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3. Regulatory Criteria
Pages 69-103

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From page 69...
... 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)
From page 70...
... 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.
From page 71...
... 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
From page 72...
... 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.
From page 73...
... 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.
From page 74...
... 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.
From page 75...
... 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)
From page 76...
... , 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.
From page 77...
... 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.
From page 78...
... 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.
From page 79...
... 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.
From page 80...
... Providers have reported during public meetings that the survey process requires such extensive maintenance, review, and abstracting of medical records and other documents that they are sometimes forced to assign resident care staff to these clerical tasks even though it interferes with the facility's ability to provide provision of necessary care to residents. Recon'n~enclation 3-3: The existing SNF conditions and standards should be rewritten in accordance with the above principles and matte applicable to all nursing homes.
From page 81...
... 3. Seven existing conditions of participation-governing body and management, utilization review, transfer agreement, disaster preparedness, medical direction, laboratory and radiological services, and medical records -- should become standards in a new condition to be called "administration." 4.
From page 82...
... 11. Social services (XI)
From page 83...
... Thus, in reorienting the approach of regulation to give more emphasis to the care being provided and its effects on the residents, a new quality-of-care condition is needed that has both process and outcome standards. The standards for the quality-of-care condition should identify desirable resident outcomes of care processes in functional status, physical well-being and safety, emotional well-being, social involvement and participation, cognitive functioning, and resident satisfaction.
From page 84...
... Introduction of the resident assessment data system recommended below will make it possible to produce, in a few years, the data required for defining the ranges of outcomes. As quantitative outcome data become available, the standards in this condition should be updated.
From page 85...
... The likelihood of improving facility performance and also of improving enforcement by the state regulatory agencies will be increased by (1) raising residents' rights to a condition of participation from its current status as 1 of 13 standards under the "governing body and management" condition of participation, and (2)
From page 86...
... b. Each resident has the right to know the name, address, and phone number of the state survey office, state or local nursing home ombudsman office, and state or
From page 87...
... The notice must contain the reason for the proposed transfer, the effective date, the location to which the facility proposes to transfer the resident, a statement that the resident may contest the proposed action, and the address and telephone number of the state or local nursing home ombudsman.
From page 88...
... The residents, however, have the right to refuse or terminate · ~ any visit. Administration According to the HCFA, the following seven conditions of participation are rarely cited as the reason for a nursing home being out of compliance: Governing body and management Utilization review Transfer agreements Disaster preparedness Medical direction Laboratory and radiological services Medical records .
From page 89...
... In the process of rewriting the seven conditions as standards, two items should be eliminated because they are examples of paperwork requirements that do not seem to serve any regulatory function: the standard on institutional planning and the requirement for routine submission of quarterly staffing reports. Staffing records may be examined if resident care problems suggest insufficient numbers of staff, but submission every 3 months to survey agencies is unnecessarily burdensome to facilities, and the reports are almost never used by the regulatory agencies.
From page 90...
... Nursing homes or other potential employers could arrange and pay for the training program for a newly hired aide. This would not put undue financial burden on the potential aide and may in fact screen out potentially unsatisfactory aides prior to their being given resident care responsibilities.
From page 91...
... As the U.S. Senate Special Committee on Agingi2 reported, Findings of a recent committee investigation show that in some areas of this country, up to 80 percent of what are called federally certified nursing homes (that is, those that voluntarily participate in the Medicare and/or Medicaid programs)
From page 92...
... The General Accounting Office20 summarized 1 1 studies conducted since 1979 and concluded that severe access problems and discrimination were occurring on the basis of resident "handicap." Individuals who required especially heavy care or substantial hands-on care, such as those suffering from Alzheimer's disease and other related disorders, experienced access problems and were often in hospitals awaiting nursing home placement even when there were empty nursing home beds in the community. The nursing homes simply refused to admit these residents.
From page 93...
... 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.
From page 94...
... 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.
From page 95...
... 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.
From page 96...
... 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
From page 97...
... 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.
From page 98...
... 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.
From page 99...
... 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.
From page 100...
... 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!
From page 101...
... 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.
From page 102...
... 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.
From page 103...
... 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.


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