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OCR for page 69
Regulatory Criteria
THE ISSUES
Government regulation of nursing homes for quality
assurance purposes has three components: (1) the criteria
used to determine whether a nursing home is providing care
of acceptable quality in a safe and clean environment, (2)
the procedures used to determine the extent to which
nursing homes comply with the criteria, and (3) the
procedures used to enforce compliance. The three
components are like the legs of a three-legged stool: All
are equally important. This chapter deals only with
quality criteria. Chapters 4 and 5 discuss the other
components.
Two sets of federal certification criteria for nursing
homes currently exist: one for skilled nursing facilities
(SNFs) and one for intermediate care facilities (ICFs).
SNFs and ICFs are defined as being capable of providing
different "levels" of care. SNFs are required to be
staffed and equipped to provide more skilled nursing and
rehabilitation services than are ICFs. The SNF criteria
consist of 18 "conditions of participation" each of which
contains one or more standards that must be met to comply
with the condition. There are 90 SNF standards contained
in the 18 conditions. The regulations containing these
69
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70 / NURSING HOME CARE
criteria were issued in final form in 1974 and have
remained in effect, essentially unchanged, since then.
The ICF criteria cio not have conditions of participation.
Originally issued in 1974, they contained 15 standards
comprising numerous elements. Later that year, the ICF
standards--with three additional standards added, bringing
the total to 18--were incorporated in a survey form. In
1978 the HCFA published a new set of ICF regulations
containing 46 standards. The 1978 version was intended to
be substantively the same as the 1974 standards, but
better organized and worded more clearly. Most of the new
standards were not new; they were elements in the 1974
version. However, the HCFA did not publish a new survey
form based on the 1978 regulations. Surveyors continue to
use the 1974 form that contains the 1974 version of the
regulations. (Both the SNF and ICF criteria are contained
in Appendix B.)
Dissatisfaction with both sets of criteria was expressed
publicly and repeatedly almost from the time they were
issued. In general, providers, consumer advocates, and
many state and federal regulators agreed that
1. the regulations do not require assessment of the
quality of care being delivered; rather, they require
assessment of the facility's structural capacity to
.
provlc e care;
2. the survey process emphasizes paper compliance
rather than observation and interviews with nursing home
residents;
3. many of the standards are vague and depend too much
on unguided judgments by surveyors, many of whom are
untrained. Surveyor judgments are frequently
inconsistent: what is deemed acceptable by one surveyor
may be unacceptable to another.
These views were publicly voiced on numerous occasions by
many people--most recently at the public meetings held by
the committee in September 1984.
The committee is convinced that it is not sound policy
to maintain two levels of care subject to two sets of
quality assurance criteria. This is the first of the
issues discussed below.
OCR for page 71
REGULATORY CRITERIA / 7 1
The second issue is the conceptual basis of the
criteria. They rest on the implicit assumption that the
presence of the potential capability and written intent on
the part of the facility to provide appropriate care is
sufficient to ensure--for regulatory purposes--that care
of adequate quality is being provided. A major
reorientation of the conditions and standards is necessary
so that they require, whenever possible, assessment of the
quality and appropriateness of care and the quality of
life--a consideration not covered in current
standards--being provided to residents, and the effects on
residents' well-being.
A third issue is the excessive reliance the current
standards place on unguided professional judgments by
surveyors in three areas: (1) what constitutes good care
for residents with differing service needs, (2) how to
interpret survey findings, and (3) how to weight or score
facility performance on individual standards, and how to
aggregate performance on individual standards to determine
whether a facility is in compliance with a condition of
participation. Elimination of professional judgment--and
the inconsistencies that are inescapably associated with
it--will never be possible, but some steps to introduce
more objectivity and reliability into the regulatory
system are possible.
CONSOLIDATING THE TWO SETS OF CRITERIA
The two classes of nursing homes--SNFs and ICFs--are
supposed to serve residents with different "levels" of
nursing and rehabilitative care needs. The regulations
differentiate between the two groups in their capacity to
provide services (for example, in the professional staff
required) and in the eligibility criteria (services needed
by the residents) set by the states. Despite these
regulatory distinctions, the actual distinctions between
SNFs and ICFs--in the variety of services provided, and in
the mix of residents they admit with different
distributions of disability and nursing care needs--is
blurred. Both types of facilities are nursing homes
providing a range of services to residents with widely
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72 / NURSING HOME CARE
varying service needs. (The history of the development of
federal regulation of nursing homes, including the
establishment of the two classes of nursing homes, is
contained in Appendix A.)
SNFs are considered more medically oriented, as implied,
for example, by the use of the term"patients" throughout
the SNF regulations. The ICF regulations refer to
"residents." SNFs are required to provide more nurse
staffing--SNFs must have a nurse on duty 24 hours a day,
whereas ICFs must have a nurse on duty only during each
day-shift. In addition, SNF standards for other staff and
for services provided are also more detailed and stricter
than ICF requirements. The minimal requirements for each
type of facility describe a broad range of facilities and
range of intensity of service in both levels of care that
overlap. Most nursing homes provide both nursing care and
assistance with activities of daily living. Furthermore,
the definitions of each, and especially of the ICF, leave
a large amount of discretion to the states as to which
facilities they will call SNFs and which ICFs, and which
residents they will consider eligible for SNF or ICF
care. The number of SNFs in a jurisdiction ranges from as
few as 3 in the District of Columbia to as many as 1,148
in California, and the proportion of facilities that are
classified SNF from 2 percent in Oklahoma to 100 percent
in Arizona. The number of ICFs ranges from none in
Arizona to 770 in Texas, and accounts for 98 percent of
Oklahoma's facilities." The Medicaid reimbursement
rates for SNFs must, by law, be higher than for ICFs. If
the rate difference is large, there is an incentive for
states to control costs by licensing more ICF beds than
SNF beds, irrespective of the distribution of residents'
needs.
States have different licensing criteria for nursing
homes. They are allowed, under the Medicaid law, to set
their own eligibility criteria for admission of residents
to SNFs and ICFs. States can have more stringent
requirements for licensure and eligibility for admission
than the federal regulations require. Examples of
different licensing requirements can be found in
Connecticut and Iowa. The homes in each state serve
residents with a wide range of service needs. In
.
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REGULA TOR Y CRI TERIA / 7 3
Connecticut, about 90 percent of nursing homes are
certified as SNFs. In Iowa, nearly all of the nursing
homes are certified as ICFs. It is highly improbable that
the reason there are mostly SNFs in Connecticut and mostly
ICFs in Iowa is that the residents' requirements for
services differ that much--that is, that they require, on
the average, more skilled nursing care in Connecticut than
they do in Iowa. The differences are more likely to be
due to other factors such as the availability of chronic
hospitals, state judgments on appropriate nurse staffing
for nursing homes, and state attitudes about Medicaid
funding.
It is hardly appropriate to apply different quality
assurance criteria to SNFs and ICFs that are, or should
be, providing similar services to similar residents. This
will become even more important as the rapid population
growth of those over age 75 increases the number of
seriously disabled residents requiring "heavy care." The
main difference between the SNF and ICE standards is the
requirement for minimum numbers of licensed practical
nurses and RNs. To raise the ICF nursing standards to the
SNF level will require an increase in nurses in many
homes. Since most of the care in nursing homes is
provided by nurse's aides who have had relatively little
training, and who tend, on the average, not to remain in
the same job very long, it is essential that all nursing
homes employ a sufficient number of licensed practical and
registered nurses to properly supervise the aides at all
times. In addition, professional nurses are needed to
supervise resident assessments and to monitor delivery of
resident health care and treatment.
In sum, the administrative distinctions between SNFs and
ICFs do not in practice display clear differences in the
residents they serve. Both kinds of facilities are
nursing homes that admit and care for residents with wide
ranges of disabilities and service needs. They therefore
should be subject to the same quality assurance criteria
and procedures. Since most of the care in nursing homes
is provided by unlicensed nurse's aides who require
careful supervision by licensed nurses, the SNF minimum
staffing standards should be applied to all nursing homes.
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74 / NURSING HO3lE CARE
Recommendation 3-1: The regulatory distinction between
SNFs and ICFs should be abolished. A single set of
conditions of participation and standards shouic' be used
to certify all nursing homes. The current SNF conditions
and standards, with the mollifications and ad`litions
recommended below, should become the bases for new
certifying criteria.
This is a recommendation that requires a change in the
law. It may lead to increases in Medicaid budgets in
several states because it will require increased RN and
LPN staffing in many nursing homes in those states. (This
is discussed more fully in the last section of this
chapter.) Some time will be needed to implement this
change in states with many ICFs. But whatever the
transition problems, applying one set of regulatory
standards to all nursing homes is essential if the goal is
to achieve overall improvement in the quality of care
being provided to nursing home residents. The nursing
home industry has matured in the past 15 years. The
shortage of nurses--advanced as one of the important
reasons for creating ICFs--that may have existed some
years ago has eased, in part as a result of sharp drops in
hospital bed occupancy rates, and the consequent
reductions in hospital employment. Moreover, a better
understanding of what is required to provide high-quality
care in nursing homes exists today than existed 15 years
ago.
RESIDENT ASSESSMENT
Providing high-quality care requires careful assessment
of each resident's functional, medical, mental, and
psychosocial status upon admission, and reassessment
periodically thereafter, with the changes in status
noted. Current regulations do not require a standardized
assessment of any kind, although the development of
individual plans of care clearly depend on resident
assessments. The outcomes of care are defined by changes
in functional, medical, mental, and psychosocial status.
As discussed in Chapter 2, much research over many years
OCR for page 75
REGULATORY CRITERIA / 75
has developed successful techniques and instruments that
can produce valid, reliable assessment data that can be
used for these purposes. Moreover, it has been
demonstrated that these instruments can be used reliably
by LPNs who have been trained to use them, as well as RNs.
The resident assessment data have several very important
uses both for facility management and for government
regulatory agencies. For the facility, standard resident
assessment data, obtained on admission and periodically
thereafter, are an essential tool for quality-of-care
purposes and for other management uses. A careful
assessment of every resident is needed to formulate a care
plan for that resident. Typically, the resident care plan
contains information on physical and mental function,
health risk factors, diagnoses, prognoses, short- and
long-term goals, as well as key social history items.
Periodic reassessment--for example, every month for the
first 2 months after admission, and quarterly
thereafter--is essential for two reasons: (1) to check on
the resident's status changes, and (2) to see what, if
any, modifications in the care plan should be made. The
data can be used by management for two other purposes:
(1) to provide very precise information on case mix in the
nursing home, how it is changing, and how appropriately
residents, staff, and other resources are--or should
be--distributed in the home; and (2) to conduct
longitudinal studies on quality of care, controlled for
case mix. For example, problems in particular bed
sections--possibly attributable to inadequate nursing
care--could be identified promptly and steps taken to
remedy them. One nursing home chain has been using
similar data for over 10 years for monitoring the case
mix, staffing, and the quality-of-care performance in its
50 nursing homes from its central office.4
Standard, longitudinal assessment data are also
essential for four state regulatory functions: (1) for
obtaining case-mix information in each nursing home for
use in sampling for survey purposes (see Chapter 4), (2)
for obtaining outcome information by examining
longitudinal assessment data in resident records, (3) for
utilization review to assure that residents meet the
eligibility requirements of Medicaid or Medicare, and (4)
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for case-mix information needed for Medicaid payment
(reimbursement) calculations (in states where case mix is
used as a factor in Medicaid payment policy).
The standards for this condition should specify the
items to be used in making the assessment, the
qualifications of the staff authorized to do the assessing
(for example, licensed nurses), the training they should
receive before being authorized to do the assessments, how
often assessments of each resident are required--for
example, on admission, once a month for the first 2
months, once every 3 months thereafter, and at discharge.
The standards should specify that these assessment records
should be retained in the resident's medical record.
Auditing by the state regulatory agency also should be
covered in a standard, and acceptable error rates
specified Once the system has been in operation for some
time, unacceptably high error rates by facilities should
be viewed as indicators of inferior performance and
subject to sanctions by the survey agency.
Introducing and phasing in this new set of requirements
will take time. Several major steps are necessary. The
assessment items will have to be selected. The assessment
data should include (but not be limited to) medical
problem identification (diagnoses), measures of physical
function such as activities of daily living and mobility,
and measures of mental and psychosocial functioning such
as appropriate behavior, cognitive ability and
depression. An operations manual will have to be written
for the ultimate users--licensed nurses. Training
programs and training materials will have to be
developed. A major training effort will have to be
initiated by the HCFA and continued by the states,
possibly with the help of the state provider
associations. All state nurse surveyors will need to be
trained in collecting this standard data in a consistent
manner since they will be responsible for auditing the
facilities. Federal regional office surveyors also will
have to be trained in addition to the thousands of
facility staff. Auditing procedures and standards for the
kinds and amounts of acceptable discrepancies between
auditor's findings and facility data should be based on
the findings of careful empirical studies.
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REGULATORY CRITERIA / 77
The requirement for nursing homes to do standard
assessments of all residents should not be immediately
coupled to a requirement that the data be entered into a
computer file. Eventually, computer access will be
essential to be able to use the data for some of the
important purposes noted above. But it will take at least
2-3 years to get the manual system installed and used with
acceptable accuracy by most nursing homes.
During the period that this system is being developed
and installed, there will be an opportunity to undertake
simultaneously a careful study of the policy and technical
problems involved in computerizing resident assessment
data, and to agree on the use of such data by state and
federal governments. The product of such a study should
be a specific plan for doing so. This is discussed in
Chapter 7.
Recommendation 3-2: A new condition of participation on
resident assessment should be added[. It should require
that in every certified facility a registered nurse who
has received" appropriate training for the purpose shall be
responsible for seeing that accurate assessments of each
resident are clone upon admission, periodically, anc!
whenever there is a change in resident status. The
results should be recorded and retained in a standard
format in the resident's medical record.
REVISING AND STRENGTHENING
THE CONDITIONS AND STANDARDS
The conditions of participation were introduced by the
Medicare law in 1965. SNFs must comply with them to be
eligible for certification under Medicaid or Medicare.
There are 18 SNF conditions governing the following
areas: state licensing, governing body, medical
direction, physician care, nursing, dietary, specialized
rehabilitation, pharmacy, lab and x-ray, dental, social
services, patient activities, medical records, transfer
agreement, physical environment, infection control,
disaster preparedness, and utilization review. If a
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78/NURSING HOME CARE
skilled nursing facility is found to be out of compliance
with one or more conditions, it is subject to
Recertification. This means the SNF is not eligible to
receive payment for care provided to Medicaid- or
Medicare-eligible residents.
The current SNF conditions and standards--which would,
under our recommendation, become applicable to all nursing
homes--need to be rewritten in accordance with the
following principles:
1. Whenever appropriate, the criteria should address
residents' needs and the effects of care on residents, and
the performance of a facility in providing care rather
than its capability to perform.
2. The criteria should be based on the best
professional standards for providing high quality of care
and quality of life to nursing home residents.
3. The criteria should be drafted clearly and with as
much specificity as possible so that they can be
understood by facilities, applied consistently by trained
surveyors, and be legally enforceable.
4. The criteria should be internally consistent.
logical, and comprehensive.
5. They should include physical, mental, and social
functioning; nursing care; nutritional status; social
services; physician care; psychological care; pharmacy;
dental care; environment; residents' rights; emotional
well-being; personal choice; satisfaction; and community
interaction.
6. The criteria should be sensitive to each facility's
case mix, that is, to the variations in the services
required and outcome expectations for residents with
different needs found in one facility.
7. The criteria should not be unnecessarily burdensome
on facilities.
An examination of the conditions of participation using
the above principles reveals the areas where improvements
are needed.
First, the current conditions and standards focus on the
facility's capacity to provide services rather than on the
quality of services received by the residents and their
OCR for page 79
REGULATORY CRITERIA / 79
effects on the residents. Most conditions and standards
begin by stating "facilities will provide . . . or
facilities have policies to ...." The conditions and
standards need to be rewritten to state, "residents will
receive . . Appropriate to their needs (as documented in
the resident's care plan)." The facility will still be
held accountable for providing the services, but the
surveyor should be concerned with how adequately the
services were provided to the residents in accordance with
their needs. That is, the emphasis should shift from
facility capability to facility performance.
Second, the conditions do not consistently reflect
current professional standards for long-term care in at
least two respects: (1) they do not explicitly recognize
the importance of quality of life, and (2) they do not
require facilities to apply the state of the art in
assessment and care planning. This is remediable by
adding a new condition on quality of life and one
requiring regular assessment of all residents. By use of
longitudinal resident assessment data to develop
statistics on outcomes of care controlled for case mix,
objective outcome standards for assessing the quality of
long-term care can be developed.
Third, a consistent criticism of the conditions is the
vagueness of their language and lack of specificity
compared to the licensing regulations in some states. The
concept of the conditions--statements of broad
requirements supported by detailed standards--is
appropriate. The standards must be as precise and
detailed as possible to be understandable to facilities,
consistently applied, and enforceable by survey agencies.
Terms such as "adequate" or "sufficient" are not precise,
but they may not be entirely avoidable when there are no
quantitative guidelines available. For example, the
nursing condition requires "an organized nursing service
with a sufficient number of qualified personnel to meet
the total nursing needs" of the residents. Such a
standard can be met through the exercise of professional
judgment by facility staff. The facility's judgment may
not be congruent with a surveyor's judgment, but the
latter's judgment should rest in part on outcome
assessments as well as observation of the workload of
OCR for page 93
REGULATORY CRITERIA / 93
the vast majority of individuals needing long-term care
will rely on Medicaid for assistance in paying for that
care. Currently, two-thirds of all middle-income
residents in nursing homes spend their life savings within
2 years of admission and become Medicaid-eligible.
It is recognized that there are many complex and
interrelated factors at work in the nursing home market
that may contribute to discrimination. The committee's
concern is to identify policies that may reduce or
eliminate discrimination that strikes at those most vul-
nerable--the poorest and most disabled.
Congress intended that the disabled should be protected
from discrimination in admission practices. The 1974
amendments to section 504 of the Rehabilitation Act makes
such discrimination illegal. It is also recognized that a
nursing home administrator cannot responsibly admit more
heavy-care residents than can be cared for properly. The
incentive to discriminate against heavy-care residents is
strengthened by reimbursement systems that set Medicaid
rates without taking into account the differences in
amounts of services required by individual residents to
meet their care needs. In some cases, the Medicaid rate
may be too low for nursing homes to provide adequate care
for certain individuals, but in all cases a rate that is
the same for light-care residents as for heavy-care
residents provides nursing homes with a strong incentive
to discriminate.
Discrimination against individuals who receive
assistance from Medicaid in paying for care poses complex
questions. Such discrimination appears in several forms.
Some nursing homes maintain separate waiting lists--one
for private-pay residents and another for Medicaid
residents--and give preference in admission to those
individuals on the private-pay list. Another
discriminatory practice is to require residents to remain
in private-pay status for a specified period of time
before the home will allow them to apply for Medicaid
support. Still another practice followed by some nursing
homes is to evict residents once they have exhausted their
private funds and become eligible for Medicaid. Some
residents have successfully challenged transfers out of
facilities, but this is a time-consuming and inefficient
OCR for page 94
94 / NURSING HOME CARE
way to enforce such rights, and it has not led to wide-
spread changes in facility practices.~5
The problem of discrimination against Medicaid
recipients is further complicated by the phenomenon of
residents spending down to Medicaid eligibility. Most
nursing home residents whose care is covered by Medicaid
will have originally entered the facility as private-pay
residents. Conversely, most private-pay residents can be
expected to spend down to Medicaid eligibility.
There is no simple solution to this problem. Because a
seller's market exists in most states, increasing the
Medicaid rate probably also would increase the private-pay
rate. Increasing Medicaid rates also increases the speed
with which private-pay residents spend down to Medicaid
eligibility. Nor would increasing the bed supply
necessarily eliminate the problem of Medicaid
discrimination in its various forms. Increased bed supply
would make more nursing home beds available to Medicaid
residents, but it would not ensure their ability to enter
the facility of their choice on an equal basis with
private-pay residents. Separate waiting lists, forced
discharges, and contracts stipulating a fixed period of
private-pay status could still occur. Such discrimination
should not occur in facilities that have chosen to
participate in government programs. Discrimination
against Medicaid recipients should not be permitted in
certified facilities.
A few states have adopted laws to reduce or eliminate
discrimination on the basis of source of payment. These
states include Minnesota, Ohio, Washington, and New York.
New Jersey requires a certified nursing home to allow up
to a specified percent of its beds to be occupied by
Medicaid residents. There is no known evidence of the
effectiveness of these laws. The HCFA should analyze the
experience in these states and develop federal criteria
based on one or more of these state laws.
In developing antidiscrimination legislation, care
should be taken to ensure that facilities are not
permitted to avoid compliance by certifying different
segments of the same institutions in different ways
("distinct part" certification).
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REGULATORY CRITERIA / 95
Recommendation 3-7C: A new standard should be written
under the administration condition that prohibits
facilities that have signed a Medicaid Provider Agreement
from having different standards of admissions transfer,
discharge, and service for individuals on the basis of
sources of payment.
Notification
Many nursing home residents have strong feelings of
personal isolation despite the group-living
situation.5 These feelings are reinforced by the
failure of facilities to notify residents' families about
significant changes in a resident's status, failure to
provide residents with a way to express opinions about
aspects of the home's operation, and obstacles to
community access. These problems should be addressed in
specific standards in the administration condition.
Notification of those who might assist the resident when
changes occur is now required by standard (j) under the
governing body and management condition. It reads as
follows:
(j) Standard: Notification of changes in patient
status. The facility has appropriate written
policies and procedures relating to notification of
the patient's attending physician and other
responsible persons in the event of an accident
involving the patient, or other significant change
in the patient's physical, mental, or emotional
status, or patient charges, billings, and related
administrative matters. Except in a medical
emergency, a patient is not transferred or
discharged, nor is treatment altered radically,
without consultation with the patient or, if he is
incompetent, without prior notification of next of
kin or sponsor.
Recommendation 3-7D: When the governing body and
management condition is rewritten and incorporated! in the
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96 / NURSING HOME CARE
new administration condition, the current standard "j"
should be changed to require the facility to record at
ad mission and periocl ically con f irm or u pd ate the id entity
of a guardian, conservator, or resident's representative
to be notified in the event of (1) care conferences; (2)
changes in the resident's physical, mental, or emotional
status; (3J an accident involving the resident; (4J change
in billing; (5) change of room; (6) discharge from the
facility; or (7J changes in federal or state residents'
rights. Notif ication should be timely.
Participation
Residents' rights to associate and express concerns
should have an analog in the administration condition, one
that obligates the nursing home to be receptive to
regular, reasonable expression of views. The
recommendation below recognizes the diversity of resident
capabilities and administrative styles while fostering
communication. It reflects current policy and practice in
many facilities and is encouraged by the national nursing
home trade associations and consumer organizations.
Recon~r''end ation 3-7E: A new stand ard should be ad d ed to
the administration condition that would require every
facility to develop and implement a plan for regular
resident participation in decision-making in the
facility's operations and policies and for presentation of
resident concerns. Forms of resident participation can
include, but are not limited to, resident councils,
regularly scheduler! resident forums, resident issue or
program committees, and grievance committees. Facilities
should include existing resident councils and/or other
resident representatives in developing this plan.
Access
Local area ombudsmen and other community volunteers are
denied access to some nursing homes in some areas despite
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REGULA TORY CRITERIA / 97
the demonstrated benefits of community presence in nursing
homes. Some local nursing home ombudsmen have
been hampered in their response to residents' requests for
assistance because they have been refused entry to the
facility and/or access to the residents' records that are
germane to the problem.23 Given the long-term-care
ombudsman's statutory role in handling complaints and
serving as an advocate on behalf of residents (see Chapter
6), and in the process complementing the work of the state
survey agency, it is essential that local ombudsmen have
legal access to nursing homes. This authority should be
clear both in the Older Americans Act (see Chapter 6) and
in the HCFA's certification standards. It also is unrea-
sonable to permit some facilities to isolate residents
from contacts with community volunteers who can provide
legal or social services to them.
Recommendation 3-7F: Two new elements should! be added to
the governing body and management standard as follows:
a. Certified nursing homes should be required to permit
access to the homes by an ombudsman (whether volunteer or
paidJ who has been certified by the state. With
permission of a resident or legal gunrcJ{ian, a certified
or''budsn~an should be allowed to examine the resident's
record s r''ni''tainec/ by the nursing hone.
b. Ally authorized employee or age''t of a public agency,
or any authorized representative of a community legal
services organizatio'', or any authorized r''en~ber of a
nonprofit con~n~unity support agency that provides health or
social services to nursing home residents should be
permitted access at reasonable hours to any indiviclual
resident of any nursing home.
Physical Environment
Older individuals are much more sensitive to changes in
temperature. They have a lower tolerance for cold and
heat and easily suffer from hypothermia and hyperthermia.
Thus, nursing home temperatures should be carefully
monitored. The comfort of staff also is important because
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98 / NURSING HO3lE CARE
it affects quality of care. The current standards are too
vague to assure that the temperatures are carefully con-
trolled; they should be strengthened. But since retro-
fitting changes in the heating, ventilation, and
air-conditioning systems in a nursing home can be very
expensive, the recommended standard could be waived for
older facilities if it would result in undue hardship.
Recommendation 3-8: Standard 5, "Other Environmental
Consiclerations" in the Physical Environment Conalition
currently reacts ". . . provision is mad e for adequate and
comfortable lighting levels in all areas, limitation of
sounds at comfort levels, maintaining a comfortable room
temperature ...." It should be amencled to add, at this
point, "that is within acceptable ranges of operative
temperature ant! humidity for persons clothed in typical
summer or winter clothing at light, mainly sedentary
activities, as specified in the ANSI-ASHRAE Standard
55-1981." This is the standard prescribed by the
nationally recognized American National Stanclards
Institute. Waivers may be grantee! for existing facilities
until such tinge as substantial renovation takes place.
NOTE ON STAFFING STANDARDS
General
Many types of professional services are required to
formulate care plans and to provide high-quality care to
meet the needs of the nursing home population.
Physicians, dentists, podiatrists, speech therapists,
physical therapists, occupational therapists, dietitians,
and activities directors are needed in addition to nurses,
social workers, and administrators. The heterogeneity of
the residents and their service needs makes it
inappropriate to prescribe detailed staffing standards for
each of these disciplines. The major recommendations
earlier in this chapter to shift the regulatory emphasis
from structural to outcome orientation has an implication
for staffing, namely, that every nursing home should be
obligated to provide its residents with the full range of
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REGULATORY CRITERIA / 99
services they need to meet the standards in the new
quality-of-care and quality-of-life conditions. This will
require sufficient staff--both numbers and types of
professionals--to meet the needs of the residents in each
home. All professionals should be trained in geriatrics
and gerontology. Special efforts are needed to ensure
that adequate physician services are provided to residents
even though physicians--except for a part-time medical
director--are not on the staff of nursing homes.
The committee did not examine the staffing standards
pertaining to all types of staff and for most does not
recommend any changes. However, it did look at social
· ~
services and nursing.
Social Services
i
The current social services condition of participation
~s weak. It requires a designated person to be
responsible for social services in each nursing home, and
consultation from a social worker with an MSW degree when
the designee is not so qualified. Reliance on this weak
requirement has produced uneven results at best. Studies
in various parts of the country show that many facilities
have a bare minimum of social services--that is, they hire
an MSW for 4 hours per month of consultation and appoint
designees who are less than full-time and have little
professional or even general education. Studies of the
consultant role have shown how difficult it is for a
nursing home consultant to design a social work program,
develop procedures for a socially and psychologically
sensitive environment, train and supervise social service
designees, and design and conduct in-service training for
all nursing home staff, given the minimal time alloted to
their role and their negligible authority as a
consultant.24~26
A full-time social worker with at least minimum
professional credentials will be needed to help implement
several of the recommendations contained earlier in this
chapter, especially the new quality-of-life condition and
the emphasis on resident outcomes. The latter implies
that facilities will be held responsible for residents'
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100 / NURSING HOME CARE
well-being, including social and emotional aspects as well
as physical.
Social services in nursing homes can be effective in
promoting a satisfactory quality of life and in improving
social and psychological outcomes.27~30 Such programs
develop interventions directed at the well-being of
individual residents or subgroups of residents (for
example, individual counseling to alleviate depression,
counseling with the terminally ill, individual or group
life review projects, orientation programs for new
residents and their families). A social service program
should be designed in collaboration with an activities
program so that the social worker's knowledge of community
resources can help residents take advantage of agencies
and programs in the community that offer social, mental
health, legal, educational, recreational, and spiritual
affiliations. The social worker's function in a nursing
home also should include training and assisting staff to
positively influence residents' psychological and social
states. One model program in a number of nursing homes
also encouraged social workers to assist nursing staff in
dealing with their own stress-induced family and personal
problems, which in turn allowed those staff to be more
comforting and supportive of residents.29
Recommendation 3-9: The present social services condition
should be changes! to require that each facility with 100
beds or more be required to employ at least one full-time
social worker. Qualifications for this position should be
a bachelor's clegree in social work, a master's degree in
social work, or some equivalent degree in an applied human
service field at the bachelor's level or higher as
approved by the state. Facilities with fewer than 100
beets or those in rural areas that have made a good-faith
effort and have been unable to recruit a qualified social
worker with the required credentials may substitute a
contractual arrangement with a community agency or with an
independent social work consultant. However, the HCFA
shout/ establish a minimum level of effort for social
services in exempted! facilities--for example, one day of
consultation per week.
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REGULATORY CRITERIA / 101
Licensed and Registered Nurses
One of the major factors affecting quality of care and
quality of life in nursing homes is the number and quality
of nursing staff in relation to the facility's require-
ments.~ Greater numbers of nurses have been associated
with improved resident outcomes in research studies. But
many nursing homes still rely largely on untrained and
unlicensed nursing personnel to provide most of the care,
with very few professional or licensed practical nurses to
supervise them.3~~33 Moreover, most professional
nurses in nursing homes have had little or no formal
training in gerontology and long-term care. Staffing
patterns vary across facilities, regions, and states, but
for the most part there are inadequate numbers of nurses
to provide the minimum care needed. Further, the wages
for nurses and nurse's aides are substantially below wages
for comparable positions in hospitals. Poor working
conditions combined with heavy resident workloads and
inadequate training are all factors that contribute to
poor quality of care and high turnover rates in some
facilities. Although there has not been extensive
research on staffing patterns, there is little doubt that
qualified nursing personnel are one of the most important
factors affecting high quality of care.
Federal SNF certification regulations require registered
nurses to act as directors of nursing. Licensed practical
or registered nurses may act as charge nurses. Nursing
homes currently have roughly equal numbers of registered
nurses and licensed practical or vocational nurses working
in long-term care facilities. About 15 percent of the
nursing personnel in the nation's nursing homes are
registered nurses, 14 percent are licensed practical
nurses, and 71 percent are nurse's aides. "Aides . . .
provide six times as much care in nursing homes as do
registered nurses, and five times as much care as do
licensed practical nurses."6
On the assumption that adequate staffing improves
quality of care, many states have adopted stricter nursing
requirements, in the form of nurse~to-resident ratios, to
supplement the federal regulations. These ratios range
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102 / NURSING HOME CARE
from as little as 0.4 nursing hour per resident-day to as
many as 4.0 hours.
There is a 4-fold variation in beds per licensed nurse,
from 4.5 in Alaska to 18.S in Oklahoma. The variation in
RN/LPN ratio among the states is 9-fold, from 0.2 in Texas
to 1.9 in New Hampshire.
Some states also set more specific duties for the
director of nursing, such as planning staff development
setting nurse practice standards and resident care
policies, assessing resident needs, and recommending staff
ratios. Facilities in each of these states must meet the
state's staffing requirements to be licensed. And homes
must be licensed in order to be certified. Most state
standards do not distinguish between professional and
nonprofessional nursing. However, they do set a
measurable standard for the amount of nursing care
required in homes according to the number of residents.
There is evidence that many homes staff above minimal
state requirements where requirements are low.34
Some individual homes and chains of nursing homes have
also adopted methods for determining necessary nurse
staffing that exceed state standards.4335
Because of the complexities of case mix--that is, the
widely differing needs of individual residents in the same
facility--prescribing simple staffing ratios clearly is
inappropriate. Although algorithms have been developed to
estimate amounts of nursing time needed by residents that
are based on functional assessment scores and requirements
for special care needs, insufficient evidence of the
validity and reliability of the algorithms is available.
Until standardized resident assessment data become
generally available, and some careful empirical studies
have been completed, prescribing sophisticated staffing
standards in the regulations will not be possible.
However, the committee is convinced that minimums for
professional supervision of the nurse's aides who provide
most of the care are too low, not only in ICFs, but also
in SNFs. Most good nursing homes now exceed these
minimums, often by a considerable margin. If the case mix
in a given nursing home, or a given bed section in a
nursing home, is such that more licensed nurses are
required to provide proper care to the residents, the
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REGULA TORY CRITERIA / 1 0 3
nursing home should be required to provide it. Further,
the committee believes that as the case mix moves toward a
larger proportion of heavy-care residents, the minimum
requirements should be raised to increasingly higher
levels.
Increasing staffing may cause some problems initially,
but the committee believes that the benefits to the
residents of increasing the ratio of better-trained staff
far outweigh the costs of increased staffing. To this
extent, nursing homes should place their highest priority
on the recruitment, retention, and support of adequate
numbers of professional nurses who are trained in
gerontology and geriatrics to ensure an adequate number
and appropriate mix of professional and nonprofessional
nursing personnel to meet the needs of all types of
resid ents in each facility.
Representative terms from entire chapter:
nursing homes
