Clinton's survey initiative: action reaction.

The Feds report that things have improved, but not enough, and outline their plans to make nursing home care better

It was not all bad news. In fact, there was much for nursing homes to be proud of during this summer's flap over the OBRA survey and enforcement process and its "failures." Part of an independent 900-page report released by Secretary of Health and Human Services (HHS) Donna Shalala showed real progress made since new enforcement regulations took effect July 1, 1995: The overuse of antipsychotics decreased from 33% to 16%; the use of historically underused antidepressants increased from 12.6% to 24.9%; inappropriate use of physical restraints declined from about 38% to under 15%; inappropriate use of indwelling urinary catheters declined by nearly 30%; and the number of nursing home residents provided with needed hearing aids increased 30%.

But then came the bad news. The study, commissioned originally to evaluate the feasibility of deeming Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) accreditation as a substitute for state surveys, concluded that deeming was not to be. The Joint Commission missed too many deficiencies, the investigators said, leading HCFA to conclude it was still the only game in town. But HCFA's own processes needed improvement, the study concluded.

This was underscored when the second shoe dropped: a General Accounting Office (GAO) report on California nursing homes indicating that over half the residents studied (62, total) received "unacceptable" care and one-third of nursing homes had been cited for serious or potentially life-threatening problems, without apparent effect. Before the Senate Special Committee on Aging conducted hearings on this, though, HHS had already weighed in with its recommended fixes.

Reaction What the DONs Say

California: Stop nitpicking about paper and look at the patients

Regulations are important to this industry in order to set high standards for performance. The problems in long-term care throughout the U.S. cannot go without corrective measures. The united efforts of surveyors, facility administrators and industry associations should be used to promote systems to improve conditions and eliminate these problems. However, intense reporting and rectifying events retrospectively deters us from making progress in these areas, because of the implementation of excessive paperwork, forms, policy revisions, and so on, many of which are needed to address only a single event.

Planned surveys, or scheduled reviews, would promote compliance with regulations and promote efficiencies of improvement far better than surprise visits that interrupt patients' care. Facilities of varying quality are grouped into one stereotype throughout the nation, and that is an image of neglect, horror and death. This makes many of them feel like dolphins caught in tuna nets. So many positive experiences happen in nursing homes that are never promoted to the public.

The healthcare industry has changed drastically with managed care. Many facilities that used to be only long-term care are now subacute hospitals with lengths-of-stay less than 12-14 days, but which are treating patients with the acuity level of an acute care patient. Legislation could best help nursing homes by revising cumbersome mandated paperwork, by promoting objective rather than subjective standards and by instituting regulations that are more appropriate to the level of care delivery of today.

Reports to the public regarding dehydration rates, skin breakdown and deaths are definitely skewed and never reflect the percentage of residents who are admitted with those conditions. Public reports also do not give the percentages of dehydration and death that are due to the will of the resident and are that resident's legal right to decide.

I would invite any government representative to spend a day in the "moccasins" of my staff before they misinterpret the allegations made against this industry. Healthcare providers love their work, but too many of the good ones are leaving in disgust and frustration, intimidated by regulations and unfair inferences expressed by authorities.

Donna D. Young, RN, MBA, ARM, is director of clinical services, Integrated Health Services, Orange, CA.

RELATED ARTICLE: Action

* HCFA will step up review of facilities' ability to prevent pressure ulcers, dehydration and malnutrition, and will work with other groups to share best practices for residents at risk of weight loss and dehydration.

* Inspectors will review facility systems to prevent, identify and stop physical or verbal abuse, neglect, and theft of resident property. A description of each nursing home's abuse prevention plan will be shared with residents and their families. Nursing homes are asked to inquire about criminal convictions when interviewing job candidates.

* Individual facility survey results and violation records will be posted on the Internet to increase accountability and make information more accessible.

* Enforcement will have special focus on chains whose members have a record of non-compliance.

* Inspection times will be staggered and conducted more on weekends and evenings to reduce predictability.

* Inspections will be held more frequently for serious repeat offenders.

* Nursing homes guilty of a second offense for violations that harm residents will face sanctions without a grace period to correct the problems before penalties ensue.

* Sanctions will not be lifted until an on-site visit has verified compliance.

* HCFA will instruct states to impose civil monetary penalties for each instance of serious or chronic violation, not for the number of days a facility is out of compliance.

* HCFA will work with the HHS Inspector General and Department of Justice to ensure that state survey agencies and others refer appropriate cases for prosecution under federal civil and criminal statutes, especially if cases result in harm to residents.

* HCFA will provide extra training and other assistance to inspectors in states that it feels are not adequately protecting residents. Training will begin this October and will focus on the problem areas of nutrition, dehydration, pressure ulcers and abuse. HCFA will enhance its reviews of state surveys and implement standard evaluation protocols in every state by this fall to avoid uneven enforcement of regulations. The President has asked Congress for an additional $13 million for inspections, for a total of $167 million.

* States that do not perform surveys adequately will lose federal funding and HCFA will contract with other entities - possibly surveyors in more successful adjoining states - to conduct the state's surveys and certification. The Administration will also ask Congress for new legislative authority to improve nursing home care and safety via the following:

* Requiring a criminal background check for employees and establishing a national registry of employees convicted of abusing residents

* Allowing more types of workers, with proper training, to perform crucial nutrition and hydration functions

* Reauthorizing a strong ombudsman program through the Administration on Aging.

HCFA will also begin to analyze Minimum Data Sets to identify potential areas of unacceptable care and assess performance in avoiding pressure ulcers, loss of mobility, weight loss and use of restraints - this in order to better identify sites for inspections and proactively address systematic problems.

Finally, HCFA has asked for legislation to collect users' fees from Medicare providers and suppliers who request Medicare certification, both for initial surveys and for recertification surveys. The fee amount would reflect the unit costs of a federal survey and costs incurred by state survey agencies as well, so costs would vary by state. Fees would be credited to HCFA's program management appropriation and the fee for the initial survey would be payable at the time of the survey.

Though this "get tough on nursing homes" approach might play well in Peoria, what about the providers and surveyors themselves, for whom state surveys are a day-to-day reality? How will this impact them? Following are excerpts from a series of interviews.

RELATED ARTICLE: New York: Start with high standards, maintain them with education

by Jill Paryz, RN

The key to good care is creating a culture of high standards that are maintained every day, 100%, with no wavering. This facility had a lot of problems two years ago when I took over as director of nursing, with 60 days to keep the doors open. And we did it by mandating high standards. The following year we had a deficiency-free survey, the first ever at this facility, and we kept that record the next year. I have a lot of the older employees from that earlier era who now subscribe to those high standards. It took handholding, teaching, building and grooming for them to learn to maintain them.

From the moment I started here, I applied that same perfectionism to the hiring process. When I hire, I work to build a good team that has a vision. During the interview, I ask applicants to tell me about the nurse's role in preventing pressure sores, for instance, or I ask if they think odors are normal in a nursing home (they're not and must be dealt with). The candidates really have to sell me on their perceived role in care and prevention. They have to tell me more than how they took care of their grandparents.

For noncertified positions, the candidates do not necessarily need to know the specifics of care, but in talking to them I can tell if they understand the standards that we are meeting. People who do not subscribe to our code of integrity and credibility are not part of the team.

In addition to maintaining the basics, we also have to stay current on new issues in geriatrics. I started a big education push in 1997 as part of a proactive nursing quality model. We developed an in-service program to keep people current. We have a universal education day every Wednesday for 30 to 45 minutes, starting strictly on time, which we videotape. We are flexible with our topics, and we use the time to stay on top of things. We pay workers for their time if they are not working that day, and if they miss it, they have a week to make it up at their convenience, or they are disciplined.

It is rigid, but it's an important way to maintain high standards. This program has been in place for about a year, and what a difference!

I think that there is a need for Clinton's initiatives. I think all nursing facilities want to give good care. I know that regulations can be a little difficult to comply with, but you must be very strict about following them. In short, we have a philosophy and a vision. We do more than minimum. We do more than our best.

Jill Paryz, RN, is director of nursing services, Mount St. Mary's Nursing Home, Niagara Falls, NY.

RELATED ARTICLE: Ohio: Keep staff happy - and keep staff

by Dianne Torgersen

As the Medicare/PPS/Medicaid system is stretched to its limit, reimbursement for the care our elderly receive in tong-term care continues to decline. Attracting and keeping good staff is a challenge facing all in the healthcare arena. The domino effect occurs when we cannot maintain the highest level of care our elderly deserve because of staff turnover.

Where are the dollars coming from to help our elderly? The country needs to evaluate its priorities and value our elderly. Our population with Alzheimer's disease and related dementias will number between 12 and 14 million as the baby boomers reach this age group. The insurance industry has developed long-term care policies and needs to continue to take a leadership role in this area.

There have been many surveys across the country that look at reasons for staff satisfaction and retention. Those who have responded generally do not put money at the top of the list of what they desire from a job. What they want is recognition, self-esteem and to be part of a team. Recognition and teamwork will lead to high-quality, compassionate care for our elderly. Other factors such as career ladders, retirement plans and tuition help will also promote staff satisfaction and retention.

Dianne Torgersen, BSN, RNC, is director of the dementia unit at East Galbraith Health Care Community, Cincinnati, OH.

RELATED ARTICLE: Florida: National associations can play a bigger role

by Laura Fain, RN, CDONA 

There have been a lot of regulatory changes, and care of the elderly has improved, such as increased use of antidepressants, decreased use of antipsychotic drugs and reduction of physical restraints. We all know there are a lot of homes that allow abuse and neglect to happen. They haven't dealt well with that situation in the past. Professional associations such as NADONA do not have the authority to deal with these facilities, but they could put standards in place and impose some kind of sanctions or provide some assistance, if requested, for facilities that do not meet standards or which are uncovered as "bad facilities." Associations, for instance, could deny the facility the privilege of displaying a quality designation of that association. NADONA is spearheading a special forum on abuse and neglect this year, and I hope that other associations would also get involved. The profession has a role to play in improving nursing home care, and I would hope that we could do this on our own, within the industry, without further regulation.

One place that more regulation might be needed, though, is in the matter of staffing. It's the biggest issue in long-term care today - the biggest resource used at our facilities and the DON's biggest challenge. I think we need to legislate, at a national level, the very minimum number of staff needed. Then we need to increase that number according to patient needs and increased acuity levels. It has to come from the top down. There are not any mandates out there that tell you the numbers of staff you need to have. You can't just give facilities the latitude to choose the number of staff, because the acuity level can change greatly in a short period of time. The DON must have the ability to assess the acuity level and staff accordingly. And with the advent of the PPS system, with its emphasis on the bottom line, staffing will probably be reduced even further. My assistant is working on a statewide study of staffing needs, and maybe we will learn something from that.

Laura Fain, RN, CDONA, is director of nursing at the LRMC Nursing Center, Leesburg, FL, and president of NADONA/LTC.

RELATED ARTICLE: Reaction

The Provider and the Regulator

Leslie Libow, MD, Chief of Medical Services, Jewish Home and Hospital for Aged, New York: "No imposition of rules or enforcement from the outside is likely to have a lasting impact on nursing home care. For that you need change from within. That means investing in training and education for staff, raising their salaries to a level more commensurate with the task and establishing a career ladder for them. But government funding has to support this.

"For decades, hospitals were supported for medical education through Medicare. This was done because society thought there was a correlation between education and quality. This is even more needed in nursing homes. Unless society has decided to cast off the frail elderly - and it may well have - there will come a realization that there is no budget for education and thus for quality. And we will end up with investigation after investigation.

"The importance of staff support is evident from our own experience with a restraint reduction program here at the Jewish Home and Hospital. We went from 50% of residents restrained, for a few minutes to a few hours per day, to 4% within two years. With a grant from the Commonwealth Fund, we were able to extend this program to a research intervention with 16 facilities in four states. The study showed that across the four states there was reduction to a level of approximately 34% in restraint utilization. Staff took tremendous pride in this achievement. They were far ahead of hospital staffs in their capabilities here and they knew it.

"A key point here, though, is that we, as a nonprofit, were able to raise a $1.7 million grant. The for-profit world needs the government to provide this sort of support or it just isn't going to work out."

RELATED ARTICLE: Becky Moore, President, Association of Health Facility Surveyors, and Assistant Deputy Commissioner for Special Health Services, Oklahoma Department of Health: "We're a little concerned regarding possible additional costs to the states. HCFA hasn't had an increase for quite some time. I agree with randomizing the surveys more, if staff is available, but most states right now are stressed to the limit.

"We definitely favor immediate imposition of penalties. We wrote HCFA in 1995 that facilities that have substandard quality of care should not have an opportunity to correct this without penalty. The concept under the enforcement regulations that such facilities would have a 'date certain' for correction and re-inspection came as a shock to us state survey directors. Since then, facilities have had about 45 days to get into compliance, but we still find facilities out of compliance by then, which is when penalties are imposed. The purpose of the regulations, though, was to get a quick resolution of substandard care.

"Some say facilities have financial problems in remaining compliant, but our responsibility as surveyors is to focus on quality of care. Financial difficulties in long-term care are a point well taken, and this probably should be looked at nationally. I will say, though, that even though we in Oklahoma have the lowest Medicaid rate in the nation, I continue to see facility cost reports showing them making money.

"As for our own funding, we are budgeted to a 'T.' In fact, we have a problem in that HCFA has taken money out of non-long-term care survey and certification programs to fund the long-term care part. One upshot of this is that we have a resurvey rate of nonaccredited hospitals of once every 10 years, compared to once every 12 to 15 months with nursing homes. Some providers are simply not getting regular oversight, and I get the feeling that someday this will blow up in our faces."

RELATED ARTICLE: JCAHO Responds

Following HCFA's stinging criticisms based on the Abt Associates report, the Joint Commission on Accreditation of Healthcare Organizations responded in a statement to the Senate Special Committee on Aging. Excerpts follow:

"We find it regrettable that HCFA, facing severe criticism by the Government Accounting Office for its own inspection and enforcement process for nursing homes, found it necessary to issue as part of its response to that criticism a negative report about the advisability of relying upon private sector accreditation. Given the highly charged political climate surrounding nursing home enforcement, coupled with HCFA's reliance on long-term care appropriations to support its certification budget, it is not surprising that the findings of its report to Congress offer an unfavorable view of the role of private sector accreditation in oversight of nursing homes."

"It is also significant that the report shifted focus from its original intent to evaluate the role that private sector accreditation could play in a constructive partnership with HCFA for improving long-term care oversight. Instead, the report presented an evaluation of the Joint Commission as if the accreditation survey had been performed in lieu of a Medicare nursing home survey. Because the Joint Commission does not have long-term care deemed status, such a comparison is at best misleading. Moreover, the Joint Commission would never wish to replicate HCFA's flawed enforcement process for nursing homes.... Private sector accreditation is never a replacement for enforcement processes. Rather accreditation can support and improve enforcement programs, and lead to the achievement of quality of care goals that regulatory approaches can never attain."

"The (Abt) study's side-by-side comparison of a cohort of HCFA and Joint Commission survey reports failed to note the areas where the Joint Commission found deficiencies and HCFA did not. In fact, the comparison was so biased as to ignore numerous instances where the Joint Commission findings were similar' or more severe than those found by HCFA, and to omit an important situation where the Joint Commission denied the accreditation of one nursing home, but HCFA continued to certify the facility."

"HCFA makes highly charged statements about instances where HCFA found significant problems in some of the 179 nursing homes in the study and the Joint Commission did not find the same problems. Yet HCFA fails to tell the reader the fact that in the majority of those cases, HCFA was the first survey team in the door. Consequently, one would not expect the Joint Commission to find the same problems 30 to 90 days later, because those problems should have been corrected in accordance with HCFA's own regulatory time frames.

"HCFA failed to report that in the majority of cases where HCFA completed its survey before the Joint Commission review took place, the Joint Commission found more problems, and more serious problems, than when HCFA was second in the door. This casts doubt on HCFA's capacity to discern and effect quality improvement in a comprehensive set of areas, because the Joint Commission survey occurred shortly after the departure of the HCFA surveyors."

"Despite HCFA's repeated agreement to allow Joint Commission input, HCFA chose to release the report under premature circumstances. In so doing, HCFA missed the opportunity to correct flagrant errors and have a meaningful report. At the same time, avoiding Joint Commission feedback on the preliminary analysis gave HCFA the freedom to make unsupportable statements about the accreditation process." NH