Regulation & Legislation
Key federal and state regulations and legislation that impact THE GREEN HOUSE® Project and the long-term care industry:
Community-Based Green House Homes Initiative
Green House homes, licensed as skilled nursing homes, should become a true part of the home and community-based care options available to elders and persons with disabilities in the communities where they want to live. Realizing this goal requires giving providers the option of moving Green House nursing homes off of long-term care campuses and into neighborhoods and small towns across America and doing so in a manner that can be financially viable for providers who primarily serve Medicaid beneficiaries. Learn how The Green House Project is partnering with The Centers for Medicare and Medicaid Services (CMS) to explore licensing options.
Green House Project Letter to CMS, June 9, 2009
Bi-partisan Letter of Support to CMS from U.S. Senators,
June 9, 2009
CMS Response to Green House Project, September 10, 2009
CMS Clarifies Guidelines Regarding Unsafe Food Sources in Long-term Care Facilities
In January 2009, The Green House Project wrote to the Centers for Medicare and Medicaid Services (CMS) on behalf of Green House providers to seek clarification on the intended impact and interpretation of new interpretive guidelines regarding unsafe food sources in long-term care facilities. The guidelines seemed to imply that federal regulations would be interpreted to prohibit outside food (e.g., brought in by family and friends) from being shared with residents other than the intended recipient, which would affect a resident’s right to choose and conflict with culture change approaches, including key Green House core principles, relating to socialization around food, and household celebrations for birthdays, holidays, and other ordinary and special events. CMS has clarified that the guidelines are not intended to prohibit residents from consuming outside food, making the distinction between food procured by the facility and food procured by others and brought in to share with residents. Thomas Hamilton, CMS Director of Survey and Certification, states: “We will also share this guidance clarification with surveyors in a future transmittal (for F tag 371) to further reinforce that all residents have the right to accept food brought into the facility by any visitor(s) for any resident(s).
Read the full text of the letter to The Green House Project from CMS dated March 24, 2009 (PDF).
Read the full text of CMS' memo to State Survey Agencies dated May 29, 2009 (PDF).
Green House Model Meets California Regulatory Requirements for Role of Certified Nursing Assistants
In October 2008, The Green House Project met with the California Department of Public Health (CDPH) to review the state’s requirements as they apply to the roles, responsibilities, and supervision of Certified Nursing Assistants (CNA’s). After careful analyses of the regulations and statues, the state’s Licensing and Certification Program concurred with The Green House Project’s interpretation that the model’s core principles and practices met the intent and requirements of California nursing home regulations fully in the areas of health and safety, staff dietetic service, and nursing services. We appreciate the support of the California Health Care Foundation, Aging Services of California, and our NCB Capital Impact colleagues in the Center for Long-Term Supports. Read the full CDPH letter, December 3, 2008 (PDF).
CMS Finds 'No Barriers' to The Green House Model in Federal Nursing Home Regulations
In a February 2007 letter, Leslie Norwalk, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), found "no barriers" that would prevent Green House homes adhering to the model's principles from being "qualified as nursing homes under Federal regulations." The letter includes the Green House model among the larger culture change movement that CMS supports, commenting that " we believe these innovations more fully implement the Nursing Home Reform provisions of the Omnibus Budget Reconciliation Act of 1987, from which our CMS nursing home regulations are derived." Read the full CMS letter (PDF).*
Federal/State Panel on The Green House Model and Regulations
An April 2007 panel of state long-term care regulators and CMS staff discussed The Green House Model and regulatory compliance at the American Association of Homes and Services for the Aging's spring conference in Washington, DC. Karen Schoeneman (Senior Policy Analyst, CMS), Carol Shockley (Director, Office of Long-Term Care, AR), and Patrick Flood (Commissioner, Department of Aging and Independent Living, VT) discussed the model's fit with federal and state rules, finding no friction. Each panelist offered advice on approaching CMS regional and state staff when planning a new Green House project. Hear the full AAHSA transcript for A Perfect Fit? Regulatory Policy & Practice Meet the Green House Model (MP3 audio file, 16,483 KB, 112 minutes).
CMS Regulatory Policy Guidance on Culture Change Practices
In a letter to State Survey Agency Directors dated December 21, 2006, the Centers for Medicare and Medicaid Services (CMS) clarified their position on several questions, perceptions and misperceptions about common practices in nursing homes embracing culture change and person-centered approaches to care. The letter provides helpful guidance and interpretation in many areas of nursing home practice that are changed in The Green House model and may serve as a valuable reference for projects in dialogue with state agencies. Read the CMS letter (PDF).*
Arkansas Bills Provide Planning Support, Staffing Flexibility, and Specialized Reimbursement for Green House Projects
Arkansas House Bills 1363 & 1364, signed into law in March 2007, provide Arkansas' Office of Long-Term Care the ability to provide support, staffing flexibility, and specialized reimbursements to organization interested in creating a Green House Project or implementing a Eden Alternative program. House Bill 1363* amends Arkansas' Long-Term Care Trust Fund, an account funded by nursing home's civil monetary penalties, to allow the Director of the Office of Long-Term Care to use funds from the trust to create programs supporting Green House Projects or Eden Alternative Programs. Discussions with the Office of Long-term Care indicate that planning grants for Green House adopters may be one such program. House Bill 1364* amends Arkansas' Code relating to nursing home staffing standards to allow The Office of Long-Term Care to create separate staffing standards and reimbursement categories for Green House Projects or Eden Alternative homes as determined necessary.
Oklahoma "Green House" Bill Signed - Provides Regulatory Flexibility
On Wednesday April 18, 2007, Governor Brad Henry signed House Bill 1510 which will help bring The Green House Project to Oklahoma. The legislation gives the Commissioner of Health the ability to waive certain provisions of the Oklahoma Nursing Home Care Act if necessary to restore "individuals to a self-contained residence in the community that is designed like a private home and houses no more than ten individuals." While The Green House Project does not typically need waivers to operate under state guidelines, the added flexibility is an excellent tool to have available.
Wyoming Long-Term Care Choices Act - Creates Pilot Program for a "Green House" Project
Wyoming adopted the Long-Term Care Choices Act (SF89)* on February 28, 2007. The Act covers several items relating to long-term care including creating a "alternative elder care home" category (modeled on The Green House principles) and a feasibility grant to fund the exploration of one Alternative Elder Care Home. An Elder Care Home is defined in the Act as a fully detached house for no more than 10 residents providing the highest level of care permitted under Wyoming's applicable health care facility rules. The Elder Care Home must provide a "residential home environment" to Medicaid supported residents, including private bedrooms and baths, a den, an open kitchen (implied), an office for a nurse, open access to all areas of the house and a secured patio during waking hours, overhead lifts, a restraint-free environment, self-managed work teams of direct care and nursing staff, and a "culture of learning and participation by the residents and honors the elder hood stage of life."
Massachusetts Issues Certificate of Need for The Green House Project in Chelsea - First in 10 Years
On July 8, 2006, Section 116 of Chapter 139 of the Acts of 2006 became law in Massachusetts, providing a Certificate of Need for 100 new skilled nursing beds to be developed using the Green House model of care by Chelsea Jewish Nursing Home. This is the first approval for new nursing beds to be granted in the state in the past 10 years. The text reads:
SECTION 116. Notwithstanding any general or special law to the contrary, for the purpose of developing an innovative and kosher skilled nursing facility in the city of Chelsea, the Chelsea Nursing Home, which has been designated to develop an urban, Greenhouse Program nursing home facility in the city of Chelsea, is hereby granted a determination of need for 100 new skilled nursing facility beds; provided, that the construction of the beds shall be assigned a maximum capital expenditure consistent with the Greenhouse Program, as determined by the department of public health, and shall be entitled to reimbursements for such capital expenditures as determined by the division of health care finance and policy.
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