Over at the Network54 Message Board, several weeks back a reader asked this:

Is there anyone familar (sic) with a “blended role” such as a C.N.A./activity Asst.? If indeed we are moving in the direction of “culture change”. I feel this could be a new job description in which to explore!

Well yes…several years ago I worked two jobs; the weekend job was at an assisted living facility that served people with dementia. The facility was divided into four neighborhoods, with 20 beds in each section. Two neighborhoods were for higher functioning relatively independent residents; another unit was for mid to late stage residents and the fourth neighborhood was for all late stage residents.

I worked in the fourth neighborhood. Most assisted living facilities don’t employ many CNA’s; they are not required to employ CNA’s and instead hire and train people to work as Resident Assistants. This is fine for less medically needy residents; the RA is more than qualified to assist people with few needs. For those with late stage dementia though, trained nursing staff should be expected.

When they hired me, I was told part of my responsibilities would include delivering activities for my assigned residents. At first I almost declined the position because I couldn’t see how it could all be done: Cares, supervision AND activities. I’d worked the nursing home beat and knew the drill: 10 to 15 people on my list, crazy expectations that were almost impossible to meet; dealing with families and overstressed charge nurses, and of course the always understanding management team…

The DON of this assisted living home must have been reading my mind: She reassured me the facility supports the blended role of CNA/Activity Assistant. To prove it, she took me on a tour to the neighborhood I would be working..and sure enough, the aides were quietly providing activities, in many different ways:

One aide had a group of four ladies sitting at a table in a small alcove like area, serving them coffee and cookies as she read from an old magazine (which wasn’t really OLD but a reproduction book);

Another aide had some men in the dining room painting little wooden plaques for some craft project they were working on;

In the main sitting room two aides had a lively group of residents doing exercises and ball tossing.

Way down in the end of this neighborhood another couple aides were doing some sensory stimulation activities with three obviously very frail, wheelchair bound residents: Scented lotion hand massages, neck massages, a CD player playing quiet Celtic tunes in the background; and to my surprise, a resident was in a recliner with a special massager pad under him- thoroughly enjoying himself.

Everyone appeared to be having a good time. The aides were not rushing and running around as I expected them to be; the residents were being tended to in very personal and productive ways. And it was ONLY 10AM.

HOW DO THEY DO THIS? I asked the DON:
The place had one Activity Director, and she was best suited working with the higher functioning residents, this left the lower functioning people with little to do. Management came up with the idea of a blended role for the aides working within the lower function unit: All the CNA’s would be responsible for resident activities as well.

The ratio for the CNA/Activity Assistant is 5:1 in this neighborhood for day shift; 7:1 for evening shift. When a resident is admitted, an aide is assigned to him or her, on a permanent basis. The facility follows the principals of consistent staffing/assignments. The aide is expected to partake in the admission process and a big part of this includes gathering information about hobbies, likes, dislikes- and plan activities for the resident. Aides from both shifts are included in this expectation.

The aides are given lots of Dementia Care Training, including the value and importance of activities…so much that activities are considered JUST AS IMPORTANT as nursing care. And at some times, MORE IMPORTANT.

The aides develop the Activity Calendar each month, based upon each resident’s likes and needs. Actually they do this two months in advance; preparation is KEY to a successful program. Many outings are planned, on both day and evening shifts- coordination is vital to make sure the trips happen. Activities are provided on both shifts as well, not just during the hours of 7 to 3…typical evening shift activities included personal care and pampering activities: Nail care with nail polish; foot soaks with a massage; Ladies Night that might introduce the women to the new face masks and latest hair care products…for the guys it often meant watching a war movie and then having a discussion after; another night it was going out to the local bowling alley…

The facility was brimming with activities…and much laughter, enlightenment and good cheer. The residents, even in their declining stages of dementia, seemed very content. There was little wandering; little exit seeking. Change of shift wasn’t at a set hour for all the aides; some came in at 6:15am and worked until 2:15pm; another couple worked 6:45am to 2:45pm- solely for the purpose of keeping this hour as distraction free as possible. They staggered the shifts and I have never seen another facility do this. This helps keep the residents from noticing an entire group of staff leaving (via hanging out at a nurses station) and the lapse of attention waiting for the next shift to arrive, get report and tend to them. There is no shift report per say- aide to aide reports are given and later if nurses need to share info, it is passed along.

This works great for assisted living facilities. I’m not sure how it work, though, for SNF- which have stringent regulation regarding activities and who can provide them. Some of these rules really go against the best interest of residents, when we think about it. Does it really matter who is tossing the ball- an activity professional or an aide? Do all games of bingo have to regulated by the government? With more and more nursing homes going through real and true culture change, these issues are being dealt with successfully. The OBRA regs are being tweaked to best suit the changes so needed in long term care. One way to do this total change is to have as few staff as possible delivering as much care and programing as possible. So, the CNA/Activity Assistant is a great role to consider.

The Manor Care/Carlyle buyout has been completed.

Just when it seemed Carlyle Group’s attempt to buy Manor Care would stretch into the new year, the private-equity company announced Friday that it closed its $6.3 billion purchase of the nation’s largest nursing home chain.

The hard-fought buyout was completed even with a credit market in turmoil, a tenacious and influential labor union opposing the deal, and concerns on Capitol Hill over private-equity firms purchasing nursing homes. To overcome worries about the deal’s impact on quality of care, Carlyle offered repeated assurances that it would provide adequate staffing and resources to the chain.

Under the deal, Manor Care, which operates 500 nursing and assisted living facilities in 32 states, will be added to a wide-ranging Carlyle portfolio that includes Hertz rental cars and Dunkin’ Donuts. In return, shareholders of Manor Care will receive $67 in cash for each share of stock.

Even down to the wire, the deal faced opposition. In West Virginia, where Manor Care operates some homes, health authorities imposed a stay that was delaying the transaction, but the order was lifted on Thursday. That same day, the Service International Employees Union got a circuit judge in Ingham County, Mich., to issue a temporary restraining order that would stall the transfer of licenses of the state’s Manor Care facilities to Carlyle. Less than 24 hours later, Manor Care’s lawyers got that temporary restraining order overturned and the licenses transferred — the last piece of the puzzle needed to complete the deal.

The wonderful thing about the Internet is that many people from different parts of the country, the world, can come together and share news, gossip, information. Specific to this, we’re in contact with many nurses and aides who work for the various Manor Care managed facilities all over the US; we will be watching and sharing pertinent info as it becomes known. Staff cuts, supply cuts and the like will be reported on. From what I can see, we have contacts in every state a Manor Care facility is located in, so we have good representation.

I just updated the page about how to use this site…which is HERE.

Highlights:

This web site is actually a BLOG.

This website is a BLOG. Blogs are different from regular web sites in that they can be updated frequently and easily. I chose this format because I wanted to be able to share the latest news and articles, sometimes several times a day, without having to fumble with an entire page template.

This site has several unique features.

1) Posts- the actual materials you read. Posts are what you see when you first load up the site. Each post has a title, a date when published. For every post, readers have the ability to leave instant feedback about the post, it’s content, or whatever, via a COMMENT section. Sometimes we moderate comments, though. There is an awful lot of spam that gets left as comments, so be patient if your comment doesn’t show up right way.

2) Finding Content: There are many ways to do this. Use the SEARCH box located in the sidebar under the CATEGORIES heading. Type in key words and see what comes up. The CATEGORIES section itself is full of all our content- posts and articles. People can browse the categories to see what’s there. Another way to find things is to go through the ARCHIVES…again, located in the sidebar. We keep archives for each month.

3) Recent Posts: You can find the latest posts here under this sidebar heading. Just click on a title to bring up the post.

And a few more bits of information about how to navigate this site; lists of content and the like.

In our article TIPS & TIMESAVERS FOR CNA’S, we advise new aides to keep a small notebook on their person. To write down answers to questions; to write down phone numbers and other info needed for the job.

Seasoned aides can also make use of a small notebook. They’re cheap, can be bought almost anywhere and come in so handy for CNA’s. A great resource, the little notebook.

I have one…pocket size that fits nicely in my scrub pockets. What do I do with it? A lot. When the nurse asks for VS on a resident/patient, I have paper to record the results. When a weight is needed; when a height is needed; when intake and output need to be recorded- these little pads come in real handy.

At the top of the page I write the date…day, month, year and shift I am working.

*I record the times I clock in and out- so if there is a discrepancy in my pay I can go back and check.

*I record what unit I’m working on, and the initials of the staff working with me. Even the nurses. And I note who is agency.

*I record my assignment- residents names. No need for more info; names are enough.

*Any falls or other incidents are recorded in my notebook as well…the vital stats are documented. Who. What. When. Where. Witnesses.

Some aides will go to the effort to write in certain info about their residents: BM’s, voids, showers, turning and the like.

Many aides use their assignment sheets to record all this info…and that’s fine. But I like to keep a personal record of these things. It can help you keep a clear record of your daily work and one never knows when this information can become necessary to defend one’s actions. Some aides prefer to write notes about their workday at home, away from prying eyes and nosy bosses. No matter where you do this, it’s pretty important to DO IT.

The legal environment in today’s nursing homes demand we keep clear records of the care we give. Most nursing home management can be trusted to not alter records, but not all. Aides can and have gotten into seriously hot water over issues and incidents that were not properly documented; flow sheets have been “corrected” to suit the best looking picture. Since aides are the lowest people in the chain of command, it’s way to easy to blame us for problems, issues, accidents and the like.

Who hasn’t been called at home, by the DON, demanding to know details about some incident that occurred last week? And who among us has a truly clear recollection of the events? If we had written down all the details, it would certainly help us during this call.

A little notebook can keep a lot of vital information. I wouldn’t go around telling everyone I have one though…management often doesn’t take well to such things. And we have to be extremely careful to respect HIPAA rules, but it is within our right to keep notes about our workday. I strongly advise all aides to do this.

Hey CNA’s, did you know your residents’ units are a reflection upon you?

Sure, the resident usually gets to decide where their personal belongings go, and some of them get really mad if you tamper with anything. While we need to be respectful of our residents preferences, we can do much to keep their unit, their home, neat and organized and safe.

When you’re giving care, it’s helpful to have all your supplies ready. Basins, soap, linens, powder and lotion and all the other items should be on hand so you don’t need to leave the room once you begin giving care. Most of us use an over-the-bed-table for all these items- it’s perfect for the tasks at hand. The table can be raised and lowered to suit people of all heights, and it’s pretty portable. Often, we make a mess on this surface: water, soapy residue, wet linens are placed here. When you’re done, clean off the table with wet cloths and then dry it. If possible, use a sanitizer.

When we’re giving showers or baths, we need to think NEAT as well. Counters next to sinks, shower rails and other surfaces should be cleaned up after the tasks are finished; personal care items should be put away and not left on the shower stall rails…if a bottle of shampoo tips over and spills we have a created a HUGE fall hazard, not to mention the waste. As for the bathroom itself: Think neat and orderly. Most nursing home bathrooms now have drawers where each resident can keep their personal care items separate from the roommates’ items. Look at the belongings: are hair brushes and combs and toothbrushes and other things dated and labeled? Can you tell who owns what toothbrush? Look at the basins and emesis basins especially! Rinse them out and make sure they are CLEAN. Keeping the counters clear of clutter reduces the chances of mix ups and loss of items.

When your resident is up and out of bed, and hopefully out of the room to activities, go back and make sure the unit is neat, clean and hazard free.

The Bed: Clean linens, wrinkle free, lowered to it’s lowest position and locked. Always. Make sure the linens have no holes and are fray free. One thing most of us know but a few do not: USE YOUR BARE HAND to check sheets, pads and blankets for wetness. A gloved hand cannot always FEEL wet linens; sometimes we cannot SEE urine stains (especially when they’re wet). Sadly, we also need to check UNDER the pads…often the sheet is wet under and for the same gloved hands reason, aides from previous shifts don’t know the sheets are wet. This leads to the famous brown stain syndrome; and odors. Finally, step back and LOOK around the bed. Under the bed. Up around the headboard…look for objects, pillows, missing items (how many times have we found a set of false teeth or a pair of eye glasses under a bed?) Look for hazards- sharp objects, frayed area rugs, broken wheel parts to the bed.

The Bed Side Table: Clear off YOUR junk. That means the lotions, wipes, foam sprays, ect ect. Find a place for these items that is out of sight yet easily accessible. It is always OK to leave a box of gloves out though- we never know when we will need them. One box is good for most of the unit though. Briefs, blue chux pads and the like do not need to be laid out either. Put them all away. Show your resident some dignity. And clean off the surface with a wet cloth, again sanitizing is best.

The Dresser: Again, like the Bed Side Table, keep this area free of YOUR STUFF. This is the residents space, not yours. Remember that. If they have knick knacks and other personal items here, be extremely cognizant of this. Treat these items with the highest respect- be careful. Be thoughtful. DON’T BREAK ANYTHING! If you work for a facility that offers consistent assignment, chances are you will have the same assigned residents every shift you work. This affords you the opportunity to gently clean off the dresser top every so often, weekly if not more often. (Yes, this might be the housekeepers job, BUT, you know as well as I do that they will not do a thorough job out of fear of breaking things). To make your job easier, you might want to keep the contents of the drawers neat and orderly. Some families do this too. If this is the situation, follow their lead and keep it all the way THEY have it. Same with the closet.

Speaking of closets, we’ve all seen messy, coat hanger infested PITS known as the resident closet. The mess, like it or not, is almost always OUR fault. When we’re working short of staff we rush through cares and dive in and out of drawers and closets looking for the easiest outfits to dress our residents in…we don’t have time to go back and clean up after ourselves. A few days of this means totally out of control, awful chaos behind those doors. It’s always up to us to clean it up, to wade through the endless empty hangers and weed out the stuff that doesn’t fit. Or is in disrepair. Talk with the charge nurses, but most nursing homes box up clothing and items that no longer fit and call family to come pick it all up.

Resident Clothing: More and more we see family taking care of these items. That’s fine and it’s often a big help. But we’ll always have those residents who have no one to do this. At some nursing homes the laundry staff put clothes away; in others, the aides do it. Either way, on a day where things aren’t so crazy, it would save a lot of time for you if you organized entire outfits: In the closets and drawers. An aide I know folds up an outfit into a neat semi ball and places many of them in a drawer: Pants, shirt, underclothing, stockings. So all she has to do is grab the ball, so to speak. This can be done with closeted outfits as well: Everything can be placed on a hanger.

ODORS: A big problem in many nursing homes. Even the cleanest rooms can have strong urine odors. Once there, it’s hard to get rid of. Carpeting is a big factor here…urine soaked rugs are almost impossible to totally clean up if the accident has been left to dry…as soon as an accident occurs try to get it cleaned up. Some aides spray the foam peri cleaners directly onto the wet spots to alleviate much of the smell. Another source of odors comes from laundry: If family does the resident’s personal laundry, wet clothing placed into hampers will smell, and the scent will get worse as it spreads to the other clothes… It’s best to bag up wet clothing and tie the bag tight in an effort to separate them from dirty but dry clothes. Some facilities don’t allow urine soaked clothing to be “kept” in hampers and insist the laundry department take care of these clothes.

One final note: Usually it is up to us to report things that need repair. We’re part of the safety chain…we often see problems before anyone else. Take this seriously. When stepping back to look at your residents units, have a critical eye and LOOK for hazards, potential hazards and other unsafe things.

An area we tend to ignore is personal furnishings. Recliners and the like can be a real comforting thing for our residents. We want to make sure they are safe for use though: Ask your resident for permission first, then actually sit in it. Test it. See how it works and if it needs any repairs.

Highlights from the Democrat candidates plans for LTC, specifically nursing homes:

From John Edwards:

Living With Dignity

9. OFFER CHOICE IN LONG-TERM CARE:

Our long-term care system is poorly equipped to give independence to older Americans and forces many families to juggle elder care, child care, and their jobs or spend themselves into poverty to pay for nursing homes. Edwards will reform Medicaid and Medicare to let people to choose home-based care in their communities and test innovations such as asset and income protection programs. He will also support states and communities offering much-needed and often less expensive alternatives – like adult day care and senior villages – that allow seniors to live at home with their loved ones.

10. IMPROVE NURSING HOMES AND CRACK DOWN ON ELDER ABUSE:

Independence is the goal, but we also need to strengthen quality and safety protection in nursing homes. Edwards will establish national standards for nursing home care, increase national enforcement against abusive nursing home chains, expand inspections and increase penalties for homes that fail to provide decent care. He will also help improve quality of care with measures like reducing patient-staff ratios and improving care provider training.

From Senator Clinton’s web site- a more detailed explanation and how Hillary intends to finance her plan:

Protecting our Seniors By Improving the Quality of Our Nursing Homes

While the majority of the nation’s nursing homes provide quality care to their residents, when persistent quality violations go unaddressed and when our seniors are subjected to unconscionable neglect, it erodes confidence in the system and makes it more difficult for all operators to function effectively. And sadly, the problem of poor nursing home quality extends far beyond the list of 54 under-performing nursing homes that the Centers for Medicare and Medicaid Services has recently released. In 2006, nearly one in every five nursing homes that received federal funds was cited for serious deficiencies in care. And from 2000-2005, nearly half of the 63 nursing homes that regulators had identified as having an established history of serious medical deficiencies continued to repeatedly fail federal requirements and still receive federal funds.

These severe, and often long-standing, quality violations are more than a regulatory problem. They offend our solemn commitment to ensure that seniors live in dignity and security. Our seniors deserve better. That is why Hillary will take aggressive steps to improve quality in our nation’s long-term care facilities by:

* Tripling Federal Support for Nursing Home Ombudsmen Programs to Protect Consumers of Long-Term Care: Effective ombudsmen programs are crucial to combating fraud and abuse in the long-term care industry. Ombudsmen are on-the-ground and act solely on behalf of nursing home residents to monitor quality: identifying and investigating complaints, providing information, monitoring regulations and participating in resident advocacy organizations. However, ombudsmen programs such as Iowa’s are struggling to meet the many new challenges that nursing home residents face. Currently, the Iowa program ranks last among the 50 states in the number of ombudsmen per nursing home facility beds. Yet while Iowa has been making progress in strengthening its ombudsman program, the office still faces many new challenges. As President, Hillary would triple federal support for state ombudsman programs to $50 million per year. The increased resources will strengthen the capacity of ombudsmen to vigorously investigate complaints and offer new training programs on emerging issues like complex insurance fraud and the purchase of nursing homes by private equity firms.

* Directing the Department of Justice and the Federal Trade Commission to Assist State Consumer Advocates and Prosecutors to Tackle New Challenges to Long-term Care: For the past year, Hillary has been raising concerns about the new regulatory challenges that we face in long-term care. Earlier this year, Hillary called for the Government Accountability Office to investigate the unconscionable mistreatment of seniors who have purchased long-term care insurance by their insurance providers—many of whom were systematically denying benefits while forcing steep premium increases. And in October, Hillary called for an investigation into whether nursing homes with new hybrid ownership structures—created in many instances by private investment groups—were evading regulators for quality violations and sub-par standards. As President, Hillary will direct the Department of Justice and the Federal Trade Commission to lend their consumer protection prosecution expertise to state regulators who are struggling to tackle these new and complex challenges. State regulators need sufficient information and sophisticated tools to effectively police nursing homes and insurance carriers, and as President, Hillary will ensure they have the support they need.

* Reversing CMS’ Inexcusable Policy and Giving Seniors Full Access to Usable Data on Nursing Homes, including Data on Nursing Home Ownership Structures: Choosing a nursing home is one of the most important life decisions a senior and their family makes. When seniors and their families are empowered with information, they become not only effective consumers but effective regulators in the nursing home marketplace. But the federal government needs to do far more to ensure that seniors and their families have the information they need to make informed choices. As President, Hillary will direct CMS to release all information on the designations it makes about the quality of nursing home facilities. CMS’s unwillingness to freely and openly share its full list of 128 under performing nursing homes is inexcusable, and must be reversed. Hillary will direct CMS to provide on the Nursing Home Compare website accurate, up-to-date data on nursing home staffing levels; the full—not just abridged—reports from inspections and complaint investigations; and any and all information about repeat offenses that CMS compiles. Finally, CMS should compile and post clear information about the ownership structures of long-term care facilities–so seniors can know who is in charge of the facilities they live in.

* Strengthening our nursing and direct care workforce with a national system of background checks for long-term care workers and a $125 million in Workforce Improvement Grants: While thousands of long-term care professionals provide admirable care to our elderly every day, abuse and neglect of our seniors in long-term care is on the rise. As President, Hillary will combat this abuse with a nationwide system of state criminal background checks for long-term care workers. In addition to ensuring our long-term care workers are qualified, Hillary will also ensure that we have a strong well-trained long-term care workforce. She will invest an additional $125 million per year to improve recruitment and retention of health and direct-service professionals and provide greater consumer choice. The new investment will: 1) provide grants to states to adopt and expand successful organizational models for workforce tracking and coordination, including the development of worker registries through a new directed spending program; 2) make federal funding available to states, in partnership with local organizations, to develop a credentialing programs for direct support professionals (where as a condition of receipt of grants, states must collaborate with state universities and community colleges to allow credentialing program to count as college credit); 3) provide grants to states to encourage the expansion of successful agency models of care that give seniors and individuals more direct control over the services they receive and the people that provide them.

The Democrat presidential candidates have come together for form an alliance, of sorts, that will deal with the needs of seniors and long term care.

Democrats Have a Plan for the “Invisible Army of Caregivers”

Senator Hillary Clinton released her awaited ”Long-Term Care Agenda” this past week, joining her fellow lead democratic candidates Barack Obama and John Edwards with a plan for how to deal with the rising needs of seniors and caregivers around the country.

The top three democratic candidates have brought the issue of eldercare in America to the forefront of their campaigns, hoping to tap into the millions of caregivers throughout the country. With a flair for the dramatic, the democratic candidates have touted their first-hand experience and each packaged their plans with key phrases like “Invisible Army of Caregivers,” elder abuse, improved nursing, lenders, tax-credits, and of course fancy titles to grab attention.

Obama’s “Fulling our Covenant with Seniors” and Edwards’ “Declaration of Independence for Older Americans” both have titles that have a slight resemblance to advertising campaigns of the 1960’s for tonic water that would cure all illness, but with all the flair and fuss, do these plans have the meat to make the powerful impact needed in this growing and costly issue of eldercare?

Hillary’s Plan can be found HERE.

Obama’s Plan is HERE.

And John Edwards Plan is HERE.

Hat tip to LTC Reform Blog.