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Improving the Quality of Care in Nursing Homes (1986)

Chapter: Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies

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Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
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Page 315
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
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Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 317
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 318
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 319
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 320
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 321
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 322
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 323
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 324
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 325
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 326
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 327
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 328
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 329
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 330
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 331
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 332
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 333
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 334
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 335
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 336
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 337
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 338
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 339
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 340
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 341
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 342
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 343
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 344
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 345
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 346
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 347
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 348
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
×
Page 349
Suggested Citation:"Appendix C: Report of Survey of State Health Facility Licensure and Certification Agencies." Institute of Medicine. 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press. doi: 10.17226/646.
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Page 350

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APPENDIX C Report of Sur vey of State Health Facility Licensure and ~ · ~ ~ ~ ~ ~ertl~catlon Agencles PURPOSE The Institute of Medicine Committee on Nursing Home Regulation conducted a mail survey of 50 state and the District of Columbia health facility licensure and certification agencies to 1. obtain data about the resources committed by each jurisdiction to inspect and certify nursing homes under the Medicaid and Medicare programs, and 2. obtain data on the statutory availability and use by states of various types of intermediate sanctions for enforcing compliance with nursing home standards. The survey was designed with the cooperation and assistance of the officers and board members of the National Association of State Health Facility Licensure and Certification Directors. The survey questionnaire was developed, and pretested in September 1984 on three health facility licensure and certification directors. On the basis of the pretest, 18 questions were modified. The final version covered eight topics: 315

316 / APPENDIX C (1) organization of nursing home activities, (2) survey agency personnel and budget, (3) survey agency workload, (4) state standards, (5) special surveyor training, (6) survey procedures and coordination agreements, (7) enforcement, and (8) survey directors' views on federal regulation. A copy of the questionnaire is attached to this Appendix. Clearance to conduct the survey was received from the Office of Management and Budget on November 2S, 1984. The questionnaires were mailed, with an endorsement from the Association of State Health Facility Licensure and Certification Directors, on November 29, 1984. The recipients were the 51 current Health Facility Licensure and Certification directors. Forty-seven responded. From January to March 1985, staff collected and analyzed the data, which were then used to produce descriptive and inferential statistics, to make interstate comparisons, and to observe changes in survey agency resources and enforcement activities from 1980 to 1984. The survey data were also merged with existing state demographic and nursing home data available from the Medicare/Medicaid Automated Certification System (MMACS), and with other data from the HCFA Office of Research and Development and from published literature, so that factors contributing to state variations could be determined. Because of the population size, and the nominative level of most of the data, the major analyses performed were (1) frequencies for all variables, and (2) two-by-two and two-by-three contingency table comparisons of major variables such as survey agency budgets, staff, numbers of surveys completed, surveyor training, and survey and enforcement procedures. Frequencies, medians, and ranges of various responses of variables are reported in the attached copy of the actual survey. Significant associations and correlations are discussed in the "Summary of Findings" section. Data validity was assessed. Because the committee intentionally designed the survey to gather information

APPENDIX C / 317 that could not be obtained from other sources, Medicare and Medicaid budget data supplied by the HCFA were the only external data available to check the validity of the information collected by the survey. Staff compared the total federal Medicare and Medicaid 1983/1984 allocations as reported in the survey with federal Medicare and Medicaid allocations to the states as reported by the HCFA. Of the comparisons (43 Medicare and 39 Medicaid), 16 of the survey figures and those provided by the HCFA were identical; 44 were within a tolerable error. Of the remaining 22 discrepancies, only 4 could not be corrected. With these corrections, the data demonstrated external validity. The survey data also were checked for their power to discriminate. Questions that received the same answer from all, or nearly all, of the respondents, and questions that had received little or no response, were not used for correlational analyses. In the first case, the informa- tion collected does not discriminate among respondents. In the second, insufficient information was collected. Although the consistency or the unavailability of data were themselves interesting and noted in the frequency analyses, the responses received were not useful as variables for comparative analyses and were therefore excluded from further analysis. Questions were considered nondiscriminating if 37 or more (80 percent) of the 47 respondents answered the question in the same way. Questions were considered to provide insufficient information if 37 or more (80 percent) of the respondents failed to answer the question. The survey data provided the committee with factual information concerning the feasibility and desirability of changing the current survey and certification system. Many of the committee's conclusions on the survey process, on state agency resources, and on state enforcement activities are based on survey findings. SUMMARY OF FINDINGS Major findings for each of the eight topics covered by the survey are summarized below. In each case, the number

318 / APPENDIX C of respondents is given as a proportion of the total respondents. Organization of Nursing Home Regulation Activities All 47 responding agencies conduct Medicare certification inspections; 46 conduct licensure, Medicaid certification inspections, and complaint investigation visits to nursing homes. Two-thirds conduct life safety code inspections (32/47) and just over a third (17/47) also are responsible for inspection of care visits. Very few make certificate-of-need determinations (7/47) or set Medicaid nursing home reimbursement rates (2/47~. The majority of the agencies are also responsible for licensing and certification activities for other types of health facilities. All but three handle acute care hospitals, all but two handle home health agencies and hospices, and most also are responsible for board-and-care facilities (33/47~. Survey Agency Personnel and Budget State agencies vary greatly in the size of their budget and staff per nursing home. The percentage of total survey agency resources allocated to nursing-home-related activities ranges from a high of 93 percent to a low of 14 percent; the median is 56 percent. The amount of money allocated for regulatory activities per nursing home ranges from a minimum of $1,296 to a maximum of $13,018, with a median of $4,700. The number of nursing homes per available full-time equivalent (FTE) licensing and certification field surveyor varies from a low of 0.78 to a high of 41.96, with a median of 13.00. Nineteen states reported that their licensing funds increased by less than 50 percent from 1980 to 1984; 17 reported that their funds increased by more than 50 percent. About half the states reported that their total budget decreased between 1980 and 1984; the other half reported that their budget increased between 1980 and 1984. Half the states reported that the number of field surveyors had decreased between 1980 and 1984; the other half reported that the number had increased.

APPENDIX C / 319 Twenty-two reported that total staff decreased between 1980 and 1984; 19 reported that total staff increased. Survey Agency Workload Of the 17 state survey agencies performing inspection-of-care (IOC) reviews in addition to licensure and certification surveys, 9 indicated that these reviews are done by the same team at the same visit as the certification survey. In the other states, IOC is done by a different team or during a separate visit. Thirty-four states reported that complaints are investigated by the regular surveyors; 10 reported that they have a separate survey staff to investigate complaints. The length of facility certification visits varies by state, by facility classification, and by type of visit. Combined licensing and certification surveys for the average-quality 100-bed nursing home ranged from 1.0 to 12.0 person-days for ICFs (with a median of 5.9), and from 1.5 to 18 person-days for SNFs (with a median of 6.~. Post-certification follow-up visits ranged from 0.5 to 4.0 person-days for ICFs (with a median of 1.5), and from 0.5 to 6.0 person-days for SNFs (with a median of 2.0~. Post-certification visits average about one per facility. Complaint visits vary in length by state, but not by type of facility. The longest average visit is 2.0 and the shortest 0.4 person-days, with a median of 1.0 for both SNFs and ICFs. Eleven states reported that the total number of visits to facilities decreased between 1980 and 1984; 20 reported that the total number of visits to facilities increased. The change in the number of follow-up visits made between 1980 and 1984 ranged from a decrease of 1,013 to an increase of 631 (or a 96 percent decrease to a 215 percent increase). State Regulatory Standards Just over half (24/47) of the respondents judged that their state's licensure requirements for ICFs are more

320 / APPENDIX C stringent than those of the federal government, one- quarter (11/47) said they were the same, and one-quarter (12/47) said they were less stringent. One-third (17/47) of the directors asserted that their state's licensure requirements for SNFs are more stringent than the federal requirements, one-third (14/47) said they were about the same, and one-third (14/47) said they were less stringent. Special Surveyor Training Thirty-three states reported that they conduct special enforcement training for surveyors. The median number of hours of training is 7.5, but ranged in different states from 1 to 96 hours. Nine states reported that training is conducted by internal staff, 1 said training is conducted by external staff, 2 use outside consultants, and 22 said that they use a combination of the above. Twenty-six pay for training in a line item in the agency budget, seven include training funds in another line item, one uses funds external to the agency, and two use a combination of internal and external funds. All of the states that have special enforcement training think that it has improved the surveyor's work and that training should continue. Survey Procedures and Coordination Arrangements Most of the agencies conduct licensure inspections once every 12 months (40/47) and certification inspections once every 12 months (42/47~. All states reported that licensure and certification surveys are combined, with roughly three-quarters always doing combined surveys (33/47~; the remainder combine surveys only some of the time. Seven states indicated that they use a screening or abbreviated survey to determine which facilities should receive a full-licensure or certification survey. Most agencies reported that their surveyors review previous licensure (45/47), previous certification (47/47), inspection-of-care reports (34/47), and complaint

APPENDIX C / 321 reports (42/47) before conducting a survey. Thirty-three states indicated that surveyors always conduct "hands-on" assessments of residents during certification surveys. Most surveyors complete HCFA Form 2567 at the office, most within 10 days of the inspection (41/47~. The number of days varies from 2 to 18. Thirty-three states indicated that some aspect of their licensure and/or certification procedures has been changed in recent years. Enforcement Nearly all state survey agencies responding indicated that they have at least several intermediate licensure sanctions available to them, but very few are applying any formal sanctions, federal or state. Eighty-five percent of the total actions are taken in 13 states. Most respondents, however, did rate their state's enforcement efforts favorably. Thirty-nine states said that any surveyor has the authority to cite a deficiency; three said that the team leader must make the decision to cite; two said that a supervisor must make the decision; and three states listed "other" authorities. Thirty-six states reported that the number of standards out of compliance that would cause the nursing services condition to be marked out-of-compliance "depends." Usually they said it depended on "the severity" of the violation. Five states listed specific standards which would put the nursing services condition out of compliance: standards 124, 134, and 181 (director of nurses, 24-hour nursing, and administration of drugs, respectively). Two states said any standard out of compliance would put the condition out of compliance; one said one standard was sufficient; two said two; and one said three. Thirty state directors thought that one onsite visit to a facility is adequate to verify a plan of correction; 13 said that several visits are necessary; 3 said that none are necessary. Most states do a routine follow-up visit for each full survey; it lasts one-third as long as the

322 / APPENDIX C original visit. Most survey agency directors think this is a reasonable procedure. Twenty-three states reported that they do not have attorneys on staff who are specially designated to deal with enforcement actions. Ten states have one attorney who specializes, five have more than one. Only 6 reported that they have hearing officers designated for nursing home enforcement; 28 do not. Four have special investigators, 30 do not. Two have special assignment surveyors. When the states take court action, 13 have a staff attorney available to defend them; 31 have a departmental attorney available, and 3 have no attorney available. Twenty said that their attorney carried out their request to file an action all of the time, 11 said most of the time, 12 said some of the time, and 2 have never requested an action. States have, on the average, ~ available sanctions under their state licensure laws. The survey inquired about 14. Some states had all 14, and some had only a few. Most states have the authority to revoke a facility's license (44/47), to decertify a facility (40/47), and to seek a court injunction (37/47~. Additionally, 36 states reported having authority to relocate residents from substandard facilities; 35 have the authority to issue conditional licenses; 32 have the authority to suspend all new admissions: 30 have the . ~· . . ~ authority to Impose criminal penalties t~or patient abuse; 26 have administrative fining authority; 25 have the authority to take licensure records into consideration in certificate-of-need recommendations; 21 have the authority to place a facility into receivership; 19 report having the authority to withhold Medicaid payments to noncompliant facilities; 15 have the authority to issue probationary licenses; 9 have the authority to reduce the Medicaid reimbursement rates of noncompliant nursing homes; and 7 have the authority to appoint a monitor to a facility (see attached copy of survey questionnaire). In states that have the sanction, the survey agencies usually have the authority to recommend a sanction but not necessarily the authority to decide whether to carry out a sanction. In 9 of the 14 categories, most of the state agencies that have the sanction have the authority to

APPENDIX C / 323 recommend the sanction, but less than half have the authority to decide whether to use the sanction. The availability of sanctions in a state seems to be associated with (1) whether surveyors receive special enforcement training, (2) the agency budget per nursing home, (3) the total number of state agency visits to nursing homes, and (4) the survey agency director's opinion of the survey process regulations. States that have special enforcement training are more likely to have more types of sanctions available. States with high budgets per nursing home also have high numbers of sanctions available. States that make a lot of visits are likely to have more sanctions available. And agency directors who are content with the procedural regulations are more likely to have more sanctions available to them.* States that have committed significant efforts to strengthening nursing home regulation, whether in special staff training, increased survey agency budgets, or frequency of inspection visits, are also those that have elected to have a variety of sanctions available. Perhaps political pressures have stirred all of these interests simultaneously, or perhaps the greater training and resource allocations have uncovered the need for more sanctions. Regarding enforcement actions, 20 states report that they have written guidelines for when and how to take a formal enforcement action; 27 do not. The total numbers of enforcement actions taken by states in each category in 1983 ranged from one to dozens, to several hundred in a few categories (civil fines, criminal penalties, and withholding of payments). However, at least 75 percent of the actions taken in each category were taken by one, two, or three states. (It was not necessarily the same state in each category; states seem to favor one or two sanctions.) The median number of types of enforcement actions used by an agency was two. The median total number of actions taken was 11. The number of reported actions taken increased in all but one category (conditional licensing) from 1980 to *Findings are significant at the .10 level of confidence.

324 / APPENDIX C 1983-1984. In 1983, 15 states revoked the license of at least 1 facility; 15 suspended admissions to one or more facilities; 14 relocated residents from a facility; 14 issued conditional licenses; 13 issued fines; 13 decertified facilities; 10 took licensure records into account on certificate-of-need recommendations; 9 obtained injunctions; ~ placed a facility into receivership; 5 issued probationary licenses; 3 withheld Medicaid payments to a facility; 3 appointed a monitor to a facility; and 1 reduced Medicaid rates to a facility. Of those reporting having taken enforcement actions, the number of types of actions taken and the total number of actions taken seem to be correlated with (1) special enforcement training, (2) whether recent changes in the survey process have taken place, (3) minimum number of required nursing hours, (4) percentage of agency resources allocated to nursing homes, (5) survey agency budget per nursing home, (6) total numbers of visits in 1983-1984, (7) changes in state licensing funds, (8) number of sanctions available, and (9) statewide per capita income. More training was positively linked with using more types of enforcement actions, as well as implementing more actions. Changes in the survey process were also positively linked with numbers of types and numbers of actions taken. States with higher nursing requirements, and those with more monetary resources and more staff/time resources allocated to nursing homes, implement more kinds of sanctions and more sanctions. Larger increases in state licensing funds from 1980 to 1983-1984 are related to fewer enforcement actions; smaller increases are related to more types and numbers of enforcement actions. The number of available sanctions is directly related to their use. And a higher per capita income is related to a higher number of types of sanctions applied. The correlations with enforcement activity seem to be a reflection of the amount of political interest states take in nursing homes. Those that have higher nursing requirements, special training, more available sanctions, that have made recent changes in the survey process, and that allocate more resources to nursing home surveying seem to be more active in enforcement. Or perhaps these factors make it easier for states to bring enforcement

APPENDIX C / 325 actions. States that take more enforcement actions have more knowledge, better rules, and more resources for monitoring the situation. Agencies tend to rate sanctions favorably. In 11 of the categories, well over half of those using the sanction rated it as very effective or effective. Fifteen agencies said that their overall enforcement efforts were very effective, 29 said their efforts were effective, and 3 said their efforts were not effective. These opinions did not correlate with availability and use of sanctions. Agencies may be reluctant to downgrade the effectiveness of the sanctions available to them, or their own efforts. When actions were taken to court, three agency directors said that the court supported the agency's position all of the time, 20 said most of the time, 15 said some of the time, and 9 have never taken a facility to court. Again, these opinions were not related to use of sanctions. Twenty states said that particular sanctions are effective because they affect the income of the provider. Other reasons given included the ability to implement the action quickly (7), the ability to remove an operator (4), and publicity (5~. The obstacle to enforcement that was mentioned most often was time delays in implementing a sanction, both administrative and legal (11~. Others mentioned the difficulty of administering some of the sanctions (3), potential harm to residents (transfer trauma, decreases in funds being taken out on patients) (4), and too little impact on the provider's income (2~. More states listed reasons for the success of sanctions than listed obstacles (37 as opposed to 19~. This is because several did not rate unfavorably any of the sanctions they used. Views on Federal Regulations The majority of respondents believe that current federal certification regulations could ensure nursing home services of adequate quality with certain modifications. A few forwarded specific suggestions for changes. Eight state agency directors reported that they believe that current federal SNF Conditions of Participation can

326 / APPENDIX C ensure adequate nursing home services as they are; 9 believe that they could ensure this quality if some unnecessary or unmeasurable provisions were deleted; 20 believe that they could ensure this quality if certain additions and modification were included, and 10 believe that they cannot ensure adequate-quality nursing home services without a major overhaul and reorientation. Six directors believe that current federal ICE Standards can ensure adequate-quality nursing home services as they are; 8 believe that certain deletions are needed and 16 believe that certain additions are needed. Thirteen believe that these standards cannot ensure adequate-quality nursing home services without a major overhaul and reorientation. Regarding the current federal survey procedures, 11 state agency directors think that the regulations work reasonably well as they are; 7 think they would work with some deletions; 20 think they would work with changes and additions; 7 think they would work if the federal government gave states more support; and 2 think they need to be completely revised. Regarding specific changes, only two respondents identified a specific federal survey and certification standard as inhibiting the quality of patient care: the utilization control condition. The utilization control condition was also mentioned consistently as not worth the time and cost of surveying (11/47~. Twenty-three other standards were stated to be not worth the time and cost by 1, 2, or 3 respondents. Consistently mentioned as ineffective were the utilization control condition (11/47) and the quarterly staffing reports standard (5/47~. Twenty-seven other standards were mentioned by either 1. 2, or 3 respondents. Consistently named as needing modification were the conditions for nursing services (5/47), medical director (4/47), and physician services (4/47~. Thirty-three others were mentioned by 1, 2, or 3, respondents. Few agencies listed more than one federal regulation as ineffective, or not worth the time and cost. Few agencies listed more than two choices for regulations which should be retained in a modified form. The five SNF Conditions of Participation identified most often as being the most important for ensuring adequate-quality patient care were nursing services ., - , ,

APPENDIX C / 327 (36/47), dietetic services (30/47), pharmaceutical services (24/47), physician services (19/47), and physical environment (13/47). Thirty-two agency directors agreed that the federal regulations should incorporate minimum nurse-to-patient staffing ratios. Thirty-six replied that the regulations, procedures, and forms for surveying skilled and intermediate-level facilities should be combined into one comprehensive survey. Thirty-four thought that states should require certification of nurse's aides. Thirty-four thought that the survey process should include a screening instrument. Twenty-eight said the time-limited agreement should be dropped. Forty-five agreed that the survey should include patient assessment. Thirty wanted survey results publicly posted. Forty-six disagreed with the proposal to allow JCAH accreditation to replace surveys. SURVEY QUESTIONNAIRE The attached copy of the IOM Committee on Nursing Home Regulation Survey of Health Facility Licensure and Certification Directors contains the frequencies of responses for each of the questions asked. For questions that had unique responses from each state, such as budget, staffing, and survey visits, the median, the lowest number, and the highest number are given.

328 / APPENDIX C Survey of State Licensure and Cert i f i cat ion Agency D i rectors Form Approved OMB No.: 0938-0395 Instructions. This survey is being conducted by the Committee on Nursing Home Regulation of the Institute of Medicine, National Academy of Sciences. In order to provide a complete picture of each state's nurs ing home regulatory system to the study Committee, this questionnaire seeks information about state laws, organizations, stat f ing, workload, and procedures . Please f ill out the following questionnaire as completely as possible, and return it in the enclosed envelope by December IS, 1984. There are lines whenever short answers are required. There are parentheses whenever a check mark is required. Please use an "X" for the check mark. In order to complete the questionnaire, you may need to confer with others. In the questionnaire, "survey agency" refers to the state agency which administers licensure and/or certif ication surveys of nursing homes, and "Medicaid agency" refers to the single state agency which administers Title XIX funds. Thank you very much for your cooperation. If you have any questions regarding the questionnaire, please call Mike McGeary at the Institute of Medicine (202) 334-2312. 1. Name of State: 2. Name of respondent: 3. Title of respondent: 4. Name of organizational unit headed by respondent: 5. Name of department in which unit is located: 6. Phone number of respondent (required in case clarifying information is needed ): HCFA-466

APPENDIX C / 329 OMB No . 0938 - 0395 STATE: A. Organization of Nursing Home Regulation Activities 7 . Does the survey and certif ication unit do any of the following activities concerning nursing homes in your state: Act ivity a. State licensure surveys of nursing homes? b. Medicaid certif ication surveys ? Medicare certif ication surveys ? d. Inspect ion of care reviews ~ e. Setting of Medicare reimbursement rates f or nurs ing homes ? f. Complaint investi gat ions concern ing nurs ing homes ? Life safety code inspect ions of nursing homes? Yes/no If no, name respons ible agency and its dept. 46/1 46/0 47/0 17/29 46/1 32/ 15 h. Certif icate of need 7/37 determinat ions 8. Does your agency also survey any of the following types of health facilities? Fac i 1 ity type a. Hospitals b. Home health agencies c . Hospices Yes/no If no, name of respons ible agency 44/3 45/2 45/2 Board and care/domiciliary/ 33/14 rest homes HCFA-466 Supervised or congregate living facilities 13/33

330 / APPENDIX C OMB No. 0938-0395 STATE: 9. Are nursing home surveys off icially delegated by your state to any city or county level government agencies? a. ( 43 ) No. b . ( 4 ) Yes, they are delegated to ( do not include your own district office, please list): B. Survey Agency Personnel and Budget* 10. What is the total number of all full-time equivalent persons in your survey agency? (Include those who work on other than nursing home surveys.) Median = 43. 5; RanRe = 3 to 530 11. What were your licensing and certification expenditures for all facilities for fiscal years 1980 and 1983 or 1984 (the most recent year for which you have data)? FY ends**_ BudRet category a. SNF 18 b. Non-SNF 18 Total Title 18 d. Federal Title 19 State match for Title 19 f. Total Title 19 g . State 1 icensure only c. e. :1980 MedianRange 101,1393,346- 1,689,724 246, 69948, 827- 1, 863, 714 240,74365,820- 3,533,438 396,42541,000- 4,294,143 56,9152,913- 2,129,361 541,98166,175- 7,049,190 206, 88045, 386- 7, 365, 516 h. TOTAL 1, 321, 052 131, 995-15, 592, 224 ( check appropriate year) 1983 ( ) or 1984 ( ) Median Range 117,970 2,327- 2,486,881 286,130 13,376- 4,500,121 307, 1 13 36, 123- 6, 494, 925 411,115 51,876- 3,673,755 209,773 11,633- 3,244,319 636, 659 63, 509- 6, 964, 348 376, 928 79, 376- 6, 964, 348 1, 526, 960 99, 632- 35, 450, 768 *Please attach an organization chart of your agency and department. **If your FY ends on a different date for each of the following questions, please note date; otherwise write S for same as listed in question 11. HCFA-466

APPENDIX C / 331 OMB No. 0938-0395 STATE: 12. Number of full-time equivalent employees engaged in all health facility licensing and certif ication activities in: FY ends: Position a. Surveyors b. Others ( e. g ., supervisory, administrative, clerical ) 1980 Median Range 23 3-200 (check appropriate year) 1983 ( ) or 1984 ( ) Median Range 26 3-151 13 2-114 14 2-114 c . TOTAL 48 6 - 250 44 6 - 246 13. Overall, what percentage of your state agency's total state survey and federal certif ication effort is devoted to: Median Range a . _% 14-93 Nursing homes (SNF and/or ICF)? b. 20% 2-65 Other long-term care facilities and services c. 20% (e.g., ICF/MRs, hospices, home health agencies, board and care/domiciliary/rest homes, congregate or supervised living facilities ) ? 0-54 Other health facilities (e.g., hospitals laboratories, ESRDs, etc. )? 100% TOTAL 14. If your agency conducts inspection of care reviews, what were your expenditures in fiscal years 1980 and 1983 or 1984 (the year for which you have the most recent data) ? Please leave blank if not done in your agency. ( check aoorooriate ~ rr--r~~~ year ) 1983 ( ) FY ends: 1 980 or 1 984 ( ) Budget Median Range Median Range a. Title 19 540,721 17,419-6,575,526 570,066 77,570- 8,506,510 b. State match 349, 045 5, 806 - 2, 586, 882 288, 904 33, 496 - 3, 448, 966 c. Total IOC expenditures 1, 019, 700 23, 225-9, 162, 408 770, 088 129, 284-11, 195, 547 HCFA-466

332 / APPENDIX C OMB No. 0938-0395 STATE: 15. How many full-time equivalent employees in your agency were engaged in inspection of care review? ( check appropriate year ) 1983 ( ) 1980 or 1984 ( ) FY ends: Position Median Range MedianRange a. RNs b. Social workers and others 9 0 - 3 7 3 c. Total FTEs 26 1 1 0- 84 9.5 0-84 5.5 0-268 0-439 18.0 0-308 16. In addition to the personnel who carry out survey and inspection of care functions who are listed above, does your agency have personnel whose specif ic duties are to process enforcement actions against facilities or individuals who violate nursing home regulations? (If yes, please indicate full-time equivalent positions on the appropriate line. ) Response 0 1 # States 23 10 3 4 8 11 1 1 a. Attorneys b. Hearing of f icers/admin. law j udges Invest igators Special assignment surveyors Other ( specify): 28 4 1 1 30 3 1 30 1 1 17 . Does your agency have under state law a nurs ing home complaint and abuse reporting system? a. ( 34 ) Yes . b. ( 7) No, but such a system is operated by another agency (please specify): c. ( 6 ) No, there is no statutory complaint system. 18. If your agency handles nursing home complaints, are they investigated by: a. ( 35 ) the regular surveyors? b. ( 10) a separately staffed unit of Median = 5; Range = 1-30 FTEs? c. ( 0) others? (please specify): HCFA-466

APPENDIX C t 333 OMB No. 0938-0395 STATE: C. Survey Agency Workload 19. How many noncertified nursing homes with SNF and/or ICF-like services did your agency license (as of September 1984) that have no federally certif fed beds? Median = 7.5 Range = 0-211 20. How many visits to certified SNFs and ICFs did your agency make in 1980 and in 1983 or 1984? ( check appropriate Year ) 1983 ( ) FY ends: 1980 or1984 ( ) Type of Visit Median Range Median Range a. Full licensure or certification surveys 250.5 15- 5,331282 18- 5,432 Abbreviated or part ial surveys 0 0- 405_ 0 O- 708 c. Post certification revisits 268 0- 1,827 187 0- 2,280 d . Complaint investigations 151.5 0- 5,371 142 0- 7,218 e. Inspection of care vis its f. Other visits Total HCFA-466 166.5 0- 1,975 102 0- 1,900 in? 59 0- 1, 157 76 0- 6, 004 914 24- 14, 370 1, 091.5 26-21, 839

334 / APPENDIX C OMB No. 0938-0395 STATE: 21. In an average visit, how many person-daYs would your agency spend on site conducting the following activities in a nursing home of average size - approximately 100 beds - and quality? (E.g., a three person team spending two days in a facility would spend six person-days). S ICE SNF/ ICE Median Range Median Range Median Range Cert if icat ion and Licensure Survey(s) 6.8 1-18 da 5.9 1-12 da 6.5 1.5-20 da b. Inspection of Care 8.0 3-14 da 7.5 2-17 da 8.0 3. 0-20 da c. Post Certif ication 2.0 0. 5-6 da 1.5 0. S-6 da 2. 0 0. 5-25 da Revisits d. Complaint Investi- 1. 0 get ions e. Other: Do all the surveyors in your agency work out of the central of f ice? a. ( 24) Yes, they are all based at the central office. b. ( 22 ) No, we have Median = 4; RanRe = 1-17 f ield or district offices and/or Median - 0; RanRe = 0-8 staff who work out of their homes. D. State Regulatory Standards 0.4-2 da 1.0 0.4-2 da 1.0 0.4- 4 da _ _ . 0.5 .5-6 da 1.0 0.5-6 da 1.0 0.5- 2 da 23. In comparison with current federal Conditions of Participation and standards, are your state's licensing requirements for skilled facilities: a . ( 14 ) Exactly or about the same as the federal rules? b. ( 14) Less stringent than the federal rules? Stringent means operationally defined and demanding. The major differences are: c. ( 17) More stringent than the federal rules? The major dif ferences are: HCFA- 466

APPENDIX C / 335 OMB No. 0938-0395 STATE: 24. In comparison with current federal standards, are your state's licensing requirements for intermediate facilities: a. ( 11 ) Exactly or about the same as the federal rules? b. ( 12) Lower/less stringent than the federal rules? The major dif ferences are: c. ( 24) Higher/more stringent than the federal rules? The major dif ferences are: E. Special Surveyor Training 25. Have your surveyors received "specific" training to better justify enforcement actions when necessary, including 1 ) how to prepare better documentation of evidence; 2 ) how to be a better participant/witness in enforcement proceedings; 3 ) how to work with the court, with the district or state attorneys, and hearing officers? a. ( 33) Yes. (If yes, answer question 26. ) b. ( 14) No. (If no, skip to question 31. ) 26. How many hours of such training does each surveyor receive in a year? 7.5 Median RanRe = 1-96 27. Who conducts the training? a . ( 9 ) Staf f internal to our agency b. ( 1) State staff external to our agency, e.g. the District Attorney ' s of f i ce c . ( 2 ) Outs ide consultants d. ( 22) Combination of the above 28. Who pays for the training? Where do the funds come from? a. ( 26 ) Line item in our budget b. ( 7) c. HCFA-466 Included in another line item ( 1 ) Funds external to agency

336 / APPENDIX C OMB No. 0938-0395 STATE: 29. Has the training assisted the surveyor to carry out his/her duties? a. ( 33 ) Yes: comment, how b. ( 0 ) No: comment, how 30. Should the training continue? a . ( 34 ) Yes . b. ( 0) No. F. Survey Procedures and Coordination Arrangements 31. Are licensure and certification surveys combined? a. ( 2) Our state only conducts the federal certification survey b. ( 33 ) Yes, all the time. c. ( 11 ) Yes, sometimes. Please explain: d. ( 1) No, but they are both done by this agency on different visits ( 0 ) No, our agency does one; another agency does the other e. 32. How frequently are facilities in your state given the full licensure and certif ication surveys? a. All facilities are surveyed for licensure every 12 months. b. All facilities are surveyed for certif ication every 12 months . c. The time period between full surveys varies, depending on: 9 responses HCFA-466

APPENDIX C / 337 OMB No. 0938-0395 STATE: 33. If a full survey is not always given, do you use a screening or abbreviated survey to determine which facilities should receive a full licensure or certif ication survey? a. ( 7) Yes. b. ( 22) No. 34. During licensure/certification surveys, do surveyors conduct a "hands-on" assessment of residents? a. ~ 33 ) Always, as as matter of agency policy. b. ( 12) Sometimes, if necessary to collect information. c . ( 2 ) Rarely. 35. Have you changed your licensure and/or certif ication survey procedures in recent years ? a. ( 14) No. b . ( 33 ) Yes; the mad or changes are: 36. Does your agency have written guidelines or policies and procedures on how surveyors should interpret State regulatory standards ? a. ( 16) Yes. (If yes, please return a copy of the guidelines with this questionnaire . ) b. ( 31) No. 37. When is the statement of def iciency form (HCFA 2567 ) completed? a. ( 3) At the facility, for the exit interview. b. ( 41) At the survey agency office within Median = 10; Range = 2-18 days after the survey is completed. c . ( 3 ) Other, explain: HCFA-466

338 / APPENDIX C OMB No. 0938-0395 STATE: 38. Who has the authority to decide whether or not an F-number on the HCFA 1569 form or T-number on the HCFA 3070 form is not met, resulting in a statement of def iciency on the HCFA 2567 form? a. ( 39 ) Any surveyor. b. ( 3 ) The survey team leader. c. ( 2 ) A supervisor. d. ( 3 ) Other (please specify): 39. In surveying a nursing home for SNF certification, how many standards have to be def icient for the nursing services condition (F123 ) to be marked "not met"? Check the appropriate box and explain if required. a. ( 2 ) any one g · ( 0 ) 6 b. ( 1) 1 h. ( 0) 7 c. ( 2) 2 i. ( 0) 8 d. ( 1) 3 j. ( 0) 9 e. ( 0) 4 k. ( 5) only specific F's, namely f ( 0 ) 5 Director of Nurs inR ( 3 ); 24 -hr nurs in% ( 4 ); administration of druRs (3) 1. ( 36 ) it depends on 40. Which of the following documents does a surveyor routinely review prior to conducting a survey? Check all that apply. (45) previous licensure ( 47 ) previous certif ication (11) MMACS (34) (42) ( O) ( 7) (16) ( ) inspection of care reports complaints none of the above ombudsman reports other total Median = 4; Range = 2 - 7 HCFA-466

APPENDIX C / 339 OMB No. 0938-0395 STATE: 41. A number of agencies in addition to the survey unit collect or receive information about conditions in specific nursing homes. When information is received indicating that a facility is providing questionable care, what other units or agencies do you usually notify? Do they usually notify the survey agency when they receive information? Please check the appropriate boxes. ARency a. Medicaid Agency b. State Ombudsman c. Your own agency' complaint unit d. Your own agency' s consultant unit Certif icate of Need unit f . Res ident Advocacy 4 Groups g. State Department of 10 Ag ing HCFA Regional Office 35 i. Inspection of Care Unit 27 j. Medicaid Fraud Unit k. Other: HCFA-466 We Inf arm Them y Ye Regularly Some- t imes They Inf arm Us Ye ReRular ly Yes Some- t imes No 7 13 16 - 24 2 8 15 34 9

340 / APPENDIX C OMB No. 0938-0395 STATE: 42. If your agency conducts inspection of care reviews, they are done: a. ( 2 ) At the same visit as the certif ication survey. b. ( 3) At a different visit. c . ( 0 ) By the same team which conducts the certif icat ion survey. d. ( 2 ) By a separate team. Both a and c: 9 Both a and d: 0 Both b and c: 1 Both b and d: 3 43. Are inspection of care review f indings cited as part of the documentation of def iciencies on the HCFA 2567 form? a. ( 14) Yes (if yes, how frequently?): b. ( 17) No. HCFA-466 i. ( 8) often/all the time. ii. ( 5) sometimes/about half the t ime . iii. ( 1 ) rarely/almost never.

APPENDIX C / 341 OMB No. 0938-0395 STATE: G. Enforcement 44. Different states have different legal provisions for enforcing their nursing home standards. Below is a table that lists down on the f irst column several provisions. There are six other column headings labeled A through F.* As instructed please complete columns A through F. For Column A, "State Has Provision, " if your state has the provision, place a "y" on the appropriate line. If it does not, place an "n" on the appropriate line. Column B. "Recommending Agency, " we are also interested if the survey agency and/or some other agency recommends the legal action. If your agency recommends the action, place a "y" on the appropriate line. If another agency recommends, write the name of the agency on the provided line. In many states different agencies determine whether the legal provision will be carried out depending on the sanction. For each sanction please list the appropriate agency or individual in Column C, "Deciding Agency. " In Column D, "Number of Recommendations Carried Out," we would like to know the number of times the recommended actions were carried out in 1980 and 1983. Please write the numbers on the provided lines. In Column E, "Order of Importance, " please rank order your perspective of the importance to the regulatory process of each of the provisions using the numbers 1, 2, 3 or 4 where 4 = Very important 3 = Important 2 = Unimportant 1 = Very unimportant Finally, in Column F. "Order of Effectiveness," please rank order how effective you feel these provisions are in assuring compliance. Please rank each of the provisions using the numbers 1,2,3 or 4 where 4 = Very effective 3 = Effective 2 = Uneffective 1 = Very unef f ect ive If you do not use some of these sanctions, place an "X" on the line. *The following table is a modified version of the table used in the original survey. A few columns have been changed to show more clearly the composite response from the 47 states that replied to the survey. Columns A, B. and C are the same here as in the original survey. Col- umns D, E, and F constitute an expansion of the original column D, which simply requested the number of actions taken by each state in 1980 and 1983. (The new columns D, E, and F deal with 1983 only; figures for 1980 were dropped because of a low response rate.) The new column G shows the number of states that ranked the sanction ef- fective and the number that ranked it ineffective and is similar to original column F ("Order of Effectiveness"). The original column E ("Order of Importance") was dropped because the responses were ba- sically the same as those in column G.

342 / APPENDIX C OMB No. 0938-0395 LeRal Provis ion C ivi 1 or admin i strative f ines 26 Court-appointed receiver State-appointed monitor STATE: A B C D E F G State Recommending Agency Deciding ARency it States Carrying 1983 Range 1983 Effective/ Has Survey Other Out 1983 of # Actions Total It Ineffective Agency ( identify) Taken Actions 24 1 17 2- 90 _ 19 3 8 8 1-4 12_ __ 7 8 7 4 3 1 3 19/5 15/3 4/2 Suspens ion of all admissions 32 24 6 17 15 1-29 96 26/5 Cons iderat ion of past record in evaluation of cer tificate of need application 25 17 12 7 10 1-36 105 26 Court injunctions against substan dard operation 37 36 1 17 9 1 3 13 19/11 State- initiated relocat ion of res idents f ram substandard homes 36 31 5 21 14 1 8 27 22/8 Reduced Med i caid rates for inferior performance 9 6 12 3 1 10 10 4/2 Conditional or provis tonal licensing 35 34 2 22 14 1-72 268 23/8 Probat ionary license 15 14 6 8 5 1-72 154 9/3 Cr iminal penalties f or pat lent abuse _ 16 14 9 5 1-300 376 13/11_ License revocation 44 41 0 28 15 1-13 59 33/4 Involuntary decert i fication _ 39 1 22 13 1-55 129 26/7_ _ _ _ _ Withho lding of payments 19 8 14 5 3 4-263 272 3/2 Per State: Total sanctions available: Median = 8; Range = 1-14 Number of tvDes of sanctions applied: Median = 2; Range = 1-12 Total number of sanctions applied: Median = 11; Range = 1-457 HCFA-466

APPENDIX C / 343 OMB No. 0938-0395 STATE: 45. Does your agency have written guidelines on when or how formal enforcement action should be taken against a facility with def iciencies? a. (20) Yes. (If yes, please return a copy of the guidelines with this questionnaire . ) b. (27) No. 46. Does your state have a law requiring mandatory reporting of patient abuse? a. (38) Yes. b. ( 9) No. 47. Does your state have a law permitting residents to sue facilities to protect their rights? a. (24) Yes. b. (18) No. 48. Does your state have other legal provisions which can be used to enforce quality of care standards? a. (30) No. b. (16) Yes. Send copy or list: 49. Does your state have a system which rates nursing homes and publicly discloses the ratings? a. (41) No. b. ( 6) Yes, it is operated by Survey Agency. 50. Do nursing homes with good compliance records (e.g., few deficiencies) receive higher Medicaid reimbursement rates or receive an incentive payment? a. ( 6) Yes. b. (41 ) No. skip to question 52 51. What proportion of the homes in your state are currently receiving the higher rate( s ) ? Median = 30% RanRe = 28-32% 52. When you recommend court action, is there an attorney on staff to take care of this? a . ( 13 ) Yes, the attorney is part of my agency' s stat f b. (31) Yes, the attorney is part of the state or district attorney's staff but is assigned to my unit. HCFA-466 c. ( 3) No. d. ( 0 ) Don' t know; we have never requested court action.

344 / APPENDIX C OMB No. 0938-0395 STATE: 53. When you recommend court action, does the state attorney general carry out your request by filing suit? a. ( 20 ) All of the time b. ( 11 ) Most of the time c . ( 12 ) Some of the time d. ( 2 ) Don' t know; we have never requested court action. When you have taken a facility to court, do you think the courts have supported the agency's position? a. ( 3 ) All of the time b. (20) Most of the time c. (15) Some of the time d. ( 9) Don't know; we've never taken a facility to court. The next several questions address the effectiveness of various enforcement efforts. For these questions effectiveness is defined as getting the facilities to comply with nursing home regulations, terminating contracts with facilities that fail to comply, as well as the speed and thoroughness with which the sanction is carried out; e. g. new admissions to the facility were stopped immediately on court order. You need to refer to your answers to question 44. 55. In general, would you say your agency or state enforcement efforts have been a . ( 15 ) Very ef fective? b. (29) Effective? c . ( 3 ) Not effective? 56. Why are the sanctions you ranked "number 4" listed in question 44, Column F. "Order of Effectiveness," effective? Affect income of provider (20) Quick implementation ( 7 ) PublicitY ( 5 ) Ability to remove operator (4) 57. What are the obstacles to effective use of the sanctions you ranked "number 1" in question 44, Column F. "Order of Effectiveness?" Delays Difficulty of Administering ( 3) Potential harm to residents ( 4) Small impact on provider income ( 2 ) (11) HCFA - 466

APPENDIX C / 345 OMB No. 0938-0395 STATE: H. Views on Federal Regulations 58. The current federal Conditions of Participation for skilled nursing facilities: a. ( 8 ) Can ensure nursing home services of adequate quality as they are. b. ( 9) Can ensure nursing home services of adequate quality, if they deleted some unnecessary or unmeasurable provisions. c. (20) Could ensure adequate quality services if they included certain additions and modifications. d. (10) Cannot ensure adequate quality services without a major overhaul and reorientation. 59. The current federal standards for intermediate nursing facilities: a. ( 6) Can ensure nursing home services of adequate quality as they are. b. ( 8) Can ensure nursing home services of adequate quality, they deleted some unnecessary or unmeasurable provisions. c . ( 20 ) Could ensure adequate quality services if they included certain additions and modif ications . d. (13) Cannot ensure adequate quality services without a major overhaul and reorientation. Which of the following statements do you feel is an accurate description of the situation in your state? 60 . The current f ederal survey Procedures: a. (11) Work reasonably well as they are in assuring that Medicare- and Medicaid-funded residents do not receive substandard services . b. ( 7 ) Would work as well if certain unnecessary or unmeasurable items were dropped. c . ( 7 ) Would work reasonably well if HCFA gave the states Bore support when they move to terminate substandard facilities. d. ( 20 ) Would work adequately if some changes and additions were made . e. ( 2 ) Need to be completely revised. HCFA-466

346 / APPENDIX C OMB No. 0938-0395 STATE: 61. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations ) inhibit quality patient care? Utilization Control (2) 62. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations ) are currently ineffective and should be dropped completely? Utilization Control ( 11 ) Quarterly Staff Reports ( 5) 63. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations) should be retained in a modif fed or alternative form? Nursing Services (52 Medical Director (4) Physician Services (4 ) 64. Which, if any, federal survey and certification regulations ( including both the Conditions of Participation and the Subpart S regulations ) are neither effective nor worth the time and cost? Utilization Control ( 11 ) 65. List what you feel are the f ive most important federal survey and certif ication regulations ( including both the Conditions of Participation and the Subpart S regulations ) for ensuring adequate quality patient care? 1. Nurs ing Services (36) 2. Dietetic Services (30) 3. Pharmaceutical Services (24) 4. Physician Services 5. Physical Environment ( 19) (13) 66. What, if anything, should be in the federal survey and certification regulations ( including both the Conditions of Participation and the Subpart S regulations ) that is not there now? Resident Assessment Outcomes (13) Intermediate Sanctions ( 6 ) Staff Ratios ( 5) HCFA-466

APPENDIX C / 347 OMB No. 0938-0395 STATE: 67. The current requirement for annual surveys of all federally certified nursing homes should be made more flexible to permit less frequent surveys of facilities with histories of compliance and more than annual surveys of facilities with histories of noncompliance. a. ( 12 ) Strongly agree b. ( 11 ) Agree c. ( 10 ) Disagree d. ( 14 ) Strongly disagree ) 23 ) 24 68. The time-limited agreement requirement should be dropped because its usefulness as an enforcement tool is outweighed by the consequent ability of facilities to predict the timing of survey visits. ( 14 ) Strongly agree c. b. ( 14 ) Agree (12) Disagree d. ( 7 ) Strongly disagree ) 28 19 69. A short screening instrument should be used in conjunction with more flexible survey cycles to identify which facilities should receive more f requent full surveys . a. ( 11 ) Strongly agree b. ( 23 ) Agree somewhat c . ( 6 ) Disagree d. ( 7 ) Strongly disagree ) 34 ) 13 70. It is desirable and practical to include a patient-centered assessment in the certif ication survey process. a. ( 30 ) Strongly agree b. (15) Agree c . ( 0 ) Disagree d. ( 1 ) Strongly disagree HCFA-466 45 1

348 / APPENDIX C OMB No. 0938-0395 STATE: 71. A sample of alert nursing home residents should be interviewed and their opinions be included as part of the survey process. a. ( 10) Strongly agree b . ( 8 ) Agree c . ( 3 ) Disagree d . ( 0 ) Strongly disagree ) 18 3 72. How many on-site visits should be required to verify correction with all items identified as deficiencies in a Statement of Deficiencies/Plan of Correction form? a. (30) One on-site revisit is adequate and more practical in most cases. b. ( 13) Several; there should be a series of on-site visits if there are multiple deadlines for corrections. c . ( 3 ) None, because on- s ite vis its are expens ive and some common def iciencies can be adequately verif fed by telephone or mail . 73. Accreditation by JCAH or some other accrediting body should be permitted to stand in place of state surveys for federal certif ication purposes . a. ( 1 ) Strongly agree b . ( 0 ) Agree c. ( 11 ) Disagree d. (35) Strongly disagree 1 ) 46 74. The federal regulations should require posting of survey results. The posting should include whether or not the facility is in compliance in general and list the specif fed elements found not to be in compliance. This posting should be in a prominent location in each facility. a . ( 17 ) Strongly agree b. ( 13 ) Agree c. ( 13 ) Disagree d. ( 4 ) Strongly disagree HCPA-466 ) 30 17

APPENDIX C / 349 OMB No. 0938-0395 STATE: 75. The regulations, procedures, and forms for surveying skilled and intermediate level facilities should be combined in to one comprehend ive survey . a. ( 18 ) Strongly agree b. ( 18 ) Agree c. ( 9 ) Disagree d. ( 1 ) Strongly disagree ) 36 ) 10 76. Should the inspection of care review system be integrated with the process of surveying nursing homes for certification? a. (26) Yes, they both should be done at the same visit by different teams so that significant inspection of care problems can be cited and corrected in the survey process while the burden on providers is reduced. b. ( 6) Yes, and to save costs and avoid duplication, they should be done by the same team as well as during same visit. c . ( 7 ) No, the two functions should be conducted by separate agencies or departments, because they have different foci (patient vs. facility) and/or two visits allow better surveillance of facilities. d. ( 7 ) No, they are separate functions, but they should be under the same supervisor in the state health or health and human services department so that the pertinent f indings of each process can be shared. 77. Federal regulations should contain a requirement for state certif ication of nurses aides . a. ( 14 ) Strongly agree b. ( 20 ) Agree c . ( 10 ) Disagree d. ( 2 ) Strongly disagree HCFA-466 ) 34 ) 12

350 / APPENDIX C OMB No. 0938-0395 STATE: 78. Specific minimum nursing staff to patient ratios should be adopted in the federal regulations. a. (13) Strongly agree ) ) 32 b. ( 19 ) Agree c . ( 13 ) Disagree d. ( 2 ) Strongly disagree HCFA-466 ) 15

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As more people live longer, the need for quality long-term care for the elderly will increase dramatically. This volume examines the current system of nursing home regulations, and proposes an overhaul to better provide for those confined to such facilities. It determines the need for regulations, and concludes that the present regulatory system is inadequate, stating that what is needed is not more regulation, but better regulation. This long-anticipated study provides a wealth of useful background information, in-depth study, and discussion for nursing home administrators, students, and teachers in the health care field; professionals involved in caring for the elderly; and geriatric specialists.

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