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A Trip to the Restroom Leads to Discovery of Unwritten Rules that are Noncompliant with HCBS Rule

Most “rules” in an organization are written in the form of policies and procedures. But organizations can also have unwritten rules. An unwritten rule occurs when an organization operates in a routine way as if there was a written rule in place. Unwritten rules can be very tricky to identify! They can be so ingrained in how an organization operates that you may not even realize they exist! That is exactly what happened to a provider when two unwritten rules were uncovered… quite an unusual way.

Yes, it sounds strange….but it was actually a trip to the restroom that led to the discovery of not just one, but TWO, an organization’s unwritten rules that were not in compliance with the CMS HCBS Settings Rule. I was evaluating a facility-based day program for compliance with the CMS HCBS Settings Rule when I needed to take a restroom break. I excused myself from the conference room table and began walking toward a nearby restroom, when the director said, “Wait! Don’t use that restroom! That one is for the program participants. I’ll show you to the restroom for staff.” I then asked, “what is the difference between the restroom for participants and the restroom for staff?” He said, “The participant’s restroom doesn’t have a lock on the door, and someone could walk in on you.”

Well, obviously I didn’t want to use a restroom where someone could walk in on me, so I gladly used the staff restroom. But I was intrigued about these separate restroom. I asked the program director if there was a specific reason for having separate restrooms and for the participant’s restroom to not have a lock on the door. With a perplexed look on his face, he said, “I don’t know. I’ve never thought about it before. I’ve been here for 10 years and it has just always been that way.”

The program director made a few inquiries and discovered that the lock was removed over 15 years ago in an attempt to stop two program participants from having sex in the restroom. (I’ll need to write a whole separate article later to address how this might have been handled better.) Well….there was a ripple effect from that decision. The staff didn’t want anyone to be able to walk in on them while they were using the restroom, so they began using a different restroom (one that had a privacy lock). Over time, one restroom became known as the “participant restroom” and the other restroom became known as the “staff restroom”.

Some staff retired in that 15-year period and new staff was hired…… But in all that time, no one ever questioned why individuals who received services couldn’t use the same restroom as the staff who supported them. No one stopped to think about the fact that none of the individuals who received services could use the restroom in private. It wasn’t a written rule. It was just the way it was……and it had been that way for so long that no one thought twice about it.

Unwritten rules aren’t always bad……I’ve seen some good ones. But the bad ones need to be fixed. And you can’t fix them….unless you find them.

So how do you find them?

Here is a three-step process that you can use to help you identify unwritten rules in your organization:

1. OBSERVE your organization’s practices to see how your organization operates on a day to day basis. Look for any patterns or routines. A pattern or routine that isn’t based on written policies and procedures is an unwritten rule.

2. ASK employees to help identify unwritten rules. Choose employees who work in different positions and in different locations. Each will bring a different perspective. Share with them the example of the unwritten bathroom rules and ask employees about any unwritten rules within the organization.

3. EVALUATE your organization’s unwritten rules to determine how well they align with the CMS HCBS Settings Rule. Be sure to pay close attention to any rule that limits a person’s choices, rights, or opportunities for integration, as the rule will most likely not be in compliance with the CMS HCBS Settings Rule.


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