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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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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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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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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.
Representative terms from entire chapter:
nursing homes
