Description
Assignment Background: This assignment will require you to research the existing types of physical plants for secured units. After conducting your research, you will create a Design Failure Mode and Effect Analysis (DFMEA) Report that addresses specific information, as outlined below, which can be delivered in any format. Create at least one visual aid, which must be included within your report. Use appropriate headers for each section of your report to ensure all aspects of the assignment are clearly identified.
Assignment Requirements:
Create a DFMEA Report:
Include all Content Aspects provided below in the assignment prompt.
Freestyle formatting allowed. You determine how you want the report to look.
Create one visual aid to support your findings.
Minimum of SIX pages, excluding the cover page and reference page.
The report should not exceed ten pages, excluding the cover page, reference page, and visual aid.
References and Correlating In-Text Citations:
Provide SIX scholarly sources, professional publications, and/or articles.
Two of the six resources must be from your own research.
All references must be from the last five years.****
Every reference must have a correlating in-text citation(s).
APA 7th Edition:
Follow APA 7th edition formatting and style.
Include an APA 7th edition cover page.
Include an APA 7th edition reference page.
Your DFMEA Report Must Include the Following Information for Each Content Aspect:
Aspect A of the Report: Introduction, State Residence, and Physical Plant Summaries
Identify the two types of secured units that you will research (PICK TWO)*****.
Examples: Alzheimer’s Adult Day Center, Dementia Unit in a Skilled Nursing Facility (SNF), Memory Care Assisted Living Facility, Geriatric Psychiatric SNF
Select a state residence to apply to your selected LONG TERM CARE (LTC) settings.
Your selection should be based on your current state’s residence – Maryland. You will use your identified state residence to address the applicable aspects of your report.
Describe the following elements for each of the physical plants’ descriptions:
Number of licensed beds or square footage of each LTC facility/setting.
Note: If you research did not provide a specific number of beds or square footage, then offer a hypothetical number of licensed beds or square feet to apply in your report.
Number of LTC residents served, or potential average daily census, of each LTC facility/setting.
Note: If you research did not provide such information, then offer hypothetical information to apply in your report.
Type of locking devices, secured devices, or means of egress used in each LTC facility/setting.
Note: If you research did not offer this information, then decide on locking devices or means of egress to apply in your report.
Other key physical plant description items for each LTC facility/setting.
Note: Offer information on the key characteristics, providing a sufficient description of the settings.
Examples: Stand alone facility, unit part of a facility/senior living community, number of floors, outdoor space, number of exits, age of facility/setting, or similar items to ensure a detailed description is provided.
Aspect B of the Report: Specific Design Failure Mode and Effects Analysis
Select one of the settings that you researched in Aspect A: Conduct a DFMEA drill, include at least two failure points for one of your selected LTC facility/setting from Aspect A. Determine why the expected or intended function did not occur, include the following four areas in your analysis:
Failure Mode and Failure Effect: Include (a.) at least two failure modes; (b.) the details for each point; (c.) the way the failure could be observed; (d.) immediate consequences of each failure on the operation, function, and/or functionality; and (e.) information on the potential impact of the residents, staff, and LTC setting.
Failure Cause: Identify the underlying cause of each failure and explain why each failure may have occurred. Include at least two of the following items in your analysis: design, system, process, quality, or parts.
Severity Rankings: Identify the severity ranking of each failure and include one of the following areas in your analysis: worst case scenario, degree of injury, degree of damage, property damage, stakeholders’ harm, or facility/setting harm.
Facility-Level Responses & Assigned Responsibility: Include (a.) one design action; (b.) one design control method; and (c.) one recommendation to reduce the chance of failure modes in the future. Include information on the (d.) team or department that will be responsible for completing the action, control method, and recommendation, and share why they were selected.
Aspect C of the Report: Visual Aid of Your Findings
Create at least one visual aid that is based Aspect B of the Report.
The visual aid can be included in the report as an appendix, table, or figure, or may be presented in a separate document as a supplement.
Examples: DFMEA Template, DFMEA Steps, DFMEA Map, Specific Failure Mode Tables, or any visual aid that you would like to create to support your findings and information.
Aspect D of the Report: Your Assessment on the Findings for Your Selected LTC Setting
Provide an assessment of your findings that includes:
Conclusions on the (a.) operational effectiveness; (b.) influence on potential evacuation plans/needs; and (c.) connections between the failures to quality of care outcomes for the residents of the secured setting based on your DFMEA research conducted.
Licensure compliance for your selected state – MARYLAND and any applicable federal requirements.
Must provide at least two requirements, laws, or standards.
Examples: Specific federal regulations, state-specific regulations, city ordinances, or similar regulatory considerations for state licensure compliance.
If your selected state residence does not have any specific requirements for locked or secured units, then include how you validated this information and the type of source that was used to validate this information.
Provide the greatest lesson learned from conducting this analysis and how you could apply it to your future career.
Resources to Assist You with this Assignment:
This information offers details on DFMEA, FMEA, Fire Safety Code, Life Safety Code, Federal K-Tags, E-Tags, CMS Survey Information, and much more! Consider reviewing some of the videos, reading a few of the PDFs, and exploring some of the websites as these resources may assist you.
Website Links:
Website link on Design failure mode and effect analysis
Quality One Website – Article on DFMEA: https://quality-one.com/dfmea/
iSixSigma Website on DFMEA: https://www.whatissixsigma.net/dfmea/
Revisions to the Life Safety Code – Health facilities compliance experts review changes included in recent editions of NFPA 101: https://www.hfmmagazine.com/articles/4108-revisions-to-the-life-safety-code
Institute for Healthcare Improvement FMEA Tool Website Link: http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
CMS Life Safety Code & Healthcare Facilities Code Requirements: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/LSC
Publications, State Operations Manuals, and Articles:
NFPA 1010 Life Safety Code 2018 PDF
Medicare SOM Appendix (CMS Medicare State Operations Manual (SOM) Appendix: Click on any appendix letter in this PDF to access specific SOM information. You can also access this information by searching on the CMS website.)
CMS QAPI Guide for Performing Failure Mode and Effects Analysis with Performance Improvement Projects PDF
CMS State Operations Manual Appendix I Survey Procedures for Life Safety Code Surveys PDF
Joint Commission Information on Locked Units PDF
Complying with Door Locking Requirements Life Safety Code Publication from 2018 PDF
Videos:
Common Life Safety Code Deficiencies and Strategies for Compliance: https://www.youtube.com/watch?v=CYTdOHzi4jQ
Fire & Life Safety Compliance in Health Care Facilities Video: https://youtu.be/Clljdpst4cU
How to create a DFMEA Design Failure Modes and Effects Analysis: https://youtu.be/gRTn2QDrCbg
An Overview of the Failure Modes and Effects Analysis (FMEA) Tool from the Institute for Healthcare Improvement (IHI): https://youtu.be/PIEzR5uhqnw
Emergency Preparedness & Life Safety Code Update:https://youtu.be/ZoiMLnJzNL4
NFPA 101 – Life Safety Code 2018 Edition: https://youtu.be/qsTIWTJTatU
Unformatted Attachment Preview
Copyright 2017. Gateway to Healthcare Management.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
CHAPTER 12
THE DESIGN OF LONG-TERM
CARE ENVIRONMENTS
Jullet A. Davis, PhD, and Christopher J. Johnson, PhD
Learning Objectives
After studying this chapter, you should be able to
➤➤ define key environmental terms and concepts as they are used in the chapter;
➤➤ understand the impact of the environment on elders and individuals with disabilities,
including people with sensory limitations and dementia;
➤➤ understand regulations, such as the Occupational Safety and Hazards Act and Life Safety
Codes, related to the physical environment of long-term care facilities;
➤➤ understand management issues related to the physical environment of residential care
settings, including renovation, retrofitting, and preventive maintenance procedures; and
➤➤ discuss the latest developments and movements in environmental design, including the
Eden Alternative and the Green House Project.
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I n t r o d u c ti o n
An organization’s environment can have profound emotional, physical, psychological, and
sociological implications for people receiving care, and long-term care administrators have
a responsibility to understand and address these concerns. Buildings, grounds, and equipment all require regular attention and ongoing upkeep, and a well-maintained environment
is essential for improving care delivery and promoting person-centered care. The Code of
Federal Regulations requires a facility to “be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public” (42 C.F.R.
483.70 (2008)). In addition, the physical design standards of long-term care organizations
are undergoing a revolution. Organizations can no longer simply use the medical model
as a guide; the culture change movement has shifted the focus toward greater resident and
client empowerment.
This chapter begins by outlining important considerations in designing or redesigning long-term care organizations, particularly for residents with dementia. The next section
reviews key regulations concerning the physical environment and the process of managing
the environment. The chapter concludes with a look at the impact of culture change on
residential care environments, as well as future directions.
psychoneuroimmunology (PNI)
A theory developed by
Robert Ader from the
field of environmental
psychology that shows
the impact of stress on
immune systems and
health.
D e si g n f o r L o n g -T e r m C a re E nv i ronments
Historical Perspectives
Healthcare facility design is a relatively new field, having emerged in the early 1990s. A key
theme in this area has been the need to transform healthcare settings into healing environments that improve resident outcomes through the use of evidence-based research. This
research comes from a variety of fields, including evolutionary biology and neuroscience.
Privacy, resident safety, and stress reduction are integral parts of this new philosophy of
facility design.
Healthcare design specialists recognize the body–mind connection—that is, the idea
that the physical environment has a strong impact on the psychological state of mind and,
therefore, on physical health and well-being (Lam et al. 2011). This concept is the result
of two major influences: Robert Ader’s science of psychoneuroimmunology (PNI) and
Roger Ulrich’s theory of supportive design.
Ader and Nicholas Cohen (1975) first identified a connection between stress in
the environment and the functioning of the immune system, and Ader collected writings
related to the topic in a book titled Psychoneuroimmunology, published in 1981. The study of
PNI led the way for Ulrich’s (1997) introduction of the theory of supportive design, which
encourages designers to promote wellness by creating “psychologically supportive” physical
surroundings. Such surroundings offer three main characteristics: (1) a sense of control
over physical/social surroundings and access to privacy, (2) access to social support from
family and friends, and (3) access to nature and other positive distractions (Dilani 2016).
theory of supportive
design
A theory formulated
by Roger Ulrich that
promotes wellness
in long-term care by
encouraging designers
to incorporate psychologically supportive
physical surroundings.
The surroundings
should encourage (1)
a sense of control over
physical/social surroundings and access
to privacy, (2) access
to social support from
family and friends, and
(3) access to nature
and other positive
distractions.
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Perspectives on long-term care environments have come to emphasize the importance of larger rooms to accommodate personal-space zones with greater privacy; the use
of adjustable, comfortable seating; the incorporation of natural elements, such as interior
green spaces and windows with views of nature; and the benefits of interacting with pets.
Many of these themes are present in the philosophies of culture change, the Eden Alternative, and the Green House Project. These approaches were introduced in chapter 4 and are
discussed at length later in this chapter.
Universal Design
universal design
A resident-centered
approach to the design
of the environment that
focuses on the needs
of the users regardless
of functional impairments or disabilities.
environmental gerontology (EG)
The study of the connection between elders
and their physical and
social environment.
environmental adaptation
Changes to the environment to help individuals with disabilities
remain independent
and to ease the burden
of care on their fami-
According to the Institute for Human Centered Design, universal design is a residentcentered approach to the design of the environment that focuses on the needs of the users.
It is not a single design element but rather a general orientation or framework that encompasses myriad design changes. Universal design is barrier-free, providing accessibility for all
residents. Its focus is not simply on residents with functional impairments but also on those
without disabilities; hence, this broad focus helps to limit the stigmatization associated with
disability aids. Universal design is also known by the terms inclusive design, design-for-all,
and lifespan design, and it is consistent with the principles of green design (Brawley 2006).
E n v i r o n m e n ta l G e r o n t o l o g y
The field of environmental gerontology (EG) incorporates a broad range of knowledge from
sociology and other disciplines in an attempt to understand, analyze, modify, and optimize
the relationship between elders and their physical and social environments (Schwarz 2013).
Sociologist Jaber Gubrium (1975), in a nursing home study, hypothesized a direct relationship
between one’s identity, the self, and long-term care institutions. In recent decades, the environmental context of aging has played a key role in gerontological theory, research, and practice.
Environmental adaptation involves interventions to help individuals with disabilities, including dementia, remain at home independently and to ease the burden of care on
their families. Adaptations may include removing or rearranging objects, adding special
equipment, or incorporating adaptive tools. The process of providing an environmental
adaptation involves assessing a person’s needs and capabilities, evaluating the environment’s
physical and social properties, selecting an appropriate adaptation, ordering and installing
that adaptation, and training the person and family members in its use.
lies. Adaptations may
involve removing or
rearranging objects or
C o n s i d e r at i o n s f o r I n d i v i d u a l s w i t h S e n s o ry L i m i tat i o n s
adding special equip-
As individuals age, their physical and sensory capabilities (i.e., vision and hearing) often
change. Many sensory changes require adjustments in the physical environment so individuals can remain independent in their communities. Changes in vision and mobility are
the two key issues that require special attention.
ment or adaptive tools.
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Chiang and colleagues (2011) found that stress and anxiety can influence the function of the immune system, which, in turn, can inhibit the healing process. Consequently,
environmental stressors, such as dim lighting, excessive noise, and brightly colored walls,
can have a negative impact on people’s health, especially for older persons. Federal statutes
require facilities to be “well lighted.” But to properly address vision needs, facilities may need
to ensure that residential areas have not only sufficient lighting but also natural lighting and
lighting that decreases glare (Brawley and Noell-Waggoner 2008; Samo 2014). Choosing
the right colors for the environment is another important consideration, and high color
contrast is key (Brawley and Noell-Waggoner 2008). As the eyes age, the lenses thicken and
become yellow, which can make distinguishing between colors difficult. Older individuals
therefore may have difficulty differentiating floors from walls and may experience problems
with depth perception. The use of contrasting colors not only is aesthetically pleasing but
also offers improved safety (Brawley and Noell-Waggoner 2008; Samo 2014).
Changes in mobility can make certain environments risky, and modifications should
be made to minimize safety risks for individuals. Such modifications can also reduce the
liability of long-term care providers. Many federal, state, and accrediting agency requirements and guidelines aim to ensure the safety of facility environments. The following are
some suggestions for preventing falls, a major risk in both community-based and residential
care settings (Brawley and Noell-Waggoner 2008; Earley 2011; Neuls et al. 2011):
◆◆ Repaint walls to create more contrast with floor surfaces.
◆◆ Do not oversimplify or make inappropriate modifications. A common error,
for example, is installing grab bars without proper structural support.
◆◆ Use lighter-colored floor surfaces.
◆◆ Minimize changes in walking surfaces, and use slip-resistant covering when
possible.
◆◆ Install a greater number of electrical outlets to minimize the use of extension
cords.
Individuals with Dementia and the Physical Environment
Individuals with dementia experience special challenges with navigating the physical environment. Zeisel and colleagues (2003, 697) discovered a positive correlation between “environmental design and agitation, aggression, depression, social withdrawal, and psychotic
symptoms of residents with Alzheimer’s disease.” These individuals may feel a greater sense
of frustration and will perceive their environment as more stressful than would individuals
without dementia (Van Hoof et al. 2010).
A facility’s physical environment should be designed to promote the highest level
of functioning possible. Zeisel and colleagues (2003) conducted a review of studies about
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environmental strategies to improve outcomes for residents with dementia; some of these
strategies are presented in the accompanying text box.
A wide range of designing or remodeling strategies can lead to improved quality of
life for residents with dementia. For example, residents with dementia tend to have better
outcomes when they live in a private room rather than a shared room (Brawley 2006). Such
modifications are not limited to new or remodeled structures; they can be implemented
in older buildings as well. Whenever possible, the administrator should look to employ
innovations in the physical environment to improve outcomes for all residents.
Space and Social Engagement
Morgan-Brown and Chard (2014) point out that interactive occupation and social engagement—important components of quality of life for residents with dementia—can be fostered
through changes in the environment. When comparing two Irish nursing homes before
CRITICAL CONCEPT
Design Strategies for Individuals with Dementia
Residents with dementia present unique challenges for long-term care administrators. To address the needs of this population, facilities should consider the following
evidence-based design strategies:
• Camouflaged exits can help reduce elopement attempts; however, note that the
camouflage must meet Life Safety Code standards.
• Private areas have proven to reduce aggression and agitation and to improve
sleep.
• Public or common areas that have an inviting décor—rather than an institutional
or hospital-like appearance—encourage more socializing.
• Walking paths that are equipped with devices to stimulate the senses and offer
activity opportunities can lift clients’ spirits and discourage desires to leave the
area. Such design elements also engage the clients’ visitors and loved ones.
• Therapeutic garden access has been shown to reduce elopement attempts and to
improve sleep (Detweiler et al. 2012).
• Facilities should use thin carpet or tile with no specks, glare, or checkerboard
designs (Brawley 2006).
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and after conversion from a traditional model to a household-style model, they found that
the shift increased the interaction and social engagement of residents, staff, and visitors in
communal living areas.
Anderson (2011) found that elders in an assisted living facility developed patterns of
movements toward places open for activities, contact, and social interaction. Anderson also
found that elders’ use of space could be influenced by architectural design and by interior
measures to enhance the design. In this way, architecture can acquire a supportive quality
that nourishes the unique person and person-centered care.
Mazzei, Gillan, and Cloutier (2013) examined the influence of the physical environment on behavior (e.g., wandering, pacing, door testing, congregating) among residents
in a traditional geriatric psychiatry unit who were relocated to a purpose-built acute care
unit. They found that color coding rooms to distinguish them from dining areas improved
way finding, and opportunities to personalize rooms helped settings feel more “homey”
for people with dementia.
Cohen-Mansfield and colleagues (2011) linked environmental factors, personal
characteristics, and stimulus attributes with varying levels of engagement for persons with
dementia, and they identified one-to-one social interaction as the most effective stimulus
for engagement. Their research supports a model known as Namaste Care—an approach
that emphasizes one-to-one interaction within a social group, the use of soft background
music, and engagement with various environmental stimuli.
Memory Care Units
Some residential care organizations use memory care units to provide specialized care to
individuals with dementia. The units, or “neighborhoods,” range from small areas with
eight to ten residents to very large areas with more than 50 residents. As a rule of thumb,
smaller is generally better.
A cross-sectional study by Palm and colleagues (2014) looked at characteristics of the
environment and staffing in five types of memory care units. Regarding the environment,
small units were found to have a higher percentage of single rooms and served meals in a
more homelike manner. The units did not differ in their interiors or in resident access to
outdoor areas. Regarding staffing, small units provided more staff, though the staff members
were not exclusively assigned to the units. Large segregated units with additional funding
provided more registered nurses and nurses with special qualifications per resident than did
other large units. In general, long-term care facilities varied in the features implemented in
their specialized memory care units.
Some individuals with dementia have difficulty finding their way to various parts
of a residential care home. A qualitative study by Caspi (2014) identified a wide spectrum
of way-finding difficulties experienced by residents with memory loss and indicated a need
for facilities to build small-scale care environments designed for seven to ten residents each.
memory care unit
A unit within a residential care setting that
provides specialized
care for individuals
with dementia.
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Animal Therapy in Residential Dementia Units
Aquariums offer an innovative way for nature and animal-assisted therapy to be introduced
in specialized dementia units. Edwards, Beck, and Lim (2014) examined the influence of
aquariums on resident behavior and staff job satisfaction in three dementia units. They
found significant improvement for residents across four domains: uncooperative behavior,
irrational behavior, sleep behavior, and inappropriate behavior. Staff satisfaction scores
significantly improved as well. Their findings were consistent with those of other studies
involving animal-assisted therapy for individuals with dementia. Aquariums in group settings have been linked not only to decreased behavioral and psychological issues but also to
improvements in residents’ nutritional intake. Aquariums allow residents to have continued
interaction with the animals, and they require less supervision than dogs and many other
animals do. The use of secured aquariums is safe for both residents and the animals.
I n n o vat i o n s i n R e s i d e n t i a l D e s i g n
Many older facilities—particularly nursing homes—may have been designed using the
medical model, which has an institutional approach (Boyd and Mitchell 2014). However,
according to the Centers for Medicare & Medicaid Services (CMS), long-term care settings
should be “homelike” (CMS 2009). Newer designs promote resident freedom, autonomy,
empowerment, self-reliance, independence, and comfort. They have noninstitutional features,
with user-friendly flooring, good-quality lighting, and safety elements throughout the space.
This section provides an overview of current concepts in institutional design. These
suggestions reflect innovations implemented by actual long-term care facilities across the
United States and are in accordance with the current gerontology architecture and interior
design principles (Anderzhon, Fraley, and Green 2007; Brawley 2006; Verbeek et al. 2010;
Zeisel et al. 2003).
Resident Rooms
Many facility designs have rooms arranged into clusters rather than grouped along corridors
(Anderzhon, Fraley, and Green 2007). The cluster design allows for fewer residents on a
given unit, and the use of single-occupancy rooms increases privacy and autonomy. If an
organization is unable to redesign its physical structure, it can take other steps to promote
good outcomes. It can make furniture and fixtures flexible and customizable, or it can allow
a resident to bring her favorite chair, for a more homelike environment.
Nursing Stations
Concomitant with the practical functions of nursing stations is their social role. Mazer
(2005) observes that both staff and residents tend to congregate around the nursing station,
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thus making it a meeting spot. The challenge for new designs is to allow for a well-organized
work location while also encouraging the station’s social role and minimizing negative aspects
such as noise and the institutional look. Small changes can be made to existing designs
to support these goals. Moving the nursing station to a room can help combat noise and
ensure privacy of resident information.
Shower Rooms
The design of the shower room should allow ease of use for both residents and staff. Simple
redesign options may involve brighter lighting, a fold-down shower seat or bench for safety
and comfort, or removable shower chairs for better accessibility. The key to designing the
shower room is flexibility. The staff should be able to make any necessary adjustments to
maximize resident comfort (Barbera 2013; Zimmerman et al. 2013).
Dining Rooms
Recent innovations in resident dining use fewer dining tables but offer a greater variety of
meal choices and more flexible dining times. Some facilities have replaced small, 4-seat tables
with larger, 8- to 12-seat tables similar to those found in family dining rooms. This change
allows for greater interaction among the residents. Another simple improvement is to set the
table with silverware, napkins, plates, and glasses, just as many households do (Brawley 2006).
Kitchens
The kitchen is an important area for purposes both functional and social. In a study of
kitchen living, Maguire and colleagues (2014) found that problems with reaching, bending,
dexterity, and sight became more common with increasing age, and many such problems
were made worse by poor kitchen layout and lack of space. Key goals for kitchen design
involve the provision of storage space at a convenient height for access and the location of
appliances close enough together to minimize effort of movement and to avoid awkward
twisting. In dementia designs, safety is of primary concern, especially with regard to appliances such as ovens and stoves.
R e g u l at i o n s a n d t h e P h y s i c a l E n v i r o n m e n t
Long-term care providers are among the most heavily regulated segments of the healthcare
industry. This section reviews the relevant federal regulations related to the long-term care
physical environment and its residents, staff, and visitors. The regulations discussed here
focus on hazardous materials, building construction, fire protection, infection control, and
resident comfort and protection.
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The Americans with Disabilities Act
National Fire Protection Association
(NFPA)
A nonprofit agency,
established in 1896,
with a mission to
reduce the impact of
fire and other hazards
on the quality of life.
The NFPA provides
training, standards,
The Americans with Disabilities Act (ADA) of 1990 established guidelines to ensure that all
public and commercial buildings are accessible to persons with disabilities. The guidelines
cover both initial construction and future physical modifications of facilities. The rules,
however, do make some allowances in cases that involve undue hardship to the facility,
such as when the cost of a compliance study is disproportionately larger than the cost of
renovations.
To ensure ADA compliance, administrators should seek advice from attorneys,
architects, contractors, and other appropriate professionals when considering construction
projects or renovations that might result in accessibility changes. Professional advice is
especially important when the facility is making modifications to achieve culture change.
For example, the creation of small corridors might be intended to achieve a homelike
environment (a goal of culture change), but in reality it could violate the ADA (or the Life
Safety Code, discussed in the next section).
and codes, including
the Life Safety Code.
Life Safety Code
A set of standards,
developed by the
National Fire Protection Association, that
address issues that can
cause fires or otherwise affect safety.
The National Fire Protection Agency and the Life Safety Code
For well over a century, the National Fire Protection Association (NFPA) has been the
leader in creating US guidelines for building safety. A nonprofit agency established in
1896, the NFPA publishes fire safety standards and codes and offers training throughout
the world. Every few years, the organization revises its Life Safety Code, a set of standards
dealing with issues that can cause fires or otherwise affect safety. It also offers the Life Safety
Code Handbook, a guide that can help administrators better understand the meaning or
application of specific codes.
The primary focus of the Life Safety Code is to minimize fire hazards. For longterm care facilities, key issues involve vigilance about items and materials that might be
CRITICAL CONCEPT
Complying with Federal Regulations
The importance of complying with regulations cannot be overstated. Administrators
must be well versed in all local, state, and federal regulations, even if the regulations
are extensive, confusing, and ever changing. Ignorance is not a valid excuse for failing
to comply. CMS is the federal regulatory body for most long-term care providers, but
it relies on codes from the Americans with Disabilities Act, the National Fire Protection
Agency, and The Joint Commission, to name a few.
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flammable, such as wall and ceiling finishes; the use of alarms and other systems for notifying
residents about safety problems; and factors that limit residents’ ability to leave an affected
area, such as barriers to egress. In 2014, CMS mandated that all long-term care providers
must abide by the 2012 edition of the Life Safety Code (CMS 2015). A key update was
the requirement that automatic sprinkler systems be installed throughout long-term care
facilities.
The Occupational Safety and Health Administration
The Occupational Safety and Health Administration (OSHA) website (www.osha.gov)
offers an excellent starting point for long-term care administrators looking to protect staff
from physical and environmental hazards. OSHA has guidelines dealing with such topics
as ergonomics; exposure to blood and other infectious material; minimizing slips, trips,
and falls; and safe handling of patients. The OSHA website also provides a Nursing Home
eTool (www.osha.gov/SLTC/etools/nursinghome/index.html) that provides illustrations and
training and helps administrators identify and control environmental hazards. Additionally,
for interested administrators, OSHA representatives are happy to provide consultation and
advice on how to create a hazard-free workplace. OSHA’s guidelines and services can help
advance safety within the long-term care industry, which has some of the highest injury
rates in the United States (US Bureau of Labor Statistics 2015).
Occupational Safety
and Health Administration (OSHA)
The United States
federal agency charged
with the enforcement
of safety and health
legislation. OSHA is
part of the US Department of Labor.
Management Issues of the Physical Environment
A long-term care administrator is responsible for all aspects of the facility’s internal and
external environment. A well-organized and properly maintained environment improves the
facility’s ability to serve residents, staff, and visitors.
Facilities Management
An effective facilities plan must pay regular attention to all aspects of the physical plant. Buildings,
grounds, and equipment age at different rates, and
scheduled maintenance, repairs, and replacements
are necessary to avoid mechanical problems and
facility obsolescence. Poor management can result
in a facility looking tired, old, and generally uninviting (Sasse 2007). Well-maintained buildings,
equipment, and grounds convey an image of a
robust facility that is inviting to guests, residents,
and staff.
KEY POINT
The Importance of Managing the Physical
Environment
The importance of the physical environment, or physical plant,
is sometimes overlooked by administrators, but without a
properly operating plant, safe and effective care cannot be delivered. Effective administrators ensure that a plan is in place
to maintain the buildings, equipment, and systems needed to
provide a safe and high-quality experience to residents, staff,
and visitors.
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Maintenance
The facility maintenance department bears primary responsibility for monitoring all aspects
of the plant. Regular assessments and a process for making needed repairs are crucial and
should be conducted both informally and formally. An informal assessment may be conducted simply by looking for problems and potential future issues while walking around
the grounds and buildings (Sasse 2007). Maintenance should also note facility odors (both
organic and inorganic), floor care, and other potential safety hazards (Dolan 2009).
Preventive maintenance involves more than simply checking to see if everything
is in good working order. A good preventive maintenance program includes such tasks as
changing air conditioning and other filters, cleaning coils, tracking temperatures, testing
sprinkler systems, and lubricating equipment. Koo and Van Hoy (2003) found that investment in preventive maintenance can lead to returns on investment as high as 500 percent.
Facilities should have agreements with external vendors and repair contractors
in place before issues arise. The need for repairs is generally either discovered during the
maintenance department’s facility inspection or through the staff’s daily activities. Under
either circumstance, a work order should be placed so that repairs can be scheduled and
completed in a timely manner.
Housekeeping
Housekeeping has the critical role of maintaining a sanitary facility. In this case, the word
sanitary means both clean and safe. Housekeeping must use proper methods to minimize
the spread of disease and to appropriately store cleaning equipment and supplies. The products or chemicals used for cleaning and sanitizing must be approved by the Environmental
Protection Agency (EPA).
Housekeeping’s sanitation efforts also must control and combat the spread of infection. Methicillin-resistant Staphylococcus aureus (MRSA) infections and other nosocomial
infections have been a growing concern in long-term care (David and Daum 2010). The
housekeeping supervisor should periodically take cultures of surfaces throughout the facility
to determine bacterial colony levels (Lidsky et al. 2002).
Green Products
To the extent possible, facilities should use environmentally safe cleaning and laundry supplies—that is, supplies that are nontoxic, noncombustible, noncorrosive, safe for aquatic
life, and biodegradable. The Green Guide for Health Care (available at http://gghc.org)
provides a wealth of information about environmentally friendly cleaning products and
recycled paper products.
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