GUEST PERSPECTIVES ON LONG-TERM CARE.

This Month: Beth A. Klitch, FACHCA, President, Survey Solutions, Inc.

In commemoration of its 50th anniversary, Nursing Homes/Long Term Care Management has invited several long-term care experts to comment on how the field has evolved during the last five decades. This month, Beth A. Klitch, FACHCA, a national authority on OBRA surveys and enforcement and former director of the state of Ohio's survey agency, reflects on the impact these groundbreaking and controversial regulations have had-for better and for worse--on the field and on her life, both professionally and personally. Questions were posed by Editor Richard L. Peck.

How did you get involved with long-term care?

I was a contract investigator examining Medicaid cost reports and settlements for potentially fraudulent claims from 1985 to 1989, then moved to the Ohio Department of Health to serve as the state's survey agency director from 1989 to 1992. In that role, I also served as the secretary, and then vice-president, of the Association for Health Facility Survey Agencies (AHFSA). In 1992, I founded Survey Solutions, Inc., offering consulting services to help nursing homes achieve and sustain compliance with Medicare/Medicaid regulations.

How did the field "look" back then, compared to now?

The nursing home industry has struggled over the past decade, and is still facing the challenge of professionalizing its leadership ranks, securing stable funding, establishing state-of-the-art systems of care, and recruiting and retaining high-quality staff. In the late 1980s, many nursing homes had not yet standardized their resident assessment processes, had not implemented formalized staff training and did not always conform their standards of care to federal requirements. Many nursing homes 15 years ago were still owned by investors and nonhealthcare professionals, who didn't always keep up with modern management and caregiving practices.

This has changed. After undergoing several years of consolidation by large, publicly owned companies that were more modern in their approaches, some nursing facilities are now being sold to smaller, privately owned and financed regional operators, many of whom are healthcare professionals, and are able to invest in genuine long-term improvements, rather than serve at the whim of Wall Street. This situation might be creating the best of both worlds.

What was the immediate impact of OBRA '87 when it was passed?

OBRA '87 literally transformed the landscape of long-term care. There was mass hysteria, widespread confusion and unadulterated panic concerning how to meet the aggressive time frames for OBRA implementation. Both regulators and providers were facing new standards, new survey procedures and new enforcement consequences. The MDS assessment form was initially perceived as "just more government paperwork," the survey requirements expanded to 323 separate requirements and, for the first time, providers faced the potential impact of intermediate sanctions, rather than the "termination or nothing" option previously available to regulators.

In general, we began the slow transition from facility-based care policies to resident-centered care practices--and we are still making that transition.

What was it like running a survey agency?

From 1989 through 1992, the state survey agency faced dozens of provider lawsuits, hundreds of union grievances--about three-fourths of all state survey agencies are unionized and/or civil service-governed, often by multiple unions--and thousands of internal accountability and management problems. As a 31-year-old novice government administrator, appointed by a lame-duck governor to run a large agency facing dramatic federal mandates, it was all quite overwhelming for me. I recall having to use a felt-tipped pen on the walls just to mark the many twists and turns from the parking garage to my office.

Not all of my surveyor staff were happy about new review policies put into place to safeguard the accuracy of survey reports, and not all providers were especially happy about the agency's intensified enforcement actions aimed at repeat offenders. I recall one particular nursing home operator who literally held me hostage in my office for more than four hours--he said he had a gun in his pocket (it was actually a stick)--because he was upset that we had proposed to terminate his facility from Medicare and Medicaid after several ventilator-dependent residents died of asphyxiation during a power outage. This occurred because he had no functioning backup generator or emergency nursing procedures to sustain the residents until they could be hospitalized.

Mostly, though, I remember advocates, providers and surveyors, of good faith and exceptional dedication, helping to steer our industry through "OBRA-roiled" waters.

What are the important changes you've seen in the field since implementation of OBRA '87 (both good and bad)?

There can be no doubt today that the original OBRA reforms were badly needed to help guide providers toward resident-centered care practices; to restore public faith in government oversight of Medicare and Medicaid spending for long-term care; to provoke our collective consciousness that, as a society, "we could do better" by our nursing home residents; and to ensure consequences for failing to do so. New generations of nursing home owners, administrators, directors of nursing and other managers now accept and expect outcomes of care to be rigorously measured and stringently enforced. I think residents have benefited from improved care practices and better oversight of Medicare and Medicaid program requirements.

The downside of OBRA has been twofold, in my opinion. First, we lost a lot of long-serving, compassionate nurse aides, who were afraid of the new nurse aide training and testing requirements, perhaps because they had been out of school for a long time, or perhaps because they lacked formal education or even literacy skills; I know that, in Ohio, we lost 20,000 such nurse aides in part for that reason. Second, we created a much more acrimonious relationship among advocates, regulators and providers, who really need, more than ever, to "pull in the same direction."

You had the somewhat unusual experience for someone in your position of being a nursing home resident yourself. What was that like?

In 1993, I suffered a serious stroke, resulting in loss of speech and paralysis of my right side. After initial treatment in an acute care setting, I was moved to a skilled nursing unit, and I can report on the care I received in OBRA survey terms: I underwent intensive physical rehabilitation (F406). I was very grateful then, and remain grateful seven years later, for the well-trained (F498), compassionate (F241), professional (F499) caregivers who assessed my condition accurately (F272), who developed a detailed care plan to meet my needs (F279), and who delivered the care I needed, every hour, every shift and every day (F309). I credit my dedicated caregivers (F353), concerned administrators (F490) and supportive family (F157) for helping me reach a full recovery. In my opinion, OBRA '87 nursing home reforms have had an enormous impact from the resident's "side of the sheets."

What is your perspective on the near-term future in regards to survey and enforcement?

I respect the need to separate survey and consultation functions from being performed by the same individuals. I don't think we can or should return to the "old days" in which surveyors consulted on one hand, and then enforced with the other, creating an untenable conflict of interest. I do think that many providers are yearning for new information, updated knowledge and "real-life" solutions to the "real-life" problems that confound delivery of care to nursing home residents today. There is room for many innovative approaches to consultation from both private and public sources.

There still is room, as well, for reform of the current survey and enforcement system, namely, that survey requirements need to be made easier to implement in the nursing home setting; that survey protocols must be made clearer to both surveyors and providers; that we must limit the amount of discretion that surveyors use in determining whether deficiencies exist and their level of scope and severity; and that we must have swift and fair consequences for repeated noncompliance. It is not necessarily the system that is off-target, but rather consistent execution of care, consistent survey interpretation and consistent consequences for demonstrated noncompliance.

Finally, as long-term-care industry professionals, we must be willing to deliver high-quality care for each and every nursing home resident and, by the same token, as American citizens, we must be willing to pay for highquality care for each and every resident.