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Index A Access to residents and records, 31, 173-174. 180 Accreditation, 1, 185 Activities of daily living assistance in, 8, 9, 47, 48 distribution of dependencies in, 372 Administration proposed Condition of Participation on, 29-31, 81, 88-89 of regulations, 6 Administration on Aging, 42, 174, 185 Admissions authority to ban, 164 suspension of, 165- 166 Alzheimer's disease, 58, 92, 197 American Academy of Family Practice, 4 American National Standards Institute, Standard 55- 1981, 31 -32 American Nurses Association, Division of Gerontological Nursing, 187 Antidiscrimination legislation, 94. See also Medicaid, discrimination Automatic cancellation clause, 151, 157- 158 B Barthel Index, 57 Bed supply control of, 5, 17, 18 policy, 23, 43-44, 190, 199 Beds demand, 10, 23, 196- 197 Medicare and Medicaid, 9 notification of lapse of hold period, 28 occupancy rates, 199 per 1,000 population, 199, 361 per licensed nurse, 102, 362 totals during 1978-1983 by state, 360 Bedsores, see Decubitus ulcers Beverly Enterprises, 187 Board and care homes, 8 Board of Internal Medicine, 4 C Care conferences, notification, 30 Case mix referencing in survey protocols, 110, 115-118, 191 reimbursement systems, 66, 92 staffing according to, 102 stratification, 131 use for measuring outcomes, 63-64 Certificates of need, 189 Certif ication Distinct party 94 expenditures, 169 federal-state role relationships, 38, 104 of geriatric competence, 4 requirements, 32 state resources committed to, 315 temporary, 156 Certification regulations conceptual basis, 71 costs of revision, 247 dissatisfaction with, 70 distinction between SNFs and ICFs, 69 HCFA requirement to modify, 15 post-1974 efforts to revise, 245 proposed, 247 proposed changes in, 25-32, 206-207 407
408 / INDEX purpose of, 6 state views on, 325-327 Charge nurses, nursing home duties of, 101. See also Nurses Civil fines, 166 Cognitive function testing, 59, 116 Cognitive impairment, 84 Commission on Chronic Illness, 239 Complaint investigation, 34, 105, 108, 121, 124-125, 138 Comprehensive Assessment and Referral Evaluation Instrument, 59 Conditions of participation administration (proposed), 29-31, 81, 88-89 dental services, 280 dietetic services, 83, 275-276 disaster preparedness, 29, 290 federal, state, and local regulatory compliance, 254-255 governing body and management, 29, 3' 95, 255-269 improvements needed in, 22, 77-98 infection control, 289-290 laboratory and radiological services, 29, 279-280 medical direction, 29, 269-270 medical records, 29, 282-284 nurse's aide training, 29, 81 nursing services, 79-80, 83, 271-275 patient activities, 282-284 pharmaceutical services, 278-279 physical environment, 285-289 physical services, 270-271 proposed, 80-81 resident assessment, 25-26 residents' rights, 27-29, 81 skilled nursing facility, 26-27, 77-80 social services, 32, 83, 99, 281-282 specialized rehabilitation services, 276-278 transfer agreement, 29, 284-285 utilization review, 29, 290-297 vagueness-in, 79-80 Congregate care, 8 Consultants to nursing homes, 150 Consultation, guidelines needed on, 154 Consumer advocates concerns, 7 effectiveness of, 41 lack of, 5 role, 19-20, 173- 183 Consumer protection, 173, 178 Contractures, 84, 118, 119, 121 Correction plans content, 152 duration and number, 154 evaluation of, 150 federal criteria for, 152 guidelines needed on, 154 noncompliance with, 152 revision of, 154- 155 . state review procedures for, 152 verification, 321-322 Council of State Governments, 240 D Data collection improvements needed in, 22 instruments, 56 on surveys, 37 Day-care centers, 8 Decertification appeals of, 159- 160 grounds for, 149, 156- 157 invocation, 13, 104 need for, 154 of SNFs, 78 voluntary, 157 Decubitus ulcers, 62, 80, 84, 116-119, 121, 379 Dehydration, 84, 118, 119, 121, 380 Demographic trends, 10, 17, 196- 197 Department of Health, Education, and Welfare, lawsuit against, 16 Depression, 49 Deregulation of nursing homes, 4 Directors of nursing, nursing home duties of, 101-102 Domiciliary care, 8 Elderly, cause of functional impairments in, 52 Employment estimates for nursing and personal care facilities, 10 Enforcement attitudes and, 13, 147- 149 data availability, 170 federal funding of, 169- 170 formal, initiation of, 153 goal of, 148 inadequacies, 146- 147 laxity, 7 legal staff for, 322 policies, improvements needed in, 22, 147-149 of residents' rights, 85 state variations in, 40, 241, 321-325 written guidelines for, 323 Enforcement procedures detailed, 154 federal, 150- 161 state, 162- 169 Expenditures, nursing home care, 10 Extended care facilities (ECFs) federal standards for, 14 funding of, 241 problems, 241 See also Nursing homes Extended survey basis, 115, 123, 383 finding followed by sanctions, 154 triggering, 120- 123 See also Surveys
INDEX / 409 F Federal funding enforcement activities, 169- 170 OAA payments, 239 ombudsman programs, 41, 179 state survey and certification activities, 36 state survey agencies, 132- 135 Federal regulation of nursing homes, history of, 238-253 Financial information, nursing home care, 18-19 Free market, see Deregulation of nursing homes Functional competency/impairment assessment, 57-58 G Geriatric Mental Status Schedule, 59 Geriatrics, importance of, 3, 186 Gerontology, nurses' training in, 101 186-187 H Health Care Financing Administration expenditures for state survey activities, 133-135, 373 hearing and appeal procedures, 159 look-behind authority, 138- 139 monitoring staff and responsibilities, 137-140 requirement to modify federal certification regulations, 15 Health insurance coverage for nursing home care, 17 Hill-Burton fire and health standards, 13, 240 hospital construction program, 238 Hill-Burton Act, 239 Hillhaven Corporation, 65, 187 Home health services, 8 Hospitals providing ICE services, standards for, 314 Hyperthermia, 97 Hypothermia, 97 I Incentives, good nursing home performance, 35, 126-127, 188-189 Index of Activities of Daily Living, 48 Infections, 84, 118, 121, 379 Information reporting requirements, 17 Inspections food, 33 life safety code, 33 number of, 133 nursing home, 1, 104 state resources committed to, 315 Inspections of care current requirements, 105 integration with survey, 38, 211 regulations governing, 141 review frequency, 140 Intellectual impairment, 49 Intellectual impairment/behavioral problem assessment, 58-60 Intermediate care facilities (ICFs) accreditation, 1 certification regulations, 14, 69-74 cost of elimination of, 212 development of regulations for, 244 establishment, 242 failing to meet conditions, 149 Medicaid reimbursement rates for, 72, 367 number and percentage by state, 72, 357 regulatory requirements, 9 resident-days of care reimbursed, 368 See also Nursing homes Intermediate care facility standards administration, 297-305 current, 297-314 environmental and safety, 306-308 health services, 310-312 meal service, 308-309 medications, 309-310 physician services, 314 rehabilitative services, 312-313 safety, 305-306 social services, 313 Intermediate care services, standards for facilities providing, 314 J Joint Commission on Accreditation of Hospitals, 1, 185-186 K Katz Index of Activities of Daily Living, 57 Kenny Self-Care Evaluation, 57 Kerr-Mills Act, 239 Key indicators of resident care dietary, 381-382 environmental, 114, 382 examples of, 378-382 operational use of, 383-385 use in surveys, 34, 64, 113-116, 118-120 L Licensed practical nurses in nursing homes, 73, 101-103 Life expectancies, 370 Life safety code deficiencies, 245 inspections, 33 Linn's Rapid Disability Scale, . Long-term care demonstration projects, 200 financing, 199 types, 8 Long-Term Care Ombudsman Program, 20 Long-term-care services alternatives tot 197 available in 1985, 8
410/ INDEX community-based, 5 for disabled elderly, 8 home-based, 5 M Malnutrition, 84, 118, 121 Management Minutes System, 65 Medicaid advent of, 241-245 beds, number of, 9 discrimination, 29, 30, 81, 91-95. See also Antidiscrimination legislation eligibility, 5, 18, 75, 104, 190 expenditures for nursing home care, 194 fraud unit, 125 funds, allocation of, 245 legislation, amendments, 14 program, sanctions under, 165 surveillance program, 141 termination, 154- 157 utilization control program, 141 Medicaid budgets federal contributions to, 194 growth control, 5, 18, 23, 198, 367 increases, 74 Medicaid matching funds reduction of, 139 withholding from states, 37, 38 Medicaid payments facilities not receiving, 9, 78 to nursing homes, 5 policies, see Medicaid reimbursement, . . po 1cles suspension for new admissions, 13, 158-161 Medicaid Provider Agreement, 30 Medicaid reimbursement policies, 17, 18, 22-23, 43, 193- 196 rates, 6, 17, 57, 72, 76, 92-93, 198 Medicaid statutes amendment, 39-40 duty imposed on Secretary of HHS by, 16 Medical Assistance for the Aged, 239 Medical care indicators, 380 Medical records access, 28-29, 173- 174 Medicare advent of, 241-245 beds, number of, 9 budgets for certification, 133 certification, federal funding for, 133 eligibility, 75 participation in 1966- 1967, 148 payments, facilities not receiving, 9 Medicare and Medicaid acts, passage of, 240 Medications, as key indicators of resident care, 378-379 Mental depression, 116 Mental Status Questionnaire, 59 Mini-Mental State Examination, 59 Monitoring nursing home performance, 12, 32-38, 75, 104-145 outcomes, 64 state activities, 105 Montana resident classification scheme, 64 N National Center for Health Statistics surveys, 19, 192 National Citizens' Coalition for Nursing Home Reform study on care quality, 51-52 National Committee on Vital and Health Statistics, 192 National Health Corporation, 65, 187 National League for Nursing, 187 National Summary of State Nursing Home Ombudsmen Reports for the United States, 92 New York State Department of Health, case-mix reimbursement system, 65-66 Noncompliance extended survey for, 122 history of, 156 Notification of resident transfer or discharge, 28-29, 81, 95-96 Nurses number of licensed, 362 nursing home duties of, 73 ratio of RNs to LPNs in 1981, 362 shortage of, 74 training in gerontology, 101, 186-187 wages, 1 0 1 See also Charge nurses; Licensed practical nurses; Registered nurses Nurse's aides importance, 52 problems, 11, 101 training, 29, 30, 73, 81, 89-91, 366 turnover rate, 11, 73, 90, 101 wages, 101 Nursing care indicators, 380 hours per resident-day, state minimum, 365 labor assessment, 65 time requirements, 65, 200 Nursing home care alternatives to, 23, 199-200 conflicts of values and ethics in, 52-53 cost assessments, 65-66 expenditures, 10 goals, 48 high-quality, requirements for providing, 48-49 inadequacies in, 21 need for, 197 payment for, 17 Nursing home compliance determinations, 107 with federal standards, 14 Nursing home costs for resident assessment system, 212 reduction measures, 10, 194 Nursing home industry
INDEX / 411 growth, 7, 238 professionalism in, 185- 188 Nursing home regulation activities, survey of, 318 federal role, 12, 142- 145 goals, 2 history, 13 improving effectiveness, 191 resident-centered, outcome-oriented, 27 state role, 12, 142- 145 state/federal role restructuring, 142-145 strengthening government role, 21-22 Nursing home service needs assessments, 65-66 use and cost predictions, 57 Nursing homes access problems, 92, 195 accreditation, 1 administrators, professionalism of, 186 admission eligibility criteria, 72-73, 198 A-key deficiencies by state, 377 attributes of quality in, 45-50 authority to close, 167- 168 basis for certifying, 243 bed demand, 10, 196- 197 bed supply, 5, 197-200 certification, post-survey phase, 151 - 152 chains, quality assurance programs of, 187 characteristics, lack of information on, 18 choosing, 5, 6 chronic problems, 149 chronically out of compliance, 146 community involvement in, 19-20, 171, 184-185 consumer involvement in, 171 compliance determinations, 107 compliance with federal standards, 14 construction, 190, 239 deficiencies, correction of, 153 deregulation, 4 distinctions between ICFs and SNFs, 71-74 elimination of distinctions between types, 25 expenditures, 239 fire, 242 food, 51 food poisoning in, 242 for-profit percentage, 10, 194 goals of federal regulation, 67-68 government-owned and -operated percentage, 10 health professional school ties with, 186 history of federal regulation, 238-253 information systems, scope and design of, 190~193 inspection and cost reports, 41, 174 LPNs needed in, 363-364 management and staff motivation, 171, 185-189 Medicare and Medicaid, 143 motivation and attitudes of owners, managers, and staffs, 20 national totals by certification status, 355 nonprofit percentage, 10 number and percentage by bed size and state, 359 number of by certification status and state, 356 number operating in 1954, 236 number operating in 1985, 9 occupancy rates, 5, 190, 201-202 operations, information collection on, 193 ownership status by state, 358 ownership, definition of, 161 paper reviews of, 144- 145 performance monitoring, 32-38, 104- 145 personalization of rooms, 11 physical environment in, 31-32, 47-48, 97-98 physician roles in, 186 poor vs. good quality, 11 populations, 5, 8, 9 problems, 2, 242 recertification, 147, 149 regulated types, 9, 71 resurvey of, 34 revenues from Medicaid, 5 rooms, single vs. multiple occupancy, 44 social services, 31 staff turnover, 112, 173 staff-to-resident ratios, 54 staffing, 10, 32, 44, 49-50, 72-74, 80, 98-103, 173, 190, 200-201 standard for certification of, 147-148 standards, state variations in, 241 state differences in licensing criteria, . 72 state inspection of, 1 substandard, 148 survey agency consultation with, 150 temperatures, 97-98 time devoted to survey process, 80 transfer opportunities, 6 use of resident assessment data, 75 in violation of Medicaid standards, 243 withholding federal funds from, 242 See also Extended care facilities; Intermediate care facilities o Office of Long-Term Care, 246 Office of Nursing Home Affairs, 14, 244, 245 Old Age Assistance, 238, 239 Older Americans Act, 20, 41, 44, 97, 175-176, 180, 206 OMB Circular A-122, effect on ombudsman program, 42, 180- 181 Ombudsman programs
412/ INDEX AoA commitment to, 179 constraints, 180 funding of, 179 legal support for, 180 national extent of, 177- 178 national leadership for, 42, 179 responsibilities, 176- 177, 180 state survey agency relationships with, 108, 182-183 statutory authority for, 175- 176, 179 strengthening of, 41-42, 179 written agreements with, 42 Ombudsmen access to residents, 31, 96-97, 180 complaint handling by, 177 definition, 177 lobbying by, 180 role, 177, 178 Quality assurance components, 12, 60-61, 69-71 interpreting and using information for, 61 -68 programs, nursing home chains, 187 Quality of care effects of Medicaid reimbursement policies on, 23 factors affecting, 17-21, 41-42, 45-50, 60-61, 171-189 incentives to ensure, 188 indicators, see Key indicators of resident care instruments for assessing, 56-60 measurement of, 61-62, 64, 83 process for ensuring, 10 standards of reference, 62-63 Quality of life Omnibus Budget Reconciliation Act, 138, 158 condition of participation, 27, 79, 81-83 Organic brain syndrome, 59 effects of Medicaid reimbursement Outcomes case mix in measuring, 63 components, 5S-56, 74 measurement of care quality, 64, 74-75, 83-84, 118-120 negative, 84, 114, 121, 122 positive, 84, 114 Overmedication, 84, 116 p Paperwork reduction, 89 Patient Appraisal and Care Evaluation, 246 Patient Assessment Computerized system, 65 Patient Care and Services (PaCS), 130-132 Patient care management system, 16 Patient Care Profile, 65 Patient Classification for Long-Term Care, 56, 249 Patient classification system, information needs of, 56 Personal care indicators, 380 Philadelphia Geriatric Center Mental Status Questionnaire, 59 Physical environment in nursing homes, 31-32, 81, 97-98 Physical restraints, 84, 116, 118, 121 Populations 85 and older, 10 elderly, by state, 369 over age 75, 10 Private-pay rates, 94 Prognostic adjustment factor, 64 Provider agreement termination, 156- 157 concerns, 7 Psychotropic drugs, 54, 118 Q Quality assessment criteria outcome component, 55-56 process component, 54-55 structural component, 53-54 policies on, 23 factors affecting, 41-42, 51-53, 171-189, 382 process for ensuring, 10 R Receivership, 166- 168 Recertification, 147, 149, 155- 156 Recommendations amendment of Medicaid statutes, 39-40, 155, 168, 205 amendment of Social Security Act Title XIX, 36, 135 changes in federal certification criteria, 25-32, 74, 77, 80, 81, 85-89, 91, 95-98, 204 complaint handling, 34, 125 consolidated "Administrations condition, 29-31, 88-89, 204 cost implications of, 210-212 data collection and analyses, 37, 137 elimination of distinctions between SNFs and ICFs, 25, 74, 204 elimination of institutional reports, 30, 89, 204 enforcement, 38, 168, 170, 205-206 environmental standards, 31-32, 98-100 extended survey for sample of facilities, 36, 128 federal funding, 36, 135 federal oversight of survey operations, 37, 38, 139-140 federal-state certification role relationships, 38, 145 incentives, 35, 127 integration of inspection of care, 38, 142 Medicaid discrimination, 30, 95, 204 Medicare/Medicaid survey and certification requirements, 32, 111 notification, 30, 96, 204 nurse's aide training, 30, 91
INDEX/413 nursing home inspection and cost reports, 41, 174 nursing home staffing, 32, 100 ombudsmen, 31, 41 -42, 97, 181 - 183 quality assessment in survey process, 34, 124, 205 quality of life as a condition of participation, 27, 81, 204 resident assessment, 25-26, 77, 204 resident interviews, 35, 124 resident participation in facility decision-making, 31, 96, 204 resident-centered, outcome-oriented approach to regulation, 27, 85, 204 residents' rights as condition of participation, 27-29, 86-88, 204 resurvey, 34, 123, 155 rewriting of SNF conditions and standards, 26, 80, 204 room occupancy, 44, 202 social services, 31-32, 97-99, 204 strengthening state regulation, 36, 135 survey development, 35-36, 120, 205 survey instruments and protocols, 33, 115, 128 survey team staffing, 37, 136 survey timing, 32-33, 113 surveyor qualifications, 37, 136 surveyor training, 36, 37, 129, 137 withholding Medicaid matching funds fron states, 37, 38, 140 Registered nurses in nursing homes, 101- 103 minimum number in nursing homes, 73 Regulation, see Federal regulation of nursing homes, history of; Nursing home regulation Regulations, 6, 7 combining SNF and ICE requirements, 15 HCFA-proposed, 15 proposed, 16 state, steps to strengthen, 36 state, use of resident assessment data, 75 See also Certification regulations Regulatory changes opposition to, 2 proposed, 1, 2, 16 Regulatory costs of recommendations, 211-212 Regulatory policies affecting quality of care, 17-19 Regulatory quality assurance goals, 67-68 Regulatory standards, violations of, 15 Regulatory system components for quality assurance, 12 goals, 12 improvements needed in, 22-23 Rehabilitation exercises, 52 services, intensive short-term, 9 Rehabilitation Act, 1974 amendments to section 504, 93 Rehabilitative care indicators, 380 Resident assessment audit, 113-114, 191 data computerization, 77, 187, 191-192 data system, 25-26, 43, 48, 49, 61-67, 73-77, 84, 102, 119, 128, 132, 135, 191-193, 207-211 data uses, 75, 115, 119, 191 instrument development, 76, 79, 117 scores, 115-116 system, cost to nursing home, 212 Resident care management system, proposed, 15 needs, 46-47 planning, 49-51, 75 Resident mix in SNFs and ICFs, 10 optimization, 17 Resident participation in advisory and family councils, 29, 87 in care planning, 51 forms of, 31 in management decision-making, 19-20, 29, 31, 81, 96, 172-173 in social, religious, and political activities, 29, 51, 88 Resident-staff relationships, 11, 52, 173 Residents 75 and older, 10, 46, 73 85 or older, 10, 196-197 ability of to choose among nursing homes, 5 abuse, 3, 121, 173 accidents, notification of, 30 bed-bound, 80, 116, 117 characteristics, 46 charge assessment, 65 classification instruments, 57-58 clinically depressed, 121 dependencies of in activities of daily living, 372 differences in social circumstances, 46 disabilities, 5 discharge, 28 financial status, 6 functional status, 48-49 heavy care, 9, 73, 91 -93, 103, 196, 198, 199, 212 interviews with, 35, 121, 123- 124 lack of information on, 18 lack of privacy, 51 length of stay, 46-47 Medicaid/Medicare, 17 mental status, 49, 116-117, 118, 121, 381, 384 needs, insensitivity to, 107- 108 neglect of, 3, 121, 173 non-English speaking, 28 ombudsman access to, 31, 96-97 outcomes, factors influencing, 55 physical inactivity of, 84 physically dependent, 117, 119, 121
414/ INDEX physically independent, 118 population, heterogeneous, 8 private-pay, 5, 17 projected number in 1980-2040, 371 receiving public assistance, 239 relocation of from substandard facilities, 322 satisfaction assessment of, 60 social activities, 51 spending down by, 5, 19, 93-94 stratification, 116 transfer of, 28, 167 treatment plan, 48 under age 65, 8 weight loss in, 119, 120 Residents' rights language arrangements for non-English speakers, 28, 86 legal, 28, 86 medical and social records, 28, 87 notification of transfer, discharge, lapse of bed-hold periods, 28-29, 86 sanctions for violations of, 165 standard, elevation to a condition, 15, 27, 81, 85-88 violations of, 7 written facility policies, 28, 87 written statement of, 28 Resource Utilization Groups classification system, 57, 66 S Sanctions against chronic or repeat violators, 39-40 appeals of, 159 application of, 148 factors influencing use, 162, 323-324 favorably rated, 164, 325 federal, 13, 154, 156 imposition of, 151 initiation of, 154 intermediate, 39, 159, 162- 169 number applied in 1983, 162, 323-324 number available by state, 322 obstacles to successful use, 164 procedures for implementing, 165 repeat deficiencies, 155 residents' rights violations, 165 state, 162-168 state availability and use, 13, 315 state variation in, 321 statutory availability and use, 315 types, 155-161, 163, 165-168 use of prior survey findings in applying, 160 withholding certificates of need, 189 Senile dementia, 49, 58 Skilled nursing facilities (SNFs) accreditation of, 1 certification regulations, 14 conditions of participation, 26, 77-98, 254-297 Recertification of, 78 development of regulations for, 244 federal standards for, 14 implementation of regulations for, 242 Medicaid reimbursement rates for, 72 Medicaid reimbursement rates per resident-day, 367 number and percentage by state, 72, 357 number failing to meet conditions of participation, 149 providing ICE services, standards for, 314 regulatory requirements, 9, 69-74 resident-days of care reimbursed, 368 staffing, 72 use of ECF standards for, 242 Social isolation, 84, 85 Social Security Act amendment of Title XIX, 36, 135, 204-206 1950 amendments, 238 1956 amendments, 239 section 1864, 143- 144 standard-setting amendment, 240 Title XIX, 133 Social services, nursing home, 31, 81, 99-100 Social workers required for nursing facilities, 32 Standard survey basis of, 114-115, 123 deficiencies found in, 154 process, scope of, 33-34 protocol, 131 resident categories, 120 scope of, 118, 121 shorter, 110 validity of, 128 See also Surveys Standardized instruments for resident assessment, 64, 74 Standards ambiguity of, 7 improvements needed in, 22 inadequacies in, 7, 70 licensure, state variations in, 13, 72-73 state regulatory, 319-320 See also Intermediate Care Facility standards; Process standards State licensure and certification agencies, survey of, 315-350 State regulatory capability, increasing, 132-140 State survey agencies activities, expenditures for, 133-135, 373-374 budgets, state variations in, 318-319 consultation, 150 enforcement procedures and guidelines of, 153 funding and staffing variations, 109, 375 HCFA expenditures for, 133-135 performance evaluation, 138
INDEX/415 relationships with ombudsman programs, 108, 182-183 sanction authority, 322-323 staffing, 375 workloads, 319 Stroke patients, rehabilitation services for, 9 Survey agency personnel, state variations in, 318-319 sanction application by, 148 staffs, 40, 107, 109, 169, 211 statement of deficiencies, 151 Survey instruments design, 116- 117 reliability and validity of, 127-128 Survey operations dissemination of data on, 137 federal oversight of, 37, 104, 138, 149 Survey procedures consolidation of Medicare and Medicaid. 111 current, 148 development of, 209 state variation in, 320-321 Survey process complaint handling in, 34 continuing improvement of, 127- 129 criticism of, 129 enforcement problems in, 246 extended, scope of, 33-34 federal requirements for, 15-16 improvements needed in, 22, 70 insensitivity to resident needs, 107-108 problems with, 105- 109 purpose, 104 quality assessment in, 34 redesign of, 109- 129 simplification of, 88 state variations in, 108 time requirements for nursing homes, 80 Survey protocols basis, 109 case-mix referencing in, 110, 115- 118 V development, 35, 117 focus of, 122 HCFA, 130 resident-outcome oriented, 131 short, 114 testing of, 36, 128 Survey team composition, 37, 136 Surveyors attitudes, 150 authority, 321 concerns, 79 judgment, 71, 79-80, 108, 109, 120, 131-132 number of, 133, 139 qualifications, 36, 37, 136 responsibilities, 150 roles, 149 training, 36, 129, 136- 137, 152, 169, 170, 244, 320 Surveys after changes in ownership, 112 consumer involvement in, 125- 126 costs, 135 current requirements, 105 data sources, 123- 124 federal look-behind actions, 13 follow-up procedures. forms, 70, 130- 131 instruments, 33, 116, 123, 127- 128, 209-210 intensity of, 107 of nursing homes and residents, 19 of state licensure and certification agencies, 315-350 outcome-oriented, 119 policies, current, 148 predictability of, 106- 107, 110 purpose, 116 questionnaire, 327-350 requirements, 32 results, consistency of, 129 scoring procedures, 109, 122 timing and frequency of, 32-33, 106-107, 111 - 113 validation, 138 visits, 1980 total, 376 See also Extended survey; Standard 112, 149, 150-154 survey U U.S. Senate Special Committee on Aging, 14, 91, 240 Urinary incontinence, 84, 116, 379 Utilization review, 141 - 142 Violations authority to punish, 148 ma jor, 161 regulatory standards, 15 repeat, 160-161 residents' rights, 7 W Well-being objective, 53 subjective, 54, 59
