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OCR for page 238
APPEN DIX A
History of Federal Nursing
Home Regulation
The federal government first became involved in nursing
homes with the passage of the Social Security Act of
1935.~2 The Act established a federal-state public
assistance program for the elderly called Old Age
Assistance (OAA). Because the drafters of the legislation
opposed the use of the public poorhouse to care for the
poor elderly, the act prohibited the payment of OAA funds
to residents of public institutions. This stimulated the
growth of voluntary and proprietary nursing homes. By the
time of the first national survey of nursing homes in
1954, there were 9,000 homes classified as skilled nursing
or personal care homes with skilled nursing facilities; 86
percent were proprietary, 10 percent were voluntary, and 4
percent were public.3
In 1950, amendments to the Social Security Act
authorized payments to beneficiaries in public
institutions and enabled direct payments to health care
providers. The 1950 legislation also required that
participating states establish programs for licensing
nursing homes, but it did not specify what the standards
or enforcement procedures should be. Although most states
licensed hospitals (it was a requirement of the 1946
Hill-Burton hospital construction program), few of them
licensed nursing homes until after 1950.
238
OCR for page 239
APPENDIX A / 239
Federal involvement in nursing homes accelerated after
that. Studies showed that there were few nursing homes
providing skilled nursing services,4~5 and a consensus
began to develop that the federal government should
promote their development. In 1954 the Hill-Burton Act
was amended to provide funds to nonprofit organizations
for the construction of skilled nursing facilities that
met certain definitions and hospital-like building
standards. In 1956, amendments to the Social Security Act
increased the level of federal funding of OAA payments and
created a separate, matching program for medical services
to public assistance recipients, including nursing home
services; payments for OAA jumped from $35.9 million in
1950 to $280.3 million in 1960.6 In 1960 the latter
program was replaced by the Kerr-Mills Act with a more
extensive program called Medical Assistance for the Aged
(MAA). This covered the "medically needy" for the first
time. By 1965, 47 states had MAA programs, with a total
outlay of $1.3 billion a year. There were about 300,000
recipients.
In the meantime, legislation in 1958 and 1959 authorized
the Small Business and Federal Housing administrations to
aid proprietary nursing home construction and
operation.7
Various studies in the 1950s found that between 30 and
60 percent of the residents in private nursing homes were
public assistance recipients.8 A Public Health
Service survey of nursing home residents in 13 states
during 1953-1954 found that 51.3 percent were public
assistance recipients.5 Another study of expenditures
for nursing and convalescent homes found that, in 1957,
even before the 1956 amendments took effect, 53 percent of
the expenditures for nursing and convalescent homes were
from federal, state, and local governments.9 In 1965,
60 percent of the residents of nursing and convalescent homes
were supported by welfare.~°
With this increasing federal financial involvement in
nursing home services and construction, federal attention
began to focus on quality issues. In 1956, the Commission
on Chronic Illness called attention to problems with the
quality of care in nursing homes. The states
themselves began to report problems. A 1955 study
OCR for page 240
240 / APPENDIX A
by the Council of State Governments reported that the
majority of nursing homes were functioning with low
standards of service and relatively untrained
personnel.~3
There were concerns about the adequacy of state
licensing standards and the variability of state
enforcement efforts throughout the period leading up to
the passage of the Medicare and Medicaid acts in 1965.
The 1950 "standard-setting amendment" to the Social
Security Act did not specify minimum state licensure
standards or procedures, and there was no mechanism for
assuring that states enforced licensure standards. The
Public Health Service found in 1958 that few states had
adequate numbers of survey staff and that the
qualifications of survey personnel varied widely.~4
About 44 percent of 30S,000 skilled nursing beds did not
meet Hill-Burton fire and health standards in 1960.~5
A special Senate Subcommittee on Problems of the Aged
and Aging was established in 1959. It reported that only
a few nursing homes were of high quality. Most facilities
were substandard, had poorly trained or untrained staff,
and provided few services. But, the subcommittee
concluded, "because of the shortage of nursing home beds,
many states have not fully enforced the existing
regulations, failure to do so reflecting the policy of the
states to give ample time to the nursing home owners and
operators to bring the facilities up to the standards.
Many states report that strict enforcement of the
regulations would close the majority of the homes."
As a result of concerns about the quality of care and
safety of conditions in nursing homes, the chronic disease
program of the Public Health Service began to study state
licensing programs in 1957. The program began to work
with the states and the industry to develop federal
guidelines for nursing home licensure programs.~7
The final product, the Nursing Home Standards Guide,
was issued in 1963. It was mostly concerned with
standards, but also made some recommendations for
regulatory organization and procedures.
The Senate created the Special Committee on Aging in
1961, and began to hold hearings on nursing home problems
in 1963, chaired by Senator Frank Moss. The Moss
OCR for page 241
APPENDIX A / 241
Committee hearings in 1965 documented great variations in
state nursing home standards and enforcement efforts on
the eve of the Medicare and Medicaid programs. The 1974
report of the Moss Committee restated the reasons for
these variations:~9
1. Enforcement meant the closure of facilities,
already in short supply, with no place to put
the dispossessed patients.
2. States have few weapons other than the threat
of license revocation to bring a home into
compliance.
3. The license revocation itself was of very
little use because of protracted administrative
or legal procedures required.
4. Even if the revocation procedure was
implemented, judges were reluctant to close a
facility when the operator claimed that the
deficiencies were being corrected.
5. Nursing home inspections were geared to
surveying the physical plant rather than
assessing the quality of care.
THE ADVENT OF MEDICARE AND MEDICAID
The next major event was the enactment of the Medicare
and Medicaid programs in 1965. This greatly expanded
federal funding of nursing home services and gave the U.S.
Department of Health, Education, and Welfare (HEW) the
authority to set stanciards for nursing homes choosing to
participate. The Medicare Act provided funding for
beneficiaries needing post-hospital convalescence in what
was called an "extended care facility" (ECF). Medicaid
paid for skilled nursing services.
The Medicare ECF program had immediate problems. Few
nursing homes could meet the health and safety standards
or provide the level of services envisioned under the
program. Of 6,000 applicants, only 740 could be fully
certified the first year. More than 3,000 nursing homes
that could not otherwise comply were certified as being in
"substantial compliance."20
Meanwhile, given the fact that thousands of Kerr-Mills
OCR for page 242
242 / APPENDIX A
recipients were in nursing homes that could not meet
Medicare standards, the Medicaid program had to give up
the idea of using ECF standards for its skilled nursing
facilities and essentially left it to the states to decide
on nursing home participation. Amendments made in 1967 to
the Medicaid program included those sponsored by Senator
Moss authorizing HEW to develop standards and regulations
to be applied uniformly by the states. The Moss
amendments included a statutory definition of a skilled
nursing facility (SNF) and specified standards for
participating homes. They also provided HEW with the
authority to withhold federal funds from nursing homes not
meeting the standards.
The new Medicaid SNF regulations were supposed to be
implemented at the beginning of 1969, but a lengthy battle
over their scope and substance ensued. The outgoing
Johnson administration went through several drafts, and
interim regulations were finally issued by the Nixon
administration later in the year.
The 1967 amendments also resulted in the establishment
of intermediate care facilities (ICFs). They were
intended to care for residents who did not need the
24-hour nursing services provided in skilled nursing
homes, but who needed more than custodial care.2
The committee report said that ICFs would lower the
overall costs of long-term care and allow many nursing
homes to participate that could not meet SNF or ECF
requirements. ICFs were established under Title XVI
(OAA). This left federal standard-setting authority
ambiguous. HEW withdrew proposed ICE regulations in 1969
when states protested.
Pressure to increase the standards for nursing homes
participating in Medicare and, especially, Medicaid, and
to improve their enforcement, began to build in the early
1970s. The Moss Committee began a series of hearings in
1969 that lasted until 1973 and resulted in 3,000 pages of
testimony and, in 1974, a series of well-publicized
reports critical of federal regulatory efforts. In 1970
and 1971, nursing home problems became front-page news
with a fire that killed 32 residents in Ohio, a case of
food-poisoning in Maryland that killed 36, and Congressman
OCR for page 243
APPENDIX A / 243
David Pryor reporting on the floor of the House his
experiences as a nursing home orderly.2
Meanwhile, a Senate Finance Committee staff study found
that some states were reclassifying nursing homes as ICFs
"wholesale."20 (ICFs were not brought into the
Medicaid program, where they would be subject to federal
regulation, until 1971.) HEW discovered that the states
were certifying Medicaid SNFs merely on the basis of
licensure requirements and that Medicaid was making vendor
payments to homes that did not comply with federal
standards.2i The U.S. General Accounting Office
(GAO) audited skilled nursing homes in three states and
found that half were in violation of Medicaid standards
for nurse staffing, physician visits, or fire
safety.22
The Senate Finance Committee staff study of Medicare and
Medicaid in 1970 was very critical of Medicare
certification.20 Congress forced HEW to stop using
"substantial compliance" as a basis for certifying nursing
homes. The department instead adopted the procedure of
certifying nursing homes with deficiencies that were not
considered an immediate hazard to patient health or
safety. The undersecretary of HEW testified at a Moss
Committee hearing in 1971 that 74 percent of the nursing
homes participating in Medicare were certified with
deficiencies and more than 70 percent of them had had
deficiencies from 1968 through 1971. He concluded that
"reliance on state enforcement machinery had led to
widespread nonenforcement of federal standards."23
Secretary of Health, Education, and Welfare Elliot
Richardson told the White House Conference on Aging that
39 states had not been complying with federal procedural
requirements.
In June 1971, with the White House Conference on Aging
pending, President Nixon made a major speech deploring
conditions in nursing homes and pledging to end federal
payments to substandard facilities. In a second speech 2
months later, Nixon announced an eight-point plan to
improve nursing home regulation. Among the points were
initiatives to centralize Medicare and Medicaid
enforcement activities and to expand HEW's enforcement
OCR for page 244
244 / APPENDIX A
staff, to increase funding for training state surveyors,
to provide full federal reimbursement for the costs of
state nursing home inspection programs, and a promise to
decertify substandard facilities.
· . · .
The president also
proposed training programs tor nursing home staff,
experimental funding of state nursing home ombudsmen, and
the creation of an Office of Nursing Home Affairs in HEW
to coordinate the new enforcement efforts and conduct a
"comprehensive study" of federal long-term-care policies.
During 1972 Congress passed the remnants of Nixon's
comprehensive welfare reform bill, which still contained
many changes in the social security, Medicare, and
Medicaid programs. The law included full federal funding
of state survey and certification activities, redefined
Medicare ECFs and Medicaid skilled facilities as "skilled
nursing facilities" (SNFs), and directed HEW to develop a
single set of standards for Medicare and Medicaid SNFs.
Although the Senate Finance Committee's report said the
provision to unify Medicare and Medicaid standards for
SNFs was "not intended to result in any dilution or
weakening of standards for skilled nursing facilities,"
the law itself reduced some Medicare provisions, such as
eliminating social workers in SNFs, reducing RN coverage
in rural SNFs from 7 to 5 days a week, and extending
indefinitely the grandfathering from state licensure
requirements of nursing home administrators with 3 years
of practical experience.
Work began in earnest to develop the regulations for
SNFs and ICFs in 1972. But interim regulations were not
issued until 1973 and the final regulations were
promulgated in January 1974. Senator Moss criticized the
interim SNF regulations as being significantly weaker than
those for ECFs, and some requirements, such as those for
medical direction, residents' rights, and 7-day RN
staffing were reinstated later in 1974. But the final ICE
regulations were less stringent than the interim
regulations in several areas, such as nurse staffing
requirements, and waivers for life safety code provisions
were allowed. The department defended the increased
generality of some of the requirements on the ground that
they were "performance standards," which could be more
flexibly applied by skilled health professional
surveyors.
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APPENDIX A / 245
Meanwhile, until 1974, states were able to use their
discretion in allocating Medicaid funds to support
residents in facilities not meeting the ICE level of care
or that could not meet new requirements for federal
reimbursement, such as the most recent life safety code
(LSC).25 The 1974 regulations made official the
inclusion of ICFs in the Medicai~i program and applied to
them SNF certification procedures (but not the standards)
and left approvals of LSC and RN staffing waivers to the
states. A study by the Office of Nursing Home Affairs
(ONHA) in January 1974, just prior to the promulgation of
the ICE standards, found that 59 percent of SNFs were
being certified with life safety code deficiencies.26
The new standards triggered another wave of conversions
from SNF to ICF.25
Finally, in 1974, "as a result of an increasing aware-
ness on the part of the federal government that many
nursing home facilities which were receiving Medicare
(Title XVIII) and Medicaid (Title XIX) funds were not
meeting standards," HEW established offices of long-term
care standards enforcement in the federal regional
offices.25 Its regional directors were delegated
the authority to approve provider agreements with Medicare
and Medicare/Medicaid SNFs and to monitor state agency
certifications and agreements with Medicaid-only
providers.
POST-1974 EFFORTS TO REVISE
FEDERAL REGULATIONS
Since 1974 there has been a series of attempts to revise
the federal nursing home certification
regulations.27 In 1974 the Office of Nursing Home
Affairs began a study of the quality of care in nursing
homes. Teams of health professionals made surprise visits
to 288 SNFs to assess their management, structural, and
staffing characteristics. They also investigated the
quality of patient care by looking at a sample of 3,454
residents with a standardized patient assessment form.
The study found that "the extent to which nursing homes
comply with the federal standards of care and safety
varies widely."28 The ONHA also found that the
OCR for page 246
246 / APPENDIX A
surveys and certification regulations only looked at
whether facilities had the capacity to deliver required
services, not whether services of adequate quality were
actually being delivered.
This finding, that the certification process focused on
the institutional framework within which care is provided,
rather than on the patient, led to an effort to develop a
patient assessment instrument based on outcome measures,
called Patient Appraisal and Care Evaluation, or PACE.
The ONHA's original intention was to test PACE and, after
evaluation and modification, to use it in a national study
of nursing homes. The ONHA then planned to use it to
develop a survey process based on the quality of care and,
ultimately, as the basis for reimbursement.25~29 As
it turned out, the PACE form and process became too
unwieldy and complex for use as a regulatory instrument.
In the end, the Health Care Financing Administration
(HCFA) merely published it for voluntary use by nursing
homes in patient assessment.
The ONHA, now called the Office of Long-Term Care, was
overseeing a substantial revision of the SNF standards by
an interagency work group as early as 1976. HEW began
another effort to revise the nursing home survey program
as part of President Carter's regulatory reform effort,
"Operation Common Sense." The HCFA announced plans to
revise the SNF conditions of participation and ICE
standards.30 The announcement was followed by
public hearings in five cities3t and numerous written
comments and meetings with interested parties. Commen-
tators criticized certain features of the regulations:
their medical orientation, focus on input and process
rather than outcomes, costs imposed on providers not
related to better outcomes, and emphasis on paperwork and
paper review.
While most of the comments focused on quality-of-care
issues, it was evident that there were enforcement
problems in the survey process. From this came the idea
of elevating certain requirements to the condition level,
to make them more enforceable. The HCFA also concluded
that revisions of the certification procedures contained
in Subpart S of the regulations were necessary (42 CFR
OCR for page 247
APPENDIX A / 247
Part 405), and began work on them in 1980 (internal HCFA
documents).
After 2 years of work and three drafts, the HCFA
published its proposed new rules in 1980.32 From
the beginning, and in line with the PACE effort, the HCFA
had planned to shift the focus of the regulations from
paper reviews of facility capability to an evaluation of
patients and the care they were actually receiving. The
new regulations would have33
1. consolidated all patient care planning
requirements into a single condition, and
required a patient care management system that
called for interdisciplinary teams to assess
patients and plan their care;
2. Reemphasized the medical model by increasing
the minimum time required between attending
physician visits, reducing the medical
director requirements, and making consultant
services discretionary after 1 year;
elevated the residents' rights standard to the
status of a condition of participation; and
4. combined the SNF and ICE regulations into a
single set in the Code of Federal Regulations.
The nursing home industry disputed the HCFA's estimates
of the costs the new regulations would impose. The HCFA
said, in its regulatory impact analysis, that the changes
would cost about $80 million a year (revised in 1981 to
$135 million), but consultants engaged by the industry
estimated first-year costs of $586 million and annual
costs thereafter of $435 million.34~35 The proposed
rules stayed in limbo until the final hours of the Carter
administration, when the rule elevating residents' rights
to the condition level was published.
The new regulation was immediately rescinded by the new
administration, which began a new regulatory reform
effort. The HCFA established a Task Force on Regulatory
Reform that reevaluated the regulations according to a
detailed protocol. Although the task force decided to
retain major elements of the 1980 proposed regulations,
OCR for page 248
248 / APPENDIX A
including the patient care management system and the
elevation of residents' rights to a condition, it also
proposed the deletion or revision of many other conditions
and standards or made them effective only if there were no
applicable state laws. The reaction from consumer groups,
state regulators, the Congress, and providers was so
strong that Secretary of Health and Human Services Richard
Schweiker announced that the draft regulations would be
dropped, leaving the 1974 rules in effect.
Finding it impossible to change the standards, the HCFA
turned to an attempt to change the procedures for applying
the standards. Many of the changes proposed had long been
considered desirable within the HCFA, such as combining
Medicare and Medicaid procedural requirements (Subpart S
of 42 CFR Part 405 and Subpart C of 42 CFR Part 442),
allowing more flexible survey cycles, and eliminating a
number of requirements that had proved unworkable or
ineffective. But the proposed regulations also would have
permitted states to accept accreditation of a nursing home
by the Joint Commission on Accreditation of Hospitals
(JCAH) as sufficient evidence that facilities met federal
requirements for Medicare and Medicaid participation.
Taken together, these changes were viewed as another
attempt to reduce federal protection of the health and
safety of nursing home residents by Congress, which
promptly imposed a moratorium on them.
In the summer of 1983, the HCFA and Congress agreed to
postpone virtually all changes in the regulations until a
committee appointed by the Institute of Medicine studied
the issues and reported its recommendations for changes,
except for certain minor changes agreed to by all members
of a group of consumer, provider, and state regulatory
representatives. The latter group, called the Subpart S
Consensus Group, met until January 1984, and agreed to
some of the 1982 procedural changes (consolidation of
Medicare and Medicaid rules, elimination of the 90-day
resurvey rule but requiring 120-day resurveys of
significant deficiencies, and elimination of quarterly
staffing reports except for problem facilities (internal
HCFA documents). It rejected some of the proposals
("deemed status" for JCAH-accredited nursing homes and
less-than-annual surveys), and suggested that others be
OCR for page 249
APPENDIX A / 249
optional, at the discretion of the state in the case of a
Medicaid-only facility or according to a joint federal-
state agreement in the case of a Medicare or a Medicare/
Medicaid facility (elimination of time-limited agreements,
automatic cancellation clauses, and the repeat deficiency
requirements). But the Consensus Group changes have not
been implemented.
In the meantime, the HCFA has begun to develop a
modified survey instrument, called Patient Care and
Services (PaCS), that is based primarily on direct patient
assessments and outcome-oriented indicators of care.
Conceptually, PaCS is a lineal descendant of PACE. It is
also based in part on the results of a series of HCFA-
sponsored demonstrations and experiments with modified sur-
vey instruments and processes. Currently (1985), the new
instrument is being tested extensively in three states and
every state is experimenting with it in a few facilities.
NOTES
Markus, G. R. 1972. Nursing Homes and Congress: A
Brief History of Developments and Issues.
Congressional Research Service. Education and Public
Welfare Division. Report No. 72-224 ED. November 1.
Washington, D.C.: Library of Congress.
2. Vladeck, B. C. 1980. Unloving Care: The Nursing
Home Tragedy. New York: Basic Books.
3. Solon, J., and A. M. Baney. 1955. Ownership and Size
of Nursing Homes. Public Health Reports
70(May):437-444.
Solon, J., and A. M. Baney. 1954. Inventory of
Nursing Homes and Related Facilities. Public Health
Reports 69(December):1 121-1 132.
Solon, J., D. W. Roberts, D. E. Krueger, and A. M.
Baney. 1957. Nursing Homes, Their Patients and Their
Care: A Study of Nursing Homes and Similar Long-Term
Care Facilities in 13 States. U.S. Public Health
Service Pub. No. 503. Washington, D.C.: U.S.
Government Printing Office.
6. Moroney, R. M., and N. R. Kurtz. 1975. The Evolution
of Long-Term Care Institutions. In S. Sherwood (ed.~.
4.
5.
OCR for page 250
250 / APPENDIX A
Long-Term Care: A Handbook for Researchers,
Planners, and Providers. New York: Spectrum
Publications.
7. Regan, J. J. 1975. Quality Assurance Systems in
Nursing Homes. Journal of Urban Law
53~2~: 154-244.
8. U.S. Department of Health and Human Services. 1980.
Proceed ings of Symposium on Integration of Health
and Safety Survey and Inspection of Care Review.
Health Standards and Quality Bureau.
9. Brown, F. R. 1958. Nursing Homes: Public and Private
Financing of Care Today. Social Security Bulletin
21 (May):7-~.
10. U.S. Department of Health, Education, and Welfare.
1967. Chronic Illness Among Residents of Nursing and
Personal Care Homes, U.S., May-June 1964. U.S. Public
Health Service Pub. No. 1000, Series 12, No. 7.
Washington, D.C.: U.S. Government Printing Office.
1. U.S. Senate. 1957. Recommendations of the Commission
on Chronic Illness on the Care of the Long-Term
Patient. Pp. 75-94 in Studies of the Aged and
Aging. vol. 2, November 1956. Committee on Labor and
Public Welfare. Washington, D.C.: U.S. Government
Printing Office.
12. U.S. Senate. 1956. Recommended State Action for the
Aging and Aged: A Summary of Recommendations on
Problems of the Aging as Compiled from Reports of
State Agencies, by the Council of State Governments.
Pp. 275-309 in Studies of the Aged and Aging. vol.
1, November 1956. Committee on Labor and Public
Welfare. Washington, D.C.: U.S. Government Printing
Office.
13. U.S. Senate. 1956. A Bill of Objectives for Older
People and a Program for Action in the Field of Aging,
by the Council of State Governments, August 1955. Pp.
183-189 in Studies of the Aged and Aging. vol. 1,
November 1956. Committee on Labor and Public Welfare.
Washington, D.C.: U.S. Government Printing Office.
14. U.S. Department of Health, Education, and Welfare.
1958. Report on National Conference on Nursing Homes
and Homes for the Aged, Washington, D.C., February
OCR for page 251
APPENDIX A / 251
25-2S, 1958. U.S. Public Health Service Pub. No. 625.
Washington, D.C.: U.S. Government Printing Office.
15. U.S. Senate. 1960. The Condition of American Nursing
Homes. A Study by the Subcommittee on Problems of the
Aged and Aging, Committee on Labor and Public
Welfare. Washington, D.C.: U.S. Government Printing
Office.
16. U.S. Senate. 1960. The Aged and Aging in the United
States: A National Problem. Report No. 1121. 86th
Congress, 2d Session. February 23. Subcommittee on
Problems of the Aged and Aging, Committee on Labor
and Public Welfare. Washington, D.C.: U.S. Government
Printing Office.
17. Underwood, B. 1961. The Development of a National
Nursing Home Standards Guide. Pp. 13-20 in the
Proceedings of the National Nursing Home Institute,
Improving Patient Care Through Education anc/t
Regulation. Washington, D.C., October 12- 14, 1960.
Washington, D.C.: American Nursing Home Association.
18. U.S. Department of Health, Education, and Welfare.
1963. Nursing Home Standards Guide: Recommendations
Relating to Standards for Establishing, Maintaining,
and Operating Nursing Homes. Public Health Service,
Division of Chronic Diseases, Nursing Homes and
Related Facilities Program.
19. U.S. Senate. 1974. Nursing Home Care in the United
States: Failure in Public Policy. An Introductory
Report. Senate Report No. 93-1420, 93rd Congress, 2d
Session, December 19. Subcommittee on Long-Term Care,
Special Committee on Aging.
20. U.S. Senate. 1970. Medicare and Medicaid: Problems,
Issues, and Alternatives. Report of the Staff to
Committee on Finance. Committee Print, 91st Congress,
1st Session, February 9. Washington, D.C.: U.S.
Government Printing Office.
21. U.S. Department of Health, Education, and Welfare.
1971. Report on the Skilled Nursing Home
Certification Project. August 20. Washington, D.C.:
Social and Rehabilitation Service, Medical Services
Administration.
22. U.S. General Accounting Office. 1971. Problems in
Providing Proper Care to Medicaid and Medicare
OCR for page 252
252 / APPENDIX A
Patients in Skilled Nursing Homes. Report No.
B-164031~3~. May 28. Washington, D.C.
U.S. Senate. 1971. Trends in Long-Term Care, Part 18.
Subcommittee on Long-Term Care, Special Committee on
Aging.
U.S. Federal Register. 1974. 39(January 17~:2238-2257.
24.
25. U.S. Department of Health, Education, and Welfare.
1976. Five Years of Accomplishments of the Office of
Long-Term Care, 1971 - 1976. Public Health Service,
Office of Long-Term Care. October.
26. U.S. Department of Health, Education, and Welfare.
1974. Enforcement of Life Safety Code Requirements
in Skilled Nursing Facilities. Office of Nursing
Home Affairs, Public Health Service. January.
27. Trocchio, J. 1984. Nursing Home Deregulation:
Regulatory Reform Ef forts. Nursing Economics
2(May-June): 185- 189.
28. U.S. Department of Health, Education, and Welfare.
1975. Interim Report: Long-Term Care Facility
Improvement Study. Office of Nursing Home Affairs,
Public Health Service. March.
29. Lynch, M. 1976. Patient Assessment--A Way to Improve
Quality of Care and Reduce Paper Compliance.
Journal of the American Health Care Association
2(May):42-43.
30. U.S. Federal Register. 1978. 43(June 8~:24873-24875.
31. U.S. Department of Health, Education, and Welfare.
1978. New Directions for Skilled Nursing and
Intermediate Care Facilities: Summaries of Public
Hearings, June-August 1978. Rockville, Maryland:
Health Care Financing Administration.
32. U.S. Federal Register. 1980. 45(July 14~:47368-47385.
33. Sherman, S. E. 1984. Background Paper on
Certification Standards. Prepared for the Institute
of Medicine Committee on Nursing Home Regulation.
September 7.
34. U.S. Department of Health and Human Services. 1980.
Draft Regulatory Analysis: Proposed Conditions of
Participation for Skilled Nursing and Intermediate
Care Facilities. Health Standards and Quality
Bureau, Health Care Financing Administration.
June 30.
OCR for page 253
APPENDIX A / 253
3S. Applied Management Sciences. 1980. Examination of the
Economic Impact of the Proposed Medicare and Medicaid
Conditions of Participation for Skilled Nursing and
Intermediate Care Facilities. Washington, D.C. August
29.
36. Kemanis, V. 1980. A Critical Evaluation of the
Federal Role in Nursing Home Quality Enforcement.
University of Coloraclo Review 51 (Summer):607-640.
37. U.S. Department of Health and Human Services. 1984.
Inspection of Care Report. Baltimore: Health Care
Financing Administration, Health Standards and
Quality Bureau, May 9.
Representative terms from entire chapter:
nursing home
