10: Regulations

Skilled Nursing Facilities are regulated by many laws and regulations. Facilities must strive to continue to maintain compliance with those regulations. The staff who work in restorative nursing programs need to realize their role in this regulatory process. If all staff do the best job possible, they will be contributing to our residents’ quality of life and quality of care.

The following are the OBRA regulations that impact the Restorative Nursing Program:

Code	Regulation	Guidelines
684	Quality of Care: The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices.	Each facility must ensure that the resident reaches optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.
676	Activities of Daily Living: Based on the comprehensive assessment of a resident and consistent with the resident’s needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.	Each facility must ensure that a resident’s abilities in ADLs do not deteriorate unless the deterioration was unavoidable. FUNCTIONAL STATUS means the resident’s ability to perform activities of daily living including bathing, dressing and grooming, transferring and ambulation, toilet use, eating and using speech language and other communication systems. Included determining the resident’s need for staff assistance and assistive devices or equipment to maintain or improve functional abilities.
677	Activities of Daily Living: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.	The intent of this regulation to stress that the facility is responsible for providing maintenance and restorative program that will not only maintain but improve as indicated by the resident’s comprehensive assessment and that residents who are dependent on staff for ADLs receive the care and services needed.
685	Vision and Hearing: The facility must, if necessary, to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, in making appointments, and arranging for transportation to and from the office of a practitioner.	The facility’s responsibility is to assist residents and their families in locating and utilizing any available resources for the provision of the services the resident needs such as assistive devices. Assistive devices to maintain vision include glasses, contact lenses, and magnifying glasses. Assistive devices to maintain hearing include hearing aids.
686	Pressure Ulcers: Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.	Restorative nursing staff must do all they can to prevent skin breakdown (e.g., pressure relieving cushions and mattresses, moving resident without causing shearing, keep clean and dry, repositioning, turning etc.) Restorative nursing staff must report any changes in skin integrity to charge nurses.
688	Mobility: The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable. The facility is to provide appropriate treatment and services to a resident with limited range of motion to increase range of motion and/or to prevent further decrease in range of motion.	Clinical conditions that are the primary risk factors for a decreased range of motion are: immobilization (e.g., bedfast); deformities arising out of neurological deficits (e.g., strokes, multiple sclerosis, cerebral palsy, polio and pain, spasms and immobility associated with arthritis or late-stage Alzheimer’s disease. The facility is responsible for developing a plan of care to prevent avoidable decline of range of motion. Restorative Nursing program can play a role in preventing a decline in the residents’ ROM or muscle atrophy. Ongoing assessment and modification of the plan of care should prevent decline in avoidable loss of a resident’s ROM. Assessment should be conducted quarterly.
689	Accidents and Incident: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents.	Facilities must identify each resident at risk for accident and/or falls, and adequately plan care and implement procedures to prevent accidents. The facility should monitor the use of resident’s assistive devices to ensure they properly fit and provide adequate supervision of the resident to prevent accidents and incidents of injury.
690	Incontinence: The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.	The facility is responsible to provide care to restore or improve bladder functioning when necessary. If staff determine that continence cannot be improved or maintained, there is to be a plan to prevent incontinentrelated complications and to maintain resident dignity. (e.g., skin care after each episode of incontinence, adult sanitary padding, etc.). Restorative Nursing staff can help by offering resident fluids, if not contraindicated, to assure resident is adequately hydrated and to prevent Urinary tract infections.
692	Nutrition and Hydration: Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; and is offered sufficient fluid intake to maintain proper hydration and health.	Parameters of nutritional status which are unacceptable include unplanned weight loss as well as other indices such as peripheral edema, malnutrition/wasting and laboratory tests. Weight loss (or gain) is a guide in determining nutrition status. An analysis of weight loss or gain should be examined in light of the resident’s former lifestyle as well as the current diagnosis. Often Restorative Nursing staff are involved in weighing residents. It is important, at least for residents at risk for weight variance that consideration be given to consistency e.g., same scale, weighing same time of day, same clothing etc. RNA/C.N.A. must report weight variance to charge nurses. The facility should provide care to reduce the risks of dehydration and assure adequate fluid intake (e.g., keep fluids next to the resident at all times and assist in or cuing the resident to drink). If adequate fluid intake is difficult to maintain, alternative treatment approaches should be developed (e.g., use of popsicles, gelatin, and other similar non-liquid foods).
604	Respect and Dignity: The resident has a right to be treated with respect and dignity, including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.	Residents that are restrained may face a loss of autonomy, dignity, and self-respect, and may show symptoms of withdrawal, depression, or reduced social contact. From a restorative standpoint, restraint use can reduce independence, functional capacity, and quality of life. Nursing staff must supervise care and services and do whatever is possible to prevent a decline in physical or mental functioning that could be caused by use of restraints.
561	Self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.	The facility has the responsibility to provide those services that will help the resident to be as functional as possible. The resident has the right to refuse treatment if the resident has capacity to make a health care decision; If a resident is unable to make a health care decision a decision by the resident’s surrogate or representative to forego treatment may, subject to law, be equally binding on the facility. The facility should determine exactly what the resident is refusing and why. To the extent the facility is able to, it should obviate the resident’s concern. For example, a resident requires physical therapy to learn to walk again after sustaining a fractured hip. The resident refuses therapy. The facility is expected to assess the reasons for the resident’s refusal, clarify and educate the resident as to the consequences of refusal, offer alternative treatments and continue to provide all other service.
600	Free from Abut and Neglect: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptom.	Restorative staff must be trained in appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; how staff should report their knowledge related to allegations without fear of reprisal; how to recognize signs of burnout, frustration and stress that may lead to abuse and what constitutes abuse. Restorative staff must demonstrate excellent technique and avoid harming residents (e.g., bruising, skin tears etc.)
550	Resident 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.	The facility has the responsibility to provide those services that will help the resident to be as functional as possible. The resident has the right to refuse treatment if the resident has capacity to make a health care decision; If a resident is unable to make a health care decision a decision by the resident’s surrogate or representative to forego treatment may, subject to law, be equally binding on the facility. The facility should determine exactly what the resident is refusing and why. To the extent the facility is able to, it should obviate the resident’s concern. For example, a resident requires physical therapy to learn to walk again after sustaining a fractured hip. The resident refuses therapy. The facility is expected to assess the reasons for the resident’s refusal, clarify and educate the resident as to the consequences of refusal, offer alternative treatments and continue to provide all other service.
583	Privacy and Confidentiality of Records: The resident has a right to personal privacy and confidentiality of his or her personal and medical record	Facility must examine and treat residents in a manner that maintains the privacy of their bodies. If an individual requires assistance, staff should respect the individual’s need for privacy. Only authorized staff directly involved in treatment should be present when treatment is given. People not involved in the care of the individual should not be present without the individual’s consent while they are being examined or treated. Often the things we do in restorative nursing are done out in the open with a lot of other people around. It’s not uncommon to have a lot of residents working out in the gym at the same time. Or to do certain treatments out in other common areas. It is important, however to be sensitive to the resident’s sense of privacy. Activities which may seem generic and common place and O.K. to do out in public” to staff, may be embarrassing to resident A common problem that we run into is facilities that conduct restorative feeding out in an open section of the main dining room. Assistance with feeding is an area that many alert residents are particularly sensitive to. In addition to looking for a more secluded area to conduct restorative feeding in order to cut down on distractions, we should be doing it in a secluded area to provide the residents with a sense of privacy during treatment. The residents’ clinical record must be maintained in a confidential manner at all times.
880	Infection Control: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections	The facility is to have an established program that includes monitoring direct care staff routine hand washing practices. Hand washing should be consistent with aseptic techniques, when appropriate. Always wash hands after touching a resident and before touching another resident. Always disinfect an item that a resident has been using before it is used by another resident. Pay particular attention to treatment mat and items that residents manipulate with their hands.
726	Nursing Services: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment	The facility’s assessment must address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. Additionally, staff are expected to demonstrate competency with the activities listed in the training requirements. Nurse aides are expected to demonstrate competency with the activities and components that are required to be part of an approved nurse aide training and competency evaluation program. Competency in skills and techniques necessary to care for residents’ needs includes but is not limited to competencies in areas such as Resident Rights, Person centered care, Communication, Basic nursing skills, and Basic restorative services.
MDS	Section O0500: Restorative Nursing Programs: Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A resident may be started on a restorative nursing program when he or she is admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.	Included are nursing interventions that assist or promote the resident’s ability to attain his or her maximum functional potential. This item does not include procedures or techniques carried out by or under the direction of qualified therapists, as identified in item O0400 of the MDS. In addition, to be included in this section, a rehabilitation or restorative practice must meet all of the following additional criteria: Measurable objectives and interventions must be documented in the care plan and in the clinical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident’s medical record. Evidence of periodic evaluation by licensed nurse must be present in the clinical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established. Certified Nurse Assistants must be trained in techniques that promote resident involvement in the activity. A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents. Restorative nursing does not require a physician’s order. Nursing homes may elect to have licensed rehabilitation professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services. In situations where such services do not actually require the involvement of a qualified therapist, the services may not be coded as therapy in item O0400, Therapies or O0425, Part A Therapies, because the specific interventions are considered restorative nursing services (see item O0400, Therapies and O0425, Part A Therapies). The therapist’s time actually providing the maintenance service can be included when counting restorative nursing minutes. Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs. This category does not include groups with more than four residents per supervising helper or caregiver.