B&F Consulting, Inc.


Individualized Care

Reducing Distress to Reduce Distressed Behaviors and

the Anti-Psychotic Medications Used in Response

MDS 3.0, QIS, and Quality of Life Surveyor Guidelines

Resources to implement individualized care...

Quality of Life Regs

Ref: S&C-09-31

Issued: April 10, 2009

Effective: June 17, 2009

Click here for a copy of the revisions

and accompanying training materials:

new CMS interpretive guidelines

Go to www.pioneernetwork.net for resources and information about the Quality of Life Surveyor guidelines, and information on individualizing food services.


  1. Bullet B & F Consulting Presentation for Pioneer Network Webinar Series, June 2009, on F 246, Self-Determination and Participation and F 246, Accommodation of Need, at Quality of Life Surveyor Guideline Revisions.B&F

  1. Bullet Learn about the How of Change, to guide you as you reorganize your systems to support individualized care for residents.

  1. Bullet View the Four Part CMS Webcast Series From Institutional to Individualized Care, which contains practical guidance for operationalizing changes in a way that reduces stress and improves clinical outcomes. These changes integrate quality of life and quality of care, rather than pitting them against each other.

  1. Bullet View video clips that can assist you in preparing for the Quality of Life revisions to the survey guidelines:

  2. 1.Individualize Mornings Through Gentle Awakening and Rhythm of Life Assessments

  3. 2.Eliminate Alarm Use

  4. 3.Implement Consistent Assignment

  5. 4.How of Change

  6. 5.Making it Home Through Low Cost Changes to the Physical Environment

  1. BulletView Look At Me, produced by the Veterans Administration, is a five minute, moving video from the viewpoint of the older person living in a nursing home. Copies may be available through your state’s Quality Improvement Organization or your State Long-Term Care Ombudsman Program.

  1. Bullet View Culture Change in Long-Term Care: A Case Study, which chronicles one nursing home’s process of changing from institutional routines to individualized routines. Produced by the American Health Quality Association as a teaching tool for QIOs and nursing homes initiating culture change, it features the work of Connie McDonald, Administrative Director for MaineGeneral Rehabilitation and Nursing Care, Augusta, ME, and her staff. They introduced Gentle Awakening to start off mornings according to each resident’s natural waking time. They individualized night routines so that residents can now get a good night’s sleep. In the process, they changed their food delivery and activities, reduced their use of suppositories and alarms, and made other changes in daily care to support residents’ own routines. Residents have thrived and so have staff.

  1. Bullet View video clip of surveyors from Rhode Island’s Department of Health, about their experience in the Individualized Care Pilot, funded by The Commonwealth Foundation. They heightened their attention to residents’ choices about waking and going to bed, eating, and bathing, and in this video, they share their reflections.

  1. Bullet Click below for Resource Materials to help implement changes. These Change Ideas developed for RI’s nursing homes by Quality Partners of Rhode Island, with B&F Consulting and the RI Department of Health. These Change Ideas address:

  1. BulletConsistent Assignment

  2. BulletDining

  3. BulletIndividual Choice

  4. BulletPleasant Bathing

  5. BulletWaking and Sleeping

  1. Bullet Click for the Individualized Care Training Curriculum that outlines the training materials and educational resources to help guide nursing homes in the adoption of innovative, transformational-change strategies. This curriculum builds on the collaboration of B&F Consulting and Quality Partners of Rhode Island during Improving the Nursing Home Culture. This study, funded by CMS in 2004, integrated quality improvement practices with individualized care and workforce retention. Individual nursing home stories are included in this report and are available at no charge in the Final Report. Their stories provide a wonderful guide for homes looking to move toward more individualized care.

  1. BulletView Partnering with Families to Individualize Care. Hear from families who have been actively involved in making Loomis House home to their loved one. These interviews were conducted by Lori Todd, Administrator, to share at the 2008 Pioneer Network conference. For more information, contact Lori Todd at ltodd@loomiscommunities.org

Based in New England, Brady and Frank work throughout the country.

Contact us by email at:

Cbrady01@snet.net or bfrank1020@me.com

or by phone at:

Cathie Brady 860-334-9379

Barbara Frank 617-721-5385


Hear from a doctor, nurses, administrators, and others, about how their residents improved when they individualized care. 

Click on Movie on right for Excerpt from From Institutional to Individualized Care, Part Four

Time: 6 min. 34 sec.

Individualized Care:

Reducing Anti-Psychotic Medications by Reducing Distressed Behaviors

Using MDS 3.0, QIS, and

Quality of Life Surveyor Guidelines as Resources

New Resources:

Guide: 10 Steps to Eliminating Off-Label Use of Antipsychotics


Video: Tracking and Trending to Reduce Off-Label Antipsychotics

Developed by B&F Consulting for

LEADER’s Project to Improve Dementia Care

Funded by CMS Civil Monetary Penalty Funds April 2015

McNally cards

For a copy of the cards, click here:  McNally cards for MDS 3.0 .pdf

For a copy of the card instructions, click here: McNally for MDS 3.0 Instructions.doc

This is a case study exercise about a resident, Mr. McNally, who came into a nursing home for short-term rehab after a stroke. He declined rapidly and in ways that were avoidable. Using the deck of cards, the group determines what caused his decline and learns how quality of life and customary routines affect quality of care. The exercise helps participants identify the importance of a critical thinking, individualized care, and a team approach to the MDS. Components of a team approach include consistent assignment, daily huddles, alignment of caregiver documentation with MDS, and interdisciplinary  care planning and performance improvement by staff closest to the resident.

Additional Resources include:

  1. 1.Organizational Practices - Consistent Assignment

  2. 2.Organizational Practices - Integrating MDS into Daily Practice

  3. 3.Organizational Practices - Ground-Up Quality Improvement

4. Relational Coordination Organizational Self-Assessment 2011

QIS Resident Interview

Ask your residents these questions yourselves, and when you hear their answers, be prepared to “assist them in exercising their choices” and “make their choices known to their caregivers” as stated in surveyor guidelines.

Excerpt from

Pioneer Network Webinar Series on Using MDS 3.0 as the Engine for High Performance

Susan Wehry, MD explains how to understand and respond to agitation and aggression by meeting needs instead of using anti-psychotic medications.

Reducing Anti-Psychotic Medications starts with reducing the external causes of resident distress, which manifests itself in what we can “behaviors” but which we really need to understand as distress signals.

If we see “behaviors” as distress signals then, rather than stop the behaviors, we need to stop the distress. To do that, we need to know what is causing the distress.

In the first video below, Susan Wehry, MD, explains that agitation means HELP and aggression means STOP. Once we understand this, we can find out what help is needed or what must be stopped. The second video, a graphic excerpt from Bathing Without A Battle, illustrates this how aggression means STOP.

Key external causes of distress include whether we are following a resident’s customary routines, whether a person feels rushed or uncomfortable in care, noises such as alarms or clanging, and a person’s need for a sense of safety, connection and well-being. The answer will come when we know that the “behavior” is not just a natural extension of a person’s dementia or mental illness but a call for us to change our behavior and help make things right for them.

To reduce use of anti-psychotic medications, use consistent assignment so staff know residents well. Have huddles to share information and problem-solve. Ask about residents’ customary routines and honor them from day one.

Dementia Beyond Drugs is a great resource from Al Power, MD