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OCR for page 203
8
Actions Required and Cost
Implications of the
Recommendations
The recommendations contained in Chapters 3, 4, 5, and 6
will require the following major implementing actions:
(1) amending the Social Security Act and the Older Ameri-
cans Act, (2) promulgating new survey anti certification
regulations and major revisions of existing regulations,
(3) designing and testing a standard procedure for
resident assessment to be done by nursing home staff and
then developing training materials and launching a major
program to train all RNs and LPNs (LVNs) in nursing homes
to conduct such assessments properly, and (4) designing
and testing new survey and certification instruments and
procedures and training state and federal regulatory
personnel to conduct the new standard and extended
surveys. The recommendations are likely to affect both
the costs of regulation and the costs of resident care.
Although insufficient information is available to make
quantitative estimates, the implications of the
recommendations for both types of costs are discussed in
general terms in the last section of this chapter.
203
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LEGISLATIVE ACTIONS REQUIRED
Amendments to the Social Security Act
The Social Security Act will have to be amended to
implement the following recommendations:
1. Recommendation 3-1. Consolidate the two levels
of care into one and have current SNF standards (with the
other changes recommended) apply to all nursing homes.
The two levels of care are now specified in Title XIX of
the Social Security Act. Since the two levels of care are
embedded in current state and federal policy, eliminating
the distinctions between ICFs and SNFs will require
changes in language in many sections of the law and also
will require numerous changes in both federal and state
regulations.
2. Recommendations 3-2 through 3-7. These recommen-
dations involve major revisions in the language and
structure of the existing regulations, including promul-
gating new conditions of participation covering quality of
life, quality of care, resident assessment, residents'
rights, and administration. The following current
conditions would be reclassified as standards under the
administration condition: governing body and management,
utilization review, transfer agreements, disaster prepared-
ness, medical direction, laboratory and radiological
services, and medical records. Ten of the current condi-
tions of participation have statutory authorization either
in Title XVIII or Title XIX of the Social Security Act.
These are
I. Compliance with Federal, State, and Local Laws
II. Governing Body
IV. Physician Services
V. Nursing Services
VII. Rehabilitation Services
VIII. Pharmaceutical Services
XIII. Medical Records
XIV. Transfer Agreements
XV. Physical Environment
XVIII. Utilization Review
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ACTIONS REQUIRED AND COSTS / 205
It will be necessary to modify the statutory language in
some cases to authorize the recommended revisions in the
language and structure of the conditions and standards of
participation.
3. Recommendation 4-7. The HCFA should increase
the federal share of funding of state survey and
certification activities from 75 percent to 100 percent.
Between 1965 and 1972, Title XIX authorized federal
funding of 75 percent of the states' costs of surveyor
salaries, travel, and training for survey and
certification of Medicaid facilities. This was increased
to 100 percent between 1972 and 1980. In 1980, Congress
reduced federal participation to 75 percent. Restoration
of 100 percent federal funding will require an amendment
to Title XIX.
4 Recommendation 4-11. This recommends that HHS
be given authority to withhold a portion of a state's
federal matching funds for Medicaid as a sanction to be
used against any state that does not carry out its survey
and certification responsibilities properly. Since this
is a politically sensitive matter, statutory authority
specifying the circumstances under which the sanction may
be used seems necessary because the current law is not
clear on this point.
5. Recor,~n~endation 4-14. The HCFA should use
federal surveyors to inspect and certify state-owned
institutions.
6. Recommendations 5-2 and 5-4. The HCFA should
require states to have a standard, federally prescribed
set of intermediate sanctions to be used in specified
circumstances to improve enforcement of the conditions and
standards. The HCFA also will need statutory authority to
authorize states to decertify facilities that have a
record of chronic or repeated violations of important
conditions and standards, rather than accept another plan
of correction.
7. Recommendation 5-3. The HCFA should have
intermediate sanctions comparable to those available to
the states. At present, the only federal intermediate
sanction authorized by law (in 1981) is a ban on
admissions, but, as of February 1986, the regulation for
implementing this authority had not yet been promulgated.
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8. Recommendation 5-5. The HCFA should develop
guidelines to make legal appeals of the Recertification
process less permissive. Although this may not require
statutory action, it probably would be more effective if
explicitly authorized by law.
Amendments to the Older Americans Act
The following recommendation will require amendments to
the Older Americans Act:
Recommendation 6-2. The ombudsman program should be
strengthened by the following statutory actions:
i
· authorizing the ombudsman program as a separate title
n the Older Americans Act;
· authorizing federal-state matching formula grants for
the ombudsman program;
· authorizing a statutory national advisory council;
· authorizing access to nursing homes and to residents'
records (with the residents' permission) by certified
substate and local ombudsmen;
· authorizing state legal assistance for ombudsmen; and
· exempting ombudsmen from lobbying restrictions in OMB
Circular A-122.
REVISION AND ADDITION OF SURVEY AND
CERTIFICATION REGULATIONS
With acceptance of most of the recommendations, the
process of revising the current regulations governing the
survey and certification process would have to be done in
three phases: (1) Drafting of the new conditions of
participation covering quality of life, quality of care,
resident assessment, and residents' rights, and revision
of some of the existing conditions and standards could be
started immediately, although they could not be formally
proposed for issuance until the statutory changes have
been enacted; (2) after the amendments to the Social
Security Act have been enacted, their detailed
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ACTIONS REQUIRED AND COSTS / 207
requirements will have to be reflected in the regulations,
and (3) detailed specifications of the standards governing
survey procedures and facility-administered resident
assessment procedures will have to be deferred until
completion of the design and testing of the instruments
and procedures and training of thousands of state
regulatory and nursing home personnel. This development
phase may require 2 or 3 years to complete.
Preliminary work on developing and testing the two new
survey instruments and procedures--the standard survey and
the extended survey--could begin promptly. Design of
these instruments has to be based on the revised
conditions of participation and standards. Policy
decisions on the latter must be made before the scope of
the instruments can be finally set. The survey procedures
depend on access to standard resident assessment data, so
that high priority should be given to developing the
resident assessment data set, the procedures for
collecting it, recording the data, prescribing standard
case-mix definitions for survey purposes, specifying
sampling procedures, and developing training programs and
materials for nursing home staff who will be required to
conduct resident assessments.
DESIGN AND TESTING ACTIVITIES
Resident Assessment Data
Design, testing, and installation of a standard
facility-administered resident assessment system is a
large and complex undertaking. It involves several tasks,
each of which requires considerable technical knowledge
and skill. The main tasks are-
1. Standard assessment elements must be selected for
recording in a prescribed way. A standard approach to
resident assessment will be necessary to get comparable
information on all residents in nursing homes.
Fortunately, so much research has been done on resident
assessment that this task can be accomplished quickly.
The data probably will be a hybrid of several of the
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instruments that already have been designed and tested and
that have been shown to be effective and reliable. It is
very important that the required standard data be viewed
by facility professional staff as a subset of that
considered to be essential for sound resident-care
planning and facility management. (The amount of data on
each resident needed by the facility for developing an
individual's plan of care usually will be much more
extensive than that needed for regulatory purposes.)
2. Standard assessment procedures must be designed for
use by nursing home staff in assessing residents, scoring,
and recording the data. Guidelines, an instruction
manual, and problem resolution techniques will have to be
developed and tested.
3. Methods must be developed to ensure the reliability
of the data collectors. A training program and training
materials for RNs and LPNs (LVNs) will have to be
prescribed. Auditing procedures (including sampling
procedures) will have to be developed and pass/fail
criteria specified that are based on the results of
interrater reliability tests. (The standards may vary for
various aspects of the data--higher consistency of scoring
might be required for functional status assessments than
for mental or behavioral status.) Instruction manuals
will then have to be developed and the surveyors in every
state will have to be trained to audit the accuracy of
facility resident assessments as part of the new survey
process.
4. Policy decisions must be made on how frequently
assessments are to be conducted on each resident. For
example, the first assessment should be done on admission,
then reassessments might be required once a month for the
next 2 months, and once every 3 months thereafter. The
frequency of regular assessments is a major issue and the
decision should be based, ideally, on empirical evidence.
5. Case-mix groupings must be defined on the basis of
resident assessment scores. The groupings will be needed
for survey sampling purposes. The initial groupings are
likely to be based on limited data and will need to be
revised as empirical evidence from longitudinal assessment
data become available and analysis reveals that alternate
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ACTIONS REQUIRED AND COSTS / 209
case-mix groupings would be more appropriate for sampling
purposes.
6. Sampling algorithms must be developed for auditing
the accuracy of the facility's resident assessment data
and for conducting the standard survey. Statistically
sound sampling is essential to establish both public and
provider confidence in the validity of a somewhat
abbreviated standard survey process.
Once this manual system for resident assessment data has
been introduced and implemented in nursing homes, the
steps needed to gain ready access to the data for regula-
tory purposes should be studied. Many nursing homes are
likely to enter the data into their own computers to take
full advantage of it for their own management purposes.
But many others--probably most--are unlikely to do so at
first. A study of the important regulatory and other
government uses for the data, and ways to obtain access to
it, will be needed. The study will have to examine and
propose methods for dealing with numerous technical and
policy questions inherent in handling large data sets
about individuals. The product should be a proposed plan
that would permit access to and analysis of the data on a
regular basis to improve the precision and objectivity of
the new regulatory system.
Survey Instruments and Procedures
The development of a short, resident-centered, outcome-
oriented standard survey procedure and a complementary
extended survey procedure must reflect the requirements of
the new and revised conditions of participation and
standards if the findings are to be enforceable. Although
development of the survey instruments, the scoring
criteria and pass/fail standards, and the procedures for
conducting the surveys can be tested on the assumption
that the revised conditions and standards will in fact be
promulgated, they cannot be introduced until the proposed
new and revised conditions and standards become official.
Moreover, the new standard survey is tied to the
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availability of data from the assessment system--a system
that will have to be developed and tested. The time
required to complete each of the three sets of activi-
ties--(l) enactment of amendments to the Social Security
Act and promulgation of new and revised conditions, (2)
development and introduction of the resident assessment
system, and (3) development and introduction of the new
survey and certification procedures--is likely to be 2 to
3 years. It therefore would be desirable to proceed
simultaneously with all three activities, making
scheduling and substantive adjustments necessary to fit
the policy decisions as they are made. If all goes well,
the entire system could be in place and functioning in 3
years.
COST IMPLICATIONS OF THE RECOMMENDATIONS
The effects of the recommendations on the costs of
regulation and on the costs of providing care to residents
are not easily calculated for two reasons: (1) The
quantitative and qualitative changes in behavior of the
various actors in the system, and the effects on
efficiency of the regulatory agencies and nursing homes,
cannot be predicted on the basis of current data; (2)
current data about staffing and costs in nursing homes and
in state regulatory agencies are not available in
sufficient detail; and (3) some immediate costs are likely
to produce long-term savings that cannot be estimated.
Given these uncertainties, any estimates made--even with
the assistance of a very elaborate cost model--would have
to present a wide range of costs to account for
interactions of varying assumptions. For this reason, the
committee chose not to divert any of its limited time and
resources to this purpose. It concentrated on developing
recommendations that will improve the regulatory system's
ability to ensure better quality of care and quality of
life for nursing home residents.
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ACTIONS REQUIRED AND COSTS / 211
Regulatory Costs
The combined effects on state regulatory agency staffing
requirements of (1) the integration of inspection of care
with the survey process, (2) the resident assessment
system, (3) the use of the standard and extended survey
system, and (4) increased enforcement capabilities is by
no means clear.
Most states now use, and are funded for, separate staff
to conduct inspections of care (IOC). In those states,
integrating the functions of surveying nursing homes with
IOC would eliminate the requirements for separate staff
and the additional travel, training, and overhead costs.
However, the new system will require well-qualified and
well-trained survey staff and this may, in some states,
require larger survey agency budgets. How much larger
will depend on the performance of the nursing homes. If
the introduction of the resident assessment system and the
standard survey improve performance of the poor and
marginal facilities so that fewer extended surveys are
necessary, there may be no significant requirement for
additional staff. On the other hand, if many extended
surveys should be necessary. this could lead to reauire-
ments for staff increases.
A,
The experience is likely to
vary widely among the states. Similar uncertainties
pertain to the costs of strengthening enforcement
capabilities.
There will be costs for developing, testing, and
conducting the training necessary to install the resident
assessment system and the new survey instruments and
procedures. These costs will have to be borne largely by
the HCFA, both in its own operating budget and in larger
federal grants to the states to carry out state survey and
certification responsibilities.
The federal regional offices will need more staff to
strengthen their look-behind capabilities and to conduct
surveys of state-owned facilities. On the other hand,
they will be relieved of the responsibility for certifying
Medicare facilities, so some of the staff devoted to those
time-consuming activities could be shifted to the
increased oversight activities.
,
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The cost effects of strengthening the ombudsman program
are not entirely clear. The federal and state contribu-
tions to the ombudsman program are now too small; they
will have to be increased if the program is to become more
effective. But the effects of an improved ombudsman
program on state survey agency costs are not clear. One
possibility is that it could increase the number of
complaints that have to be investigated by the survey
agency. But another is that it could have the opposite
effect: The volume of complaints could go down as
ombudsmen work more effectively in resolving problems
within nursing homes. Probably both types of effects will
occur, but it is clearly impossible to make any quanti-
tative forecasts of the net effect on costs.
Program Costs
The recommendation to eliminate ICFs will increase the
costs of care in some states more than in others, but it
is not clear by how much. In many states that have mainly
ICE facilities, the actual average staffing is already
well above the minimum federal requirements because the
homes have had to accommodate a growing proportion of
heavy-care residents. Nevertheless, requiring compliance
with SNF standards almost certainly will increase costs in
some nursing homes in some states. This may lead to
increases in Medicaid budgets in some states.
The costs to the nursing homes of the resident
assessment system are not likely to be significant. All
nursing homes should be doing resident assessments as a
basis for care planning anyway. The good nursing homes
have been conducting very comprehensive assessments of
their residents as part of their normal resident care
activities. The federal requirement to do so in a stan-
dard way should not add significantly to resident care
costs.
In sum, the regulatory changes recommended in this
report will increase both regulatory and program costs in
the short term, but the benefits to society and to the
nursing home residents will be well worth the additional
costs.
Representative terms from entire chapter:
nursing homes
