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1 Introduction and Summary PURPOSE OF THE STUDY This is the report of a study of government regulation of nursing homes (excluding intermediate care facilities for the mentally retarded). The study's purpose was to recommend changes in regulatory policies and procedures to enhance the ability of the regulatory system to assure that nursing home residents receive satisfactory care. In May 1982, the Health Care Financing Administration (HCFA) announced a proposal to change some of the regulations governing the process of certifying the eligibility of nursing homes to receive payment under the Medicare and Medicaid programs. The changes were responsive to providers' complaints about the unreasonable rigidity of some of the requirements. The proposed changes would have eased the annual inspection and certification requirements for facilities with a good record of compliance, and would have authorized states, if they so wished, to accept accreditation of nursing homes by the Joint Commission on Accreditation of Hospitals (JCAH) in lieu of state inspection as a basis for certifying that Skilled Nursing Facilities (SNFs) and Intermediate Care Facilities (ICFs) are in compliance with 1

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2 / NURSING HOME CARE the federal conditions of participation and operating standards. The HCFA proposal was strongly opposed by consumer groups and most state regulatory agencies because the proposed changes were seen as a movement in the wrong direction--that is, towards easing the stringency of nursing home regulation--and because they did not deal with the fundamental weaknesses of the regulatory system. The controversy generated by the proposal caused Congress in the fall of 1982 to order the HCFA to defer implement- ing the proposed changes until August 1983 and ultimately resulted in a HCFA request to the Institute of Medicine (IOM) of the National Academy of Sciences to undertake this study. The contract between the HCFA and the IOM became effective on October 1, 1983. The charge to the IOM Committee on Nursing Home Regulation was to under- take a study that would "serve as a basis for adjusting federal (and state) policies and regulations governing the certification of nursing homes so as to make those policies and regulations as appropriate and effective as possible." THE PUBLIC POLICY CONTEXT OF THE STUDY There is broad consensus that government regulation of nursing homes, as it now functions, is not satisfactory because it allows too many marginal or substandard nursing homes to continue in operation. The implicit goal of the regulatory system is to ensure that any person requiring nursing home care be able to enter any certified nursing home and receive appropriate care, be treated with courtesy, and enjoy continued civil and legal rights. This happens in many nursing homes in all parts of the country. But in many other government-certified nursing - homes, individuals who are admitted receive very inadequate--sometimes shockingly deficient--care that likely to hasten the deterioration of their physical, mental, and emotional health. They also are likely to have their rights ignored or violated, and may even be

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INTRODUCTION AND SUMMARY / 3 subject to physical abuse. The apparent inability of the current regulatory system either to force substandard facilities to improve their performance or to eliminate them is the underlying circumstance that prompted this study. In the past 15 years many studies of nursing home care have identified both grossly inadequate care and abuse of residents.2~23 Most of the studies revealing sub- stantial evidence of appallingly bad care in most parts of the country have dealt with conditions during the 1970s. However, testimony in public meetings conducted by the committee in September 1984, news reports published during the past 2 years, recent state studies of nursing homes, and committee-conducted case studies of selected state programs have established that the problems identified earlier continue to exist in some facilities: neglect and abuse leading to premature death, permanent injury, increased disability, and unnecessary fear and suffering on the part of residents. Although the incidence of neglect and abuse is difficult to quantify, the collective judgment of informed observers, including members of the committee and of resident advocacy organizations, is that these disturbing practices now occur less frequently. Residents and resident advocates, both in public hearings and in a study of resident attitudes conducted by the National Citizens' Coalition for Nursing Home Reform,24 expressed particular concern about the poor quality of life in many nursing homes. Residents are often treated with disrespect; they are frequently denied any choices of food, of roommates, of the time they rise and go to sleep, of their activities, of the clothes they wear, and of when and where they may visit with family and friends. These problems may seem at first to be less urgent than outright neglect, but when considered in the context of a permanent and final living situation they are equally unacceptable. The quality of medical and nursing care in many homes also leaves much to be desired. Geriatrics is becoming, in the mici-l9SOs, an area of concentration within internal

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4 / NURSING HOME CARE medicine, family medicine, and psychiatry. (Both the American Academy of Family Practice and the Board of Internal Medicine have decided to establish certificates recognizing geriatric competence.) Many conditions that were once accepted as inevitable consequences of old age now can be treated or alleviated. Physicians and nurses in nursing homes are not always aware of advances in geriatrics so that even in pleasant and humane institutions examples may be found of residents whose disability could be reduced, whose pain could be controlled, or whose depression could be treated if they received proper medical care. A lower standard of medical and nursing practice should not be accepted for nursing home residents than is accepted for the elderly in the community. Given the fragility of nursing home residents and their dependence on medical care for a satisfactory life, practice standards should even be higher. Thus, physicians, as well as nurses, have substantial responsibility for quality of care in nursing homes. These observations do not mean that the picture of American nursing homes is entirely gloomy or that the regulatory efforts of the past decade have been entirely unsuccessful. Today, many institutions consistently deliver excellent care. Good care can be observed in all parts of the country; it exists under widely varying reimbursement systems and all types of ownership. Such facilities serve both as evidence that overall performance can be improved and as markers for how that improvement can be accomplished. The question asked by the committee was: How can the problems observed in nursing homes in the l980s best be addressed? The current national tone is antiregulatory. Nursing homes are a service industry. Could not the observed problems be solved by decreasing regulation and allowing market forces to work? This viewpoint was advocated by some who spoke at public meetings or submitted ideas to the committee. Those who wished to see a freer market were particularly anxious to have restrictions on bed supply lifted. A freer market was not considered by the committee to be a serious alternative to more effective government regulation for two reasons.

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INTRODUCTION AND SUMMARY / 5 First, under present circumstances, a free market for nursing home care will remain a theoretical concept until such time, if ever, that a major portion of the financing of long-term care services has shifted from public sources (primarily Medicaid) to private insurance. This is not likely to occur very soon. About half of current nursing home revenues come from appropriated state and federal funds through state-controlled Medicaid programs. Most people enter nursing homes as private-pay residents and soon "spend down" their income and assets until they become eligible for Medicaid. With few exceptions, community-based or home-based long-term care services--that might keep some people who require long-term care from entering nursing homes--are not eligible for Medicaid or other sources of public support. Most states maintain tight control on bed supply to control growth of their Medicaid budgets. They have learned that if they allow uncontrolled growth of nursing home beds, the additional beds would quickly be filled with residents now being cared for privately and informally in the community. Such residents would initially be private-pay, but would soon "spend down" to Medicaid eligibility. Second, historical experience hardly supports an optimistic judgment about the effects on quality of care of allowing market forces, to exert the primary influence over nursing home behavior. Nursing homes were essentially unregulated in most states prior to the late 1960s. Their operations were governed almost entirely by market forces, and the quality of care was appalling. (See Appendix A.) Persons needing nursing home care generally suffer from a large array of physical, functional, and mental disabilities. A significant proportion of all residents are mentally impaired. The average resident's ability to chose rationally among providers and to switch from one provider to another is therefore very limited even if bed occupancy rates are low enough to make such choices feasible. But they are not. In most communities, bed availability is the controlling factor- because occupancy rates are very high. Moreover, some who reside in nursing homes lack close family to act as their advocates. Even

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6 / NURSING HOME CARE if they have family, the choice of a nursing home is usually made relatively hastily in response to a new illness or disability level; once in an institution, the opportunities for transfer to another nursing home are very limited.25 The difficulties inherent in choosing among nursing homes are further exacerbated by the financial status of manY residents. Because of the costs few individuals or families can afford a prolonger! nursing home stay. As a result, government programs, primarily Medicaid, assist in paying for more than 60 percent of all care. In most states, Medicaid rates are lower than those Laid bY private residents. . ~. 9~ As a result the nursing home market is in tact two markets--a preferential one for those who can pay their way and a second, more restricted one, for those whose stays are paid by Medicaid.27 Regulation is essential to protect these vulnerable consumers. Although regulation alone is not sufficient to achieve high-quality care, easing or relaxing regulation is inappropriate under current circumstances. The federal regulations now governing the certification of nursing homes under the Medicare and Medicaid programs have been in place, essentially unchanged, since the mid-1970s. Their central purpose is to assure that nursing home resiclents28 receive adequate care in a safe facility and that they are not deprived of their civil rights. The regulations have a number of conceptual and technical weaknesses that were recognized almost from the time the regulations were promulgated. And, the regulations are administered and enforced very unevenly by the states. Yet there is consensus that regulations have made a positive contribution, although reliable comparative data are not available to support this judgment. The committee found that the consumer advocates, providers, and state regulators with whom it discussed these matters believe that a larger proportion of the nursing homes today are safer and cleaner, and the quality of care, on the average, probably is better than was the case prior to 1974. But there is substantial room for improvement. Providers, consumer advocates, and government regulators all are dissatisfied with specific aspects of the

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INTRODUCTION AND SUMMARY / 7 regulations and the way they are administered.29 Consumer advocates (nursing home residents, their families, and representatives of organizations concerned with protecting the interests of nursing home residents) contend that the standards are inadequate and their enforcement is too lax because too many nursing homes that pass inspection still provide unacceptably poor or only marginally adequate care. Moreover, they contend that violations of residents' rights occur in many homes and that often such violations either are not detected or are ignored by the regulatory authorities. The providers (nursing home operators, administrators, and professional staff) are concerned with the excessive attention to detailed documentation, the emphasis on structural specificity with the inherent (and sometimes irrational and costly) inflexibility that such specificity implies, and with the ambiguity of some of the standards (for example, the use of such words as "adequate") that result in inconsistent, subjective interpretations by state and federal surveyors. Some government regulators at both state and federal levels believe there is merit in both sets of contentions. Since the present regulatory framework was set in place about 10 years ago, there have been developments that make possible a more effective regulatory system. There is deeper understanding of what is meant by high-quality care for nursing home residents and how to provide it, more knowledge of how to assess quality of care objectively, and better understanding of what it takes to operate a more effective quality assurance system. The nursing home industry itself has grown in managerial capability and professionalism. These developments make it possible now to redesign the regulatory system so that it will be much more likely to assure that all nursing homes provide care of acceptable quality.

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8 / NURSING HOME CARE PERSPECTIVE ON THE ISSUES The Role of Nursing Homes In most places in this country, when an elderly (or disabled younger*) person requires more assistance in the activities of daily living30 than can be provided by immediate family or friends, and especially if the individual is incontinent and/or mentally impaired, he or she may be placed in a nursing home. Also, when an elderly patient, after surgery or an acute medical episode in a hospital, requires rehabilitative/convalescent nursing care for several weeks or months, and neither a rehabilitation hospital bed nor home health services are available in the community, the patient may be discharged to a nursing home. Home health services, congregate housing, domiciliary care, day-care centers, and other professionally organized arrangements exist in some communities and provide long-term care services to elderly persons with disabilities comparable to those found among some residents in nursing homes. Although more of these types of long-term care arrangements are being developed, they still represent collectively only a small fraction of the total person-days of care provided by nursing homes.3t In 1985, in most communities in this country, long-term care services for the physically frail and mentally impaired elderly are available only through informal support provided by family or friends or in nursing homes. Nursing homes must provide care to a very heterogeneous resident population. Some require short-term, intense rehabilitation services. Many others are incontinent, mentally impaired, or so seriously disabled that they require extensive and continuous care for months or years. A small fraction are younger people who are severely disabled. A few are simply very old and very fin 1980, 13 percent of nursing home residents were under 65 years of age. This figure is projected to drop to 9 percent by the year 2000. (See Appendix D, Table Q.)

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INTRODUCTION AND SUMMARY / 9 frail but are mentally competent and alert and require only moderate assistance in the activities of daily living and opportunities to participate in activities to satisfy their psychosocial needs. It is not easy to provide high-quality care to meet such a broad spectrum of physical, medical, and psychosocial needs in one facility. Not all nursing homes admit all of these types of residents, but many do. If, in the future, alternate arrangements become available to provide proper care to some individuals requiring intensive short-term rehabilitation services (for example, stroke patients), and for those requiring on a long-term basis only moderate amounts of support services, nursing homes will not be expected to accommodate these kinds of residents. Nursing home beds are increasingly being filled with long-term, very disabled residents who cannot be cared for anywhere else. Pressures to admit a higher proportion of residents requiring "heavy care" (nursing home jargon referring to residents requiring at least 2-1/2 hours per day of personal and nursing care), many of whom are mentally impaired, has been experienced by nursing homes for some time. These pressures are certain to increase.32 There were about 15,000 nursing homes in operation in the United States in 1985, with a total of about 1.5 million beds, that are certified to receive patients/ residents under the Medicare and/or Medicaid programs.33 About 1,000 nursing homes and perhaps 6,000-7,000 "board and care" homes (sometimes referred to as "domiciliary care" facilities) without nursing services are licensed by the states but are not certified to accept Medicare or Medicaid payments.34 There are two types of nursing homes recognized in federal regulations: Skilled Nursing Facilities (SNFs) and Intermediate Care Facilities (ICFs). SNFs are required to be staffed and equipped to care for residents requiring skilled nursing care. ICFs are required to be staffed and equipped to care for residents requiring less nursing care and more personal service care. In practice, the states are not consistent in making distinctions between the two types of nursing homes: some states have almost no SNFs; others have almost no ICFs. Forty-three percent of all nursing homes are ICFs (Appendix D, Table

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10/NURSING HOME CARE C). The mix of characteristics and service needs of the residents found in SNFs in those states that have few ICFs do not appear to differ significantly from those found in ICFs in states that have few SNFs. About 70 percent of the certified nursing homes, with 80 percent of the beds, are operated on a for-profit basis. Of the rest, 22 percent of the facilities are operated by nonprofit organizations and the other 8 percent are government-owned and -operated.35 In almost every state, occupancy rates average well over 90 percent, an indication that the demand for nursing home beds is very high.36 Demographic trends--the rapidly growing numbers of persons over 75 years old, about 1 in 10 of whom are now in nursing homes--make it certain that the demand for nursing home beds will continue to grow. A recent report projected the population aged 75 and over in the year 2000 to be 17.3 million, a 46 percent increase over the 1985 population of that age group. For people 85 years of age or older, one in five of whom is currently in a nursing home, the numbers are projected to increase from 2.85 million in 1985 to 5.1 million in 2000, an 80 percent increase.37 In 1984, over $30 billion was spent on nursing home care.38 According to Department of Labor estimates, "nursing and personal employed over 1 million people in 1982.~9 Quality of Care and Quality of Life care" facilities Providing consistently high quality care in nursing homes to a varied group of frail, very old residents, many of whom have mental impairments as well as physical disabilities, requires that the functional, medical, social, and psychological needs of residents be individually determined and met by careful assessment and care planning--steps that require professional skill and judgment. This process must be repeated periodically and the care plans adjusted appropriately. Not all nursing homes have enough professional staff who are trained and motivated to carry out these tasks competently, consistently, and periodically. Care is expensive because it is staff-intensive. To hold down costs, most of the

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INTRODUCTION AND SUMMARY / 11 care is provided by nurse's aides who, in many nursing homes, are paid very little, receive relatively little training, are inadequately supervised, and are required to care for more residents than they can serve properly. Not surprisingly, the turnover rate of nurse's aides is usually very high--from 70 percent to over 100 percent per year--a factor that causes stress in resident-staff interactions. Quality of life is intimately related to the quality of resident-staff relationships. Kindness, courtesy, and opportunities to choose activities, food, and mealtimes are involved, as are factors such as privacy for intimate conversations with family or friends. This is difficult when most rooms are semiprivate--as is the case in most nursing homes. Making one's room as home-like as possible is important to many residents, but fire safety codes may limit the use of personal furniture or other belongings. And, it may not be possible to choose or change one's roommate. Difficult as these problems may be, they can be handled satisfactorily by competent management and staff. In most regions of the country, very good homes can be found--places that are well-managed, where competent, caring staff provide services in a conscientious, sensitive manner; where the dignity, privacy, and human needs of the residents are respected and provided for in thoughtful, even imaginative ways. There are both for-profit and not-for-profit homes in this group. The exact number of very good homes is unknown because no objective, reliable methods exist for making interfacility comparisons of quality. The committee has the impression, obtained primarily from the Health Care Financing Administration's data collected from state reports on nursing home deficiencies, and from discussions with knowledgeable state and federal regulatory agency personnel, that the poor-quality homes outnumber the very good homes.

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34 / NURSING HOME CARE Recommendation 4-4: Both standard and extended surveys should assess samples of residents stratified by standard case-mix categories. Case-mix definitions, and the procedures and sample sizes requires! to attain a prespecifiect level of precision, should be established by the HCFA. Recommendation 4-5: The standard survey should rely on "key ind icators" of quality of resid ent life and care that would be prescribed by the HCFA. These key indicators would measure poor resident outcomes and other resident and facility conditions that might be causes! by noncompliance with the federal conditions and standards and should be investigated further by the survey agency. Recon~n~endation 4-6: Facilities that perform poorly on key indicators of quality of resident care or life should be subjected to a full or partial extended survey, depending on the range of problem areas discovered. The purpose of the extended survey is to determine the extent to which the facility is responsible for the poor outcomes due to noncompliance with the federal cond itions and standards. Recommendation 4-7: Quality assessment in the survey process should rely heavily on interviews with, and observation of, residents and staff, and only secondarily on "paper compliance,"such as chart reviews, official policies and procedures manuals, and other indirect measures of actual care given and resident outcomes. 5. The survey process should be coordinated with the complaint-handling process, and the latter would be strengthened. Recon~n~encintion 4-8. The HCFA should require states to have a specific procedure and sufficient staff to properly investigate complaints. 6. The survey process should formally seek information directly from consumers (residents and their advocates).

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INTRODUCTION AND SUMMARY / 3 5 Recommendation 4-9: The HCFA should incorporate in its survey operations manual the following ad d itional procedures to be followed by surveyors in addition to interviews with those residents sampled for the survey protocols: At the beginning of the survey, surveyors should meet briefly with members of the facility's resident council or with a group of willing and capable residents to elicit general information about services and resident satisfaction as well as to identify any areas of particular concern. Resident representatives should participate in the part of the exit conference where deficiencies are cited and the plan of correction is discussed. At the close of the survey, the following notice should be posted in a location accessible to residents and visitors: The (state survey agency) completed its regular certification survey of {facility name) on Mated. Anyone wishing to provide add itional information may contact the (state survey agency ~ before (date (ad d ress ) (~hone ) i 7. Positive incentives for good performance should be ncorporated into the survey and certification process. Recon~n~endation 4-10: In addition to exempting good facilities front extended surveys, ways should be explored to commend su perior performance. 8. The HCFA should require the state agencies to implement a program to develop and support consistent and reliable surveys. Recommendation 4-11: The new survey protocols, including the forms, procedures, and guidelines used by surveyors, should be designed in accordance with the revised and

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36 / NURSING HOME CARE amended conditions and standards recommended in Chapter 3, and they should be revised as the conditions and stand ard s are changed in the f uture. Recomr''enc/tation 4-12: All survey protocols (instruments and procedures) should be tested so that they are capable of yielding reliable and consistent results when used by properly trained surveyors anywhere. Recommenclation 4-13. A sample of facilities shouicl be sub ject to an extend ed survey each year. In formation f rom this sample should be uses! to validate and improve the standard survey. Recommendation 4-14: The HCFA should require the state agencies to implement a program to develop and support consistent and reliable surveys. This program should be based on effective training and monitoring of surveyor performance to reduce inconsistency. 9. Several steps should be taken to strengthen the regulatory capacity of the states: Full federal funding should be provided for state survey and certification activities. State surveyor qualifications should be strengthened. Both federal and state surveyor training efforts should be increased. The results of research and evaluation studies should be analyzed and disseminated by the HCFA. Recommendation 4-15: Title XIX of the Social Security Act should be amendect to authorize 100 percent federal funding of costs of the nursing home survey and certification activities of the states. This authority should be extender! for 3 years, after which time a federal-state matching ratio should be reestablished. The HCFA should clevelop a standard! formula for distributing funds to the states uncler this authority so that each state is funded on an equal basis in proportion to its federal certification workload.

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INTRODUCTION AND SUMMARY / 37 Recommendation 4-16: The HCFA should revise its guidelines to make them more specific about the qualifications of surveyors and the composition and numbers of survey team staff necessary to conduct adequate resident-centered, outcome-orientec/t inspections of nursing homes. As a minimum, every survey team should include at least one nurse. For use on extencled surveys, the survey agency should have specialists on staff (or, in small states, as consultantsJ in the disciplinary areas covered! by the conditions and standards (for example, pharmacy, nutrition, social services, and activitiesJ. Recommenclation 4-17: Fed eral training e fforts and su pport of state-level training programs should be increasecl, especially during the period of transition to the new survey process, and cluring the implementation of the new resident assessment cond ition of participation. Recommendation 4-18: National data about survey operations and results, and from any experiments and demonstrations sponsored by the HCFA or the states, should be collected, analyzed, and disseminated by the federal government to facilitate continued improvement in survey methods. 10. Federal oversight capabilities vis-a-vis state survey operations should be strengthened and the HCFA should be given authority to withhold a portion of Medicaid matching funds from states that perform the survey and certification function inadequately. Recommendation 4-19: The HCFA should increase its capabilities to oversee state survey and certification of nursing homes and to enforce federal requirements on states as well as facilities by adding enough additional federal surveyors to each regional office to ensure that the random sample of nursing hones surveyed each year in each state is large enough to allow reasonable inferences about the adequacy of the state's survey anc/t certification activities;

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38 / NURSING HOME CARE scheduling "look-behind" surveys so that valid comparisons can be made of the findings of fecleral anc/t state surveys; and amending Title XIX of the Social Security Act to authorize the HCFA to withhold a portion of Meclicaid matching funds from states that perform inadequately in their survey and certification of nursing homes. 11. Inspection of care should be integrated with the certification survey. Recon~n~end ation 4-20: The ins pection-o f -care f unction should be carried out as part of the new resident-centered, outcome-orientec! survey process. But ind ivid ual resid ent reviews should be required for a sample of residents (private-pay as well as Meclicaid) rather than for all relic/tents (although individual states may elect to continue 100 percent reviews). 12. A realignment of federal and state certification role relationships vis-a-vis Medicare and state-owned facilities is necessary. Recommendation 4-21: The respective roles and responsibilities of the federal and state governments should be realigned as follows. The states should be responsible for certifying all Medicare and Medicaid facilities (except state institutionsJ according to federal requirements. The NCFA should monitor state performance more actively and be responsible for conducting surveys of, and certifying, state-owned institutions directly. Enforcing Compliance with Federal Standards The following improvements in enforcement are recommended: 1. The HCFA should revise its guidelines for the post-survey enforcement process.

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INTRODUCTION AND SUMMARY / 39 Recomn~enciation 5-1. The HCFA should revise its guidelines for the post-survey process. Revisions should includ e specifying that survey agency personnel not be used as consultants to providers with compliance problems; specifying how to evaluate plans of correction and what constitutes an acceptable plan of correction; specifying the circumstances under which onsite followup visits may be waived; s peel f ying circumstances und er which f ormal enforcement action should be initiated, and how actions should be taken; anc/t ~ requiring that states have formal enforcement procedures and mechanisms. 2. The Medicaid authority should be amended to authorize a set of intermediate sanctions for use by the states and the federal government. Recommendation 5-2: The Medicaic! authority should be amender! to authorize a specifies' set of intermediate sanctions for use by states and by the federal government in enforcing compliance with nursing home conditions of participation and standards. The HCFA should then develop and issue detailed regulations and guiclelines to be followed by the states and by the HCFA in using these sanctions. The sanctions should include ban on aa missions, civil fines, . . . receivership, emergency authority to close facilities and bans fer resid ents. 3. The Medicaid statute should be amended to authorize sanctions for use against chronic or repeat violators of certification regulations. Recommendation 5-3: The bIeclicaid statute should be amended to provide authority to impose sanctions on chronic or repeat violators of certification regulations.

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40 / NURSING HO3lE CARE The HCFA shouIc' clevelop detailed procedures to be followed by the states to deal with such facilities. Procedures should include, but not be limited to, the authority to impose more severe sanctions. a requirement to consider a provider's previous record before certifying or recertifying, and the responsibility to obtain satisfactory assurances prior to recertifying, that the deficiencies that led to a termination will not recur. 4. The Medicaid statute should be amended to strengthen the effectiveness of sanctions. Recommendation 5-4: The Meclicaici statute should be amended to make the appeals process on sanctions, particularly Recertification, less permissive. The [ICFA should issue regulations anc! guidelines to implement this new authority. 5. The HCFA should strengthen state enforcement capabilities. Recommendation 5-5: The HCFA should strengthen state en forcement ca pabilities by ~ requiring states to commit adequate resources to enforcement activities, including legal and other enforcement-related staff; ~ requiring survey anc/t certification survey agency staffs to incIncle enforcement-related specialists, such as lawyers, auditors, and investigators, to work as part of special survey teams for problem situations and to help support enforcement decision-n~aking; including more training in investigatory techniques, witness preparation, and the legal syster'' in the basic surveyor training course; and ~ providing federal training support for state survey agency and welfare agency attorneys in nursing home enforcement matters.

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! INTRODUCTION AND SUMMARY / 41 Other Factors Affecting Quality of Care and Quality of Life in Nursing Homes The following means to enhance the effectiveness of consumers and consumer advocates in quality assurance are recommended: 1. The HCFA should require states to make public all nursing home inspection and cost reports. Recommendation 6-1: The HCFA should require states to make public all nursing home inspection and cost reports. These documents shouic! be required to be reaclily accessible at nominal cost to consumers and consumer advocates, including state and local ombudsmen. 2. The ombudsman program should be strengthened by amending the Older Americans Act. Recommendation 6-2: The Older Americans Act should be amended to: establish the ombudsman program under a se parate title in the Act; increase funds for state programs by authorizing federal-state matching formula grants for state ombudsman programs. The formula should provide each state with a minimum annual budget in the range of $100,000 fl985 clollarsJ plus an additional amount based on the number of elderly residents in the state. The federal-state matching ratio should be two-thirds federal to one-third state funds. (Although the committee did not study in any depth the budget requirement, this minimum amount is intended to provide the ombudsman program with, for example, the capability to support, at a minimum, a full-time professional and secretary and sufficient travel and training funds to recruit, train, and certify volunteers as local ombudsmen.) establish a statutory National Advisory Council composed of state on~budsn~en, state and local aging agencies, provider and consumer representatives, state regulators, health care professionals (physicians, nurses,

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42 / NURSING HOME CARE administrators, social workers;, and members of the general public to advise on administration, training, program priorities, development, research, and evaluation; authorize state-certified substate and local ombudsmen, including trained, unpaid volunteers, access to nursing homes and, with the permission of the resident, to a resident's medical and social records; authorize public legal representation for ombudsman programs; exempt the ombudsman programs, including substate ombudsmen who are supported by funds from the state ombudsman program, from the antilobbying provisions of OMB Circular A-122. 3. The Secretary of HHS should direct the Administration on Aging (AoA) to take steps to provide effective national leadership for the Ombudsman Program. Recommendation 6-3: The Secretary of HHS should direct the Administration on Aging (AoAJ to take steps to provide effective national leadership for the Ombudsman Program. At a minimum the Commissioner of AoA should designate a senior f till-time professional and some sit Sporting sta ff to assume responsibility for administering the program. Priority should be given to establishing a national resource center for the program that would develop, in consultation with state programs, an information clearinghouse, training and other materials to assist states, and guidance to states on data collection and analysis. The center should advise on establishing program priorities, and sponsor research and evaluation studies. 4. The HCFA should require state long-term care regulatory agencies to develop written agreements with state ombudsman programs covering information-sharing, training, and case referral. Recommendation 6-4: The HCFA shouic! require state long-term-care regulatory agencies to develop written agreements with state ombudsman programs covering information-sharing, training, and case referral.

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INTRODUCTION AND SUMMARY / 43 Issues Requiring Further Study Information Systems HHS should undertake a study to design a system for acquiring and using resident assessment data. A study also should be initiated to determine what other data about nursing homes are needed for regulatory, policy development, and other public purposes. Recommendation 7-1: The Secretary of NHS should ord er a study to design a system for acquiring and using resident assessment data to meet the legitimate and continuing needs of state and federal government agencies. The Secretary also should orcler a study to determine the needs for other data about nursing homes that would facilitate regulation and policy clevelopment. This study should recommend specific ways to collect, analyze, and publish or otherwise retake such data publicly available. pried icaid Payment Policies Further study is needed to determine optimal Medicaid payment policies. Nursing Home Bed Su p ply The policy on controlling the supply of nursing home beds is related to the issue of developing a broader array of interrelated long-term-care services. This, in turn hinges on the development of more appropriate private and public financing arrangements and policies. The federal government should undertake a systematic study of these interrelated issues to facilitate development of appropriate policies in these areas. If the committee's major recommendations are carried out there may be some effect on the number of currently certified nursing homes that will continue to participate in the Medicaid program. It is likely that poorly managed marginal or substandard facilities will be forced either

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44 / NURSING HO3lE CARE to improve their performance or go out of business. Most of those that go out of business are likely to be sold to other owners that will install more competent management and staff and continue in operation. It is possible, however, that some facilities may elect to withdraw from participation in the Medicaid program. There is no way of determining beforehand to what extent, if any, this is likely to occur. Or, if it does occur to a significant extent, whether states will respond by easing their restrictions on expansion of bed supply only for certified homes, or by making licensure contingent on participation in the Medicaid program. Sta f f ing o f Nursing Homes Based on the availability of systematic resident assessment data, two kinds of staffing studies should be undertaken: (1) studies to develop a minimum staffing algorithm relating staffing to case mix, and (2) studies on staff qualifications. Single- Versus ~lultiple-Occu pancy Rooms The HCFA should commission a study of the costs and benefits of single-occupancy rooms compared to multiple-occupancy rooms in nursing homes. Recommendation 7-2: The HCFA should commission a stucly of the costs anc! benefits of single-occupancy rooms compared to multiple-occupancy rooms in nursing homes. The study should be designed to obtain data about the effects of single rooms on the quality of life of various types of nursing home residents. It should be completed within 2 years after it has been authorized. It should contain recommendations for the desired proportions of single- and multiple-occupancy rooms in nursing homes. It also shouic! recommend required proportions in future new construction anc! ma for reflood cling of existing build ings.