Office of Long-

Term Care as a Green House® facility,

the facility must meet the minimum

standards, and have approval to use

the Green House® service mark, issued

by the Green House® Project and NCB

Capital Impact at the time of designa-

tion and at all times thereafter.

703 Staffing

Facilities designated by the Office of

Long-Term Care as Green House® fa-

cilities shall employ the same staffing

ratios and otherwise comply with Sec-

tion 520 of these regulations; provided,

however, that CNAs utilized in Green

House® facilities may act as universal

workers. For purposes of this regula-

tion, universal worker means a Certi-

fied Nurse Assistant (CNA) who, in

addition to performing CNA duties,

performs dietary, laundry, housekeep-

ing and other services to meet the needs

of residents.

19


While the Green House® regulations rely heavily on the Green House® Project for monitoring of compliancewiththeGreenHouse® model, the HomeStyle regulations are very prescriptive . Thismodelisdescribedinregulationasa“pilot”and,assuch,willbemonitoredforresidentquality of care and quality of life improvement:

“Facilitiesparticipatingintheprojectwill berequiredtomaintaindetailedmedicalandsocialrecordsofresidents.Therecordswillcontain an initial assessment of the medical and social conditions, and needs of residents atthetimeofadmission,whichwillformabaselinemeasure.ThebaselinewillbecomparedbytheOfficeofLong-TermCareoritsdesigneeswithsubsequentrecordsmaintainedbythefacilitytodeterminethelevel of functioning, social interaction and medical conditions of residents to determine whetherHomeStylefacilitiesresultinimprovementsinthoseareas,includingbutnot limited to the type and dosage amounts, and frequency of medications . Further, facilitieswillberequiredtomaintaindetailedfinancialrecords.”26

In addition to Federal and state regulations regardingstafftraining,CNAsintheHomeStylemodel must take an additional 80 hours of training focused on person-centered care and theHomeStylemodel.Thistrainingwasbasedon the training that the Green House® Project providestotheShahbaz.

In order to encourage the spread of Green House® model,theLegislaturepassedAct193,whichamendsArkansas’Long-TermCareTrustFund,anaccountfundedbynursinghome’sCivilMonetaryPenalties,toallowtheDirectoroftheOfficeofLong-TermCaretousefundsfromthe

trust to create programs supporting Green House®projectsorEdenAlternativePrograms.Theseplanninggrantswerelimited to$500,000perprojectandcouldbeusedtooffsettheincreasedcostsofbuildingthisnewmodel.Additionally,theStateworkedwithCMStocreateastateplanamendment(subcategory ofnursinghome)allowinganenhancedMedicaiddaily rate for nursing homes that implemented Green House® and HomeStyle models . The LegislaturealsopassedAct192thatallowedfor auniversalworkermodelforstaffingofbothGreen House® and the HomeStyle .

THERE ARE THREE GREEN HouSE® PRoJECTS iN ARkANSAS AND A NumbER oF HomESTylE moDElS:

Green House Cottages of Southern Hills,ownedbySummitHealthResources,afor-profitproviderinRison,is operating six 12-unit elder homes that replaceda50-bedtraditionalinstitution.

Wentworth Place of magnolia is also ownedbySummitHealthResourcesandis operating four 12-unit homes .

Green House Homes at legacy Village inBentonvilleisownedbythelocalnonprofitNorthwestArkansasSeniorServices, Inc ., and is licensed as assisted living . They currently operate three 10-unithomeswithanadditionalthreehomes in the planning stage .

20


Key lessons

Tennesseehadanadvocatewithinthestate long-term care hierarchy, though thatpersonwasnotthedrivingforce for change .

Tennesseewasveryinvolvedinthe EdenAlternative,andEdenhad strongpartnershipswithintheindustryassociations.CMPfundshadbeenusedfor nursing homes that sought education abouttheEdenAlternative.

Theprocessforchange(waiversfromtheBoardforLicensingHealthCareFacilities)waslessonerousthaninmanystatesandtheBoardmemberswereamenabletochange.

AnearlyGreenHouse®reviewofthestatebuildingstandardssurfacedonlyminor issues, though challenges, around thekitchenandanumberofotherareasarose during the approval process .

Implementation of Green House® model did not require statutory changes, only regulatory changes .

ItisimportanttonotethatArkansasisone ofthefewstatestoimplementaGreenHouse® model under an assisted living licensure category . Arkansas’assistedlivingleveltwocategoryallowsresidentstoremaininassistedlivingdespite frailty that might force them to move to skilled nursing in other states . The challenge withthismodelisthereducedreimbursement(lessthanSNF)providedbytheassisted livingwaiver.

Arkansashasmadeeveryefforttoensurethatthesmallhomemodelwillnotbe“anecdotal”orenactedbasedonanalternativemeansofcompliance.Thestatebelievesinthemodel, andhascreatedregulationsandreimbursementto encourage its spread . They hope that those whodon’tactuallytransitiontoGreenHouse® willaspiretotakeontheattributesof Green House® and provide a higher quality of life and quality of care to its residents .

21

Tennessee


The Process

While changes necessary for Green House® homescameeasyinTennessee,thegroundworkforthiswasinprocessforsometime.ProvidersinTennesseehavebeeninvolvedwithculturechange since the early days of the Eden Alternative.TheTennesseeEdenAlternativeCoalition(culturechangecoalition)hasstrongpartnershipswithindustryassociationsandtheDepartmentofHealth.Theywereinstrumentalinpassingastatelawtoprovideannual Eden grants, using CMP funds, to homes to support their need for Eden education and other resources for their journey . The coalition has alsoestablishedregionalsupportgroupsfor the Western, Central and Eastern sections of the state .

TheTennesseeHealthServicesandDevelopmentAgencyisresponsibleforregulatingthehealth careindustryinTennesseethroughtheCertificate ofNeed(CON)program.TheCONprogramservesasagrowthmanagementandcostsavingstool since it requires certain health providers toestablishtheneedfornewservicesandfacilitiesbeforetheproviderswillbeallowed tobuildfacilities,becomelicensedorconductcertainbusiness.

It is interesting to note that the Tennessee CON applicationonlyrequiresverybasicarchitecturaldrawingsanddoesnotcommentonstructuraltype .27ArchitecturalplansarethensubmittedtothePlansReviewSectionofHealthCareFacilities,whichperformsasimilarfunctiontoOSHPDinCalifornia,andreviewsandapprovestheplans.Approximately30to45dayspriorto

completion of the construction, applicants send alettertotheBureauofHealthLicensureandRegulationRegionalOfficetorequestasurvey of the facility .

Asinotherstates,theTennesseeDepartmentofHealth,BureauofHealthLicensureandRegulationandDivisionofHealthCareFacilitiesstruggledwithanumberofconceptsaroundtheGreen House® model, including the open kitchen; thefireplace(hearth);acovereddrop-offareaandpedestrian entrance at grade level for inclement weather;separatediningareasforstaffandresidents; physical therapy equipment in each house;anadministrative/publiclobbyareaforreception and information; and administrative office(s)andmultipurposerooms.Toresolvetheseissues, Green House® staff made presentations totheBoardforLicensingHealthCareFacilitiesandBoardmemberswereimpressedwithboththe physical structure and the operating model . Asaresult,theBoardadoptedthefollowingone-timewaiversfromexistingstateregulations:

With the open kitchen area a focal point in the Green House® model as a means to stimulate the residents appetite through smell, and the location of a fireplaceinthegatheringareawilladdtothehomeatmosphere,thefollowingcode references, Standard Building Code Table409.1.5andNFPA10118.5.2.3(a),maybeaccomplishedbyprovidingone-hour rated, smoke-tight, separation fromthebuildingcoreattheresidentroomwall.Residentroomsshallhave20-minute rated doors and frames . Doorclosersarenotrequiredon resident room doors .28

22


Kitchencookingappliance(s),ifresidentialtype,musthaveaUL300Asuppressionsystem.Allfuelsources(gasand/orelectric)forthekitchenorfireplaceshallbecontrolledthroughthefirealarmcontrolpanelusingsolenoidvalves or shunt trip device, respectively . Acarbonmonoxidedetectorshallbelocatedadjacenttogasfireappliancestodetectpossiblegasleaksandalsobetiedintothefirealarmcontrolpanel.

Avehicledrop-offandpedestrianentrance at grade level, sheltered from inclementweatherandaccessibletothedisabled,shallnotberequired.

Separate dining areas for staff and residentsshallnotberequired.

Equipment for carrying out each type of PhysicalTherapythatmaybeprescribedmaybestoredinaspaceatanadjoiningnursinghomeandbroughttotheGreenHouse® for resident therapy .

Anadministrative/publiclobbyareaforreceptionandinformationshallnotberequired.Accesstotelephonesandpublictoilet(s)shallbeprovidedinthefacility.

Administrativeoffice(s)andmultipurposeroomsmaybelocatedinanadjoiningon-campusfacility/building.

THERE ARE TWo GREEN HouSE® PRoJECTS iN TENNESSEE:

Ave maria Home,anonprofithealthcare provider in Bartlett, is under construction on four 10-unit homes to replace35traditionalskilledbedsontheir existing campus .

Jefferson County Nursing Home inDandridgehasbuiltthreeGreenHouses®tobringtheirtotalnursinghomebedcountto160.

ADDiTioNAlly, THERE iS A SmAll HomE moDEl:

uplands Retirement Village,anonprofithealth care provider in Pleasant Hill, has constructed four homes that serve 15–16 individuals each . While larger than the conventional Green House®, they have many of the same characteristics .

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Key lessons

InthecaseofMichigan,theDirectorofthe Bureau of Health Systems at the MichiganDepartmentofCommunityHealthwasbothanEdenAdvocate(tooktheEdentraining)andanadvocateofthe Green House® model .

Michiganwasoneofthekeyleaders in the culture change movement in the 1990s .

MichiganwasastatewithavibrantEdenAlternativemovement.

Grantsweremadeavailabletoproviderspursuing quality of care and culture changethroughtheEdenAlternative.

Michigan’s provider community embracedthesmallhomemovementwithanumberofproviderswilling to make the transition .

Implementation of Green House® did not require statutory changes, only regulatory changes .

Therewassomelevelofinvolvement bytheMichiganlegislatureinencouraging the model’s adoption .

AsoneofthefirstimplementersoftheGreen House®/small home model in the country, regulators, providers and legislators encountered challenges for whichtherewerenoexistingprecedents.Assuch,theywerenotabletofallbackon lessons from other states .

The ProcessMichigan is an interesting example of the role of politics, innovation and enlightened partnerships betweenregulatorsandproviders.Michiganwasat the forefront of the culture change movement inthelate1990swithavibrantculturechangecoalitionandstateagenciesfocusedonbothculture change and quality improvement in nursing homes . In 1998, the state provided $10 million in grants to providers pursuing quality improvement and culture change throughtheEdenAlternative.BringingtheEdenAlternativetoMichigan(BEAM)wasformedin2000andthestatesoonbecameafrontrunnerinthe national culture change movement . Michigan providersembracedGreenHouse®homes,LEAP and the household model and, to this day, Michigan hasthemostEdenAlternativeregisteredhomesand small house projects in the country . What madeMichigansuccessfulwasthecollaborationamong advocates, regulators and providers and, once again, an advocate in a highly placed position instategovernmentwhochampionedthechange.

ToopenanewnursinghomeinMichigan,theprocessbeginswithanapplicationforCertificateofNeed.ThearchitecturalplansmustbereviewedandapprovedbyHealthFacilitiesEngineeringSectionoftheDivisionofHealthFacilitiesandServices.ThisDivisionhasarolethatissimilartoOSHPDinCalifornia.Michiganuses the International Building Code29andNFPA101LSC.Whentheplansareapproved,the

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michigan


applicantmustnotifytheDivisionofNursingHomeMonitoringforassignmentofaLicensingOfficer.Attheconclusionofconstruction, the Bureau of Fire Services and the Health Facilities Engineering Section staff must inspect thefacility.ArecommendationforapprovalforoccupancywillbemadetotheLicensingOfficeraftertheconstructionprojecthasbeeninspectedand found to meet all requirements .

TheprocessforopeningthefirstGreenHouse® in Michiganwaschallenging.Whileacarefulreviewoftheregulatorystructurebytheproviderdidnot originally indicate any issues, the regulatory agenciesstruggledwithmanyofthesameissuesthatotherstateshadidentified:theopennatureof the kitchen, proximity of the Green House® tothetraditionalfacility,thenatureofthenewstaffingmodelthatincorporatedmuchofthedailytaskstotheShahbazim,liftsintheceilingandahostofotherissues.Additionally,otherthantheoriginalTupeloGreenHouse(Tupelo)site,theVillageatRedford(Village)wasoneofthefirstGreenHouse® projects in the country, and many of the regulatory questions around thephysicalenvironmenthadnotbeenexploredat either the state or national level . Much like Tupelo,theVillagehadtobreaknewgroundtoopen their Green House® . The Village took a very different route in seeking to meet the challenges of the regulatory process . They convened a meetingwithkeyhealthcareregulatoryandlicensingdepartmentheadsandkeymembers of the Michigan legislature in order to educate allconcernedaboutthebenefitsofGreenHouse® homes and to assess the regulatory challenges that lay ahead .

Someoftheadditionalissueswere:

Requirement to have a commercial hood, rather than a residential hood, for the kitchen.Additionally,providersneeded

amanualpullstationincaseoffireatleast 10 feet from the kitchen in the direction of egress .

Thenursingoffice(notastation)musthavewindowsthatlookoutontotheliving areaandbeinsightlineforalltherooms.

BecausetheShahbazspendaconsider- ableamountoftimeinthekitchen,the kitchenneededtobedesignedsoresident roomdoorsarevisiblefromthekitchen.

Receivedwaiverforaunisextoiletbecausetheyhadfewerthan15male/female staff .

THERE ARE FouR GREEN HouSE® PRoJECTS iN miCHiGAN AND mANy SmAll HomE moDElS (NoT liSTED):

Pinecrest medical Care Facility, anonprofithealthcareproviderinPowers,isoperatingtwo10-unithomes.PinecrestisownedbythecountiesofDelta,DickinsonandMenominee.

Porter Hills,anonprofitproviderwitheight campuses in the Grand Rapids area,isoperatingtwo10-unithomes.

The Village of Redford,anonprofitprovider in Redford, is operating two10-unithomesonalarge, multi-level campus .

The Resthaven Care Community, anonprofitallianceofchurchesinHolland, operates one 10-unit home atoneofitsfivehousingandhealth care locations .

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CAlIFORNIA GREEN hOUSE® PROJECTS PENDING

Currently,therearetwoprojectsmakingtheirwaythroughtheregulatoryprocess–Mt.SanAntonioGardens(Gardens)inPomonaandMercyRetirementandCareCenter(Mercy)inOakland.TheGardenshasbeenworkingonGreenHouse®forabouttwoyearsandhasencounteredconsiderablechallenges.Giventhattheyarefirstprojectinthestate,thatistobeexpected.MercyisexaminingthebenefitsofGreenHouse®,studyingthefinancialimplicationsandworkingwiththestatetofleshoutissuesaroundimplementation .

Mt. San Antonio GardensMt.SanAntonioGardensisanationallyaccredited continuing care retirement community ownedandoperatedbyCongregationalHomes,Inc.,anonprofitcorporation.TheGardens,locatedona30-acrecampusinthetownsofPomonaandClaremont,hasbeenservingolderadults since 1961, and currently has more than 470 residents in independent living, assisted living, memory care and skilled nursing . The nursingfacilityattheGardenshasafive-starratingfromCMSanda“superior”ratingfromCalQualityCare .org .

TheGardensbeganworkingonGreenHouse® in 2009 and, very quickly, discovered that there wereanumberofsignificantroadblockstoimplementation . The Gardens chose a residential architect to design the Green House®buildings,whichcreatedissuesforbothOSHPDandtheGardens . While the Green House®ismeanttobearesidentialstructurethatfitsintoaresidentialneighborhood,thereweresignificantchallengesfor that architect and the Gardens as they came

togripswiththecomplexprocessesofOSHPDandthecomplexhealthcarebuildingtype.Additionally,OSHPDviewedthisasanewmodelofcarewithoutcorrespondingcodelanguage,withacomplicatedprojectsitethatspannedtwolocalfirejurisdictionsandtwocities.Additionally,theprojectpresentedanewopenkitchenconceptandthereweresignificantcommunicationdifficultiesbetweenOSPHDandthesponsor.

Oneofthemajorissueswasthedistance(780+feet)betweentheproposedGreenHouses® and the existing traditional nursing facility . This broughtupissuesofasecondlicenseandwhetherornotthenewGreenHouses®wouldbelicensedunder the existing nursing homes license . Ifaseparatelicensewasrequired,thentheprojectwouldnotbeviable.Havingaseparatelicensewithonly20units(twohouses)wouldnotbeoperationallypossiblegiventhestaffingrequirements for nursing facilities . Title 22 states that facilities acting under one license must beonthe“samegrounds.”WhiletheGardenswouldbeonthesamecampus,thatcampusisdividedintwobythecitylimitsofClaremontandPomona–thelinerunsrightdownthemiddleofthe campus and the Green Houses®wouldbeinonecity,whilethetraditionalfacilitywouldbeintheother.L&Cdidgrantawaiverforthisissue(programflexibilityunderSection72213),whichwouldnotcreateaprecedentforotherprojects.UsingprogramflexibilitywouldalsoallowL&Ctodenyotherapplicantsiftheyweren’tinasimilar campus type situation as the Gardens .

ThenextmajorissuewastheinvolvementofDepartmentofEnvironmentalHealth.Californiahas an additional layer of regulatory approval not found in other states, requiring approval from thelocalhealthdepartment,LosAngelesCountyDepartmentofEnvironmentalHealth,forthedesign and construction of the kitchen . While small homes and Green House® are

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designedtoberesidentialinnature,ithadbeendetermined that they fall under the regulations forretailfoodfacilities(restaurants).UndertheCalifornia Food Code, licensed medical facilities must adhere to the Code though Residential CareFacilitiesfortheElderly(assistedliving)havebeenexcluded.Healthdepartmentcodesrequirea“fullpartitionseparatingthekitchenfromlivingandsleepingareaswithnodoorsoropenings(windows).”Inthisscenario,inordertoservethefood,ithastobecarriedoutsidethebuildingandthenbackintothediningarea. Thisrulewasimple-mentedtostopthelargenumbersofhomesinLosAngelesthatwerebeingturnedintosmalleateries,buthasnorealrelevance to nursing facilities . Every nursing facilityinthecountryhasdoors(openings)thatallowfoodtobetransportedfromthekitcheninto the dining area that is often adjacent to the livingareas.AwaiverhasbeengrantedfromEnvironmental Health to resolve this issue .

Thefollowingarechallengesthathave required the application for an alternative method of compliance:

1 . Reduce the size of the clean utility and the soiled utility, as these rooms only serve 10 elders .

2 . Rather than having a desk for the dieticianinthekitchen(theGreenHouse® residential kitchen has no room foradesk),dieticianwillshareadeskarea in the nurses’ station .

3. Lockerswillbeprovidedinoneunisexstaff locker and general dressing room forbothdieteticstaffandgeneralemployees, as there are not separate dietary staff in the Green House® .

4. Anemployeedressingroomwithtoilet,lavatoryandlockerswillbeinoneunisexroom.Astherearefewerthanfiveemployees, separate male and female staff toilet rooms are not required .

5. Administrativeandstaffworkareas willbeprovidedinthemainSNF, rather than in the Green House®, as administrative staff are not located in the Green House® .

6. Wheelchairstoragewillbelimited tohousetwowheelchairsonly,asthereare only 10 residents .

7. Combinethecleanlinenstorageandlaundryservicesasoneunit.Combinethe soiled linen storage and laundry servicesasoneunit.Soiledlinenwill bekeptineachresident’sbathroom inahamper.Cleanlaundrywillbe takendirectlybacktoresident’sroom for storage .

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The Gardens began working on

Green House ® in 2009 and, very quickly,

discovered that there were a number of significant roadblocks to

implementation.


Asthefinalkitchendrawingshavenotbeenapproved,itisanticipatedthattherewillbesomechallengesaboutthenatureoftheopenkitchen.CodedoesnotallowandOSHPDwillnotapproveany type of heat-producing hearth, so the hearth willbeanartificialfireplace.

Mercy Retirement and Care CenterThe Mercy Retirement and Care Center, establishedin1872bytheSistersofMercyinOakland,CA,offersassistedliving,memorycareand skilled nursing . The Care Center includes 59skillednursingbeds,twodiningroomsand an in-house therapy room . Since 1997, Mercy has beenapartoftheElderCareAlliance(ECA), aregionalorganizationthatoperatestwoskillednursing and four assisted living facilities . Mercy isafive-starratedfacilitywithfewdeficiencies.ItwasratedbyNewsweekmagazineasoneofthehighest quality facilities in the country . Mercy hasafive-starratingfromCMSanda“superior”rating from CalQualityCare .org . Currently the payer mix at Mercy’s nursing facility is 70 percent private-pay, 27 percent Medicaid, and 3percentMedicare.Alloftheroomsaresemi-private,withtheexceptionofthreeprivaterooms.

Mercy has plans to completely replace their skillednursingfacilitywithsix12-unit Green House®homesbuiltinanurbanhigh-risestyle(fourstories)thatisinkeepingwiththeOaklandFruitvaleneighborhoodwhereMercyis located . Mercy’s foray into Green House® has beenexceptionallymethodical.IncontrasttotheGardens,whichisonlybuildingtwohouses,

Mercy is replacing their entire facility and movingfromadebt-freeenvironmenttoalargerfacilitythatwillcarryasubstantiallevelofdebt.Assuch,Mercyhasbeenveryfocusedonthefinancialviabilityoftheproposedproject.

Mercy has also taken a very conservative approachtotherelationshipwithbothOSHPDandL&C.Theyhavehiredanarchitectthathasanexceptionalhistorywithhealthcarefacilities,andhavebroughttogetherallofthenecessaryregulatoryparticipantsforanearlyreviewofthe project in hopes of targeting any potential challengesintheschematicdrawingstageandcreatingcontinuitythroughoutthedesignreviewprocess.Mercymaynotbeaschallengedinthekitchenarea,astheywillhaveafullcommercialkitchendietaryserviceinthebuildinginadditionto the kitchens in each of the Green Houses® .

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Mercy has plans to completely replace their skilled nursing facility with six 12-unit Green House ® homes built in

an urban high-rise style that is in keeping with the Oakland Fruitvale neighborhood where

Mercy is located.


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TheMercyproject(andtheGardens)isabletotakeadvantageofanewsetofregulationsthatwaspassedin2011butwon’tgointoactualuseuntil 2012: Title 24, Part 2, Volume 1, 1225 .5 .2 HouseholdModel.ThesenewregulationsaredesignedforproviderswhowishtocreateaHouseholdModelwithinanexistingfacilityorbuildnewunitsdesignedinasmallhome/householddesign.Thenewregulationsmakesome important changes:

Roomsmayholdnomorethantworesidents,andtheymustbevisuallyseparatedfromeachotherbya“fullheightwallorapermanentlyinstalledsliding or folding door or partition, and shallprovideeachpatientwithdirectuse of and direct access to an exterior windowatalltimes.”

One toilet room shall serve no more than tworesidents,andresidentsshouldnothave to enter a corridor to use the toilet .

Dimensionsandarrangementofresidentroomsshallbedesignedtoaccommodateatleasttwobedpositionstoprovidepatientchoiceofbedplacement.

Ratherthanspecificareasforstaff(dietary,administration,nursing,socialwork,etc.),therecanbeonecentralizedworkarea.

Anoutdoorareamustbeprovidedfortheuseofallpatientsandincludeswalkingpaths,benches,shadedareasandvisualelements like sculptures or fountains .

WhileMercywillstillneedanumberofwaiversusingalternativemeansofcompliance,thesenewregulationsprovideastepforwardintheeffortstocreatearegulatorystructurethatworksforbothsmallhomesandneighborhoods.


history of Environmental Changes1987 ThepassageoftheNursingHomeReformActofOBRA1987,calledforcareprovided

“inamannerandinanenvironment that promotes maintenance or enhancement ofeachresident’squalityoflife.”

1990s Pioneers like Charlene Boyd of Providence Mount St . Vincent in Seattle, Pauline BrecanierofTeresianHouseinAlbany,GarthBrokawofFairportBaptistHomes inFairport,NY,andSteveShieldsofMeadowlarkHillsinManhattan,KS, createfacilitiesdesignedasneighborhoodsandsmallhomes.

1992 Dr.BillThomas’workontheEdenAlternativeleadstothevisionfor“GreenHouse® astheEdenAlternativemadereal.”Thomasenvisionedfreestandingresidential homes, licensed as skilled nursing residences, that look like any person’s home .

1993 First Green House®homesbuiltinTupelo,MS.

1997 ThePioneerNetwork,formedin1997totransformthecultureofaging,identified“environment”asoneofthecorevaluesandrecognizedtheneedtotransformthetraditional institutional environment of skilled nursing facilities .

2006 CMSissuesadetaileddocumenttostatesurveyagencydirectorsexplaininghow the Green House®andsimilarculturechangemodelsfitintothecurrentFederal survey requirements .

2007 CMS issues a letter indicating that culture change models, such as Green House®, “morefullyimplementtheNursingHomeReformprovisions[OBRA1987],includingqualityoflifegoals.”CMSstatedthatnoFederalregulatorybarriersexistforthe model and similar culture change approaches .

Wyoming,ArkansasandOklahomaallenactlegislationtofacilitateand/orsupport the spread of Green House®withintheirstate.

2008 CMS convened a symposium on the implications of traditional nursing home physicalenvironmentsandtheLSConculturechangeandidentifiedstrategiestomeetLSCrequirementswhileembracingculturechangeprinciplesrelatedtothephysical environment .

2011 The Green House® concept spreads to more than 99 Green House® homes operating on 43 campuses in 27 states .

ThePioneerNetwork’sNationalLong-TermCareLiveSafetyTaskForcereceives approvalfromNFPAonchangestoregulationsforkitchens,seatingincorridors,decorationsandfireplaces.

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About the Foundation

The California HealthCare Foundation works

as a catalyst to fulfill the promise of better

health care for all Californians. It supports

ideas and innovations that improve quality,

increase efficiency, and lower the costs of

care. For more information, visit the California

HealthCare Foundation online at:

www.chcf.org.

About Chi Partners

Chi Partners is a health care consulting firm

focused on innovation in long-term care

and service-enriched housing for seniors.

It works with state units of government and

the private sector on public policy, market

research, and strategic and business planning.

Visit Chi Partners at:

www.chipartners.net

Author

David Nolan, Principal, Chi Partners

Acknowledgements

The author would like to thank the following

individuals for their assistance in writing this

document:

Carmen Bowman, author of The Environmental

Side of the Culture Change Movement:

Identifying Barriers and Potential Solutions

to Furthering Innovation in Nursing Homes,

provided content and significant background

for this issue brief.

Carol Shockley, director of the Arkansas

Office of Long Term Care, and Walter Wheeler,

former director of the Bureau of Health

Systems, Michigan Department of Community

Health, provided background on their states’

work with small homes and presented their

“lessons learned” to providers in California.

Dan Kotyk, chief of the Licensing and

Certification Division of the California

Department of Public Health, and Glenn Gall,

regional supervisor, Office of Statewide

Health Planning and Development, provided

assistance in understanding the complexities

of California’s regulatory system.

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ENDNOTES 1 “TheEnvironmentalSideoftheCultureChange Movement: Identifying Barriers and Potential Solutions in furthering Innovation in Nursing Homes,”CarmenS.Bowman,2008.

2 See“Background”foradescriptionofGreenHouse®, smallhomesandhouseholds/neighborhoods.

3 “OutcomesinSmallNursingHomes:ALongitudinal Evaluation of the Initial Green House®Program,” Dr.RosalieKane,PhD,June2007,and“Effectsof Green House® Nursing Homes on Residents’ Families,”Dr.TerryLumandDr.RosalieKane, HealthCareFinancingReview,Winter2008–2009, Volume30,Number2.

4 AssociationofHouseholdsInternational, http://www.ahhi.org/Householddefinition.html

5 Code of Federal Regulations, Title 42, Part 483, SubpartB.

6 CodeofFederalRegulations,Title42,Part483.70(a)(2)

7 Title24isthe24thtitlewithintheCaliforniaCode ofRegulations(CCR).Stateregulationsshouldnotbe confusedwithstatelawsenactedthroughthelegis- lative process . State regulations in the CCR are adoptedbystateagenciesasdeterminednecessaryto implement, clarify and carry out the requirements of statelaw.

8 Title22isthe22ndtitlewithintheCaliforniaCode ofRegulations(CCR).CCRTitle22,Division5, Chapter 3 is reserved for state regulations that govern the licensing of skilled nursing facilities .

9 Nursing homes that participate in the Medicare or Medicaidprogramsmustcomplywiththeregulations forFederallycertifiednursinghomesthatare contained in Title 42 of the Code of Federal Regulations(42CFR),Parts483.1through483.75. Theseregulationscanbefoundathttp://www.access. gpo.gov/nara/cfr/waisidx06/42cfr483_06.html

10 “Snapshot:TheChangingFaceofCalifornia’s NursingHomeIndustry,”CaliforniaHealthCare Foundation, 2007 .

11 “RethinkingtheNursingHome:CultureChange MakesHeadwayinCalifornia,”California HealthCare Foundation, 2008 .

12 “AReportonShortfallsinMedicaidFundingfor NursingHomeCare,”BDOSeidman,LLP,2007.

13 CDDIC,hostedbyAgingServicesofCaliforniaand theCaliforniaAssociationofHealthFacilities, providesaforumforthoseseekingclarificationand changes to California’s regulatory environment .

14 L&ChasbeenintheprocessofupdatingTitle22for overadecadealreadywithnosignificantprogress to date .

15 Final Express Terms for Proposed Building StandardsoftheOfficeStatewideHealthPlanning andDevelopmentregarding proposed changes to California Building Code, California Code of Regulations(CCR),Title24,Part2,Volume2.

16 CaliforniaHealthandSafetyCode,Section1276(b)

17 CaliforniaRetailFoodCode,Part7(“aplacewhere food is stored, prepared, packaged, transported, salvagedorotherwisehandledfordispensing”).

18 SeesectionsonMt.SanAntonioGardensandMercy Retirement and Care Center .

19 PioneerNetwork,NationalLong-TermCareSafety Task Force, http://www.pioneernetwork.net/Policy/NFPA/

20 The Green House® Project Guide Book, 2007 .

21 Asmokecompartmentis“aspacewithinabuilding enclosedbysmokebarriersonallsides,includingthe topandbottom.”

22 KarenShoeneman,PioneerNetwork.

23 42CFR§483.70(d)(1)(iv)

24 ArkansasDepartmentofHumanServiceslicenses skilled nursing facilities .

25 RulesandRegulationsforNursingHomes,Arkansas OfficeofLong-TermCare

26 Section 801, Pilot Project, Rules and Regulations for NursingHomes,ArkansasOfficeofLong-TermCare

27 TennesseeCertificateofNeed(CON)application: “Attachafloorplandrawingforthefacilitywhich includeslegiblelabelingofpatientcarerooms(noting privateorsemi-private),ancillaryareas,equipment areas,etc.,onan81/2-inchx11-inchsheetofwhite paper.Donotsubmitblueprints.Simpleline drawingsshouldbesubmittedandneednotbe drawntoscale.”

28 TennesseeusestheAmericanInstituteofArchitects (AIA)BuildingCodes.

29 TheInternationalBuildingCode(IBC)isamodel buildingcodedevelopedbytheInternationalCode Council(ICC).Ithasbeenadoptedthroughoutmost of the United States .

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