Get ready for the GAO survey enforcement report.

Does imposing enforcement remedies work? Does tough enforcement deter poor performance by other nursing facilities? Does it punish poor-performing facilities? Does it prevent future noncompliance by facilities? Does it result in the closing of "bad" facilities? Does it enhance the quality of life for Medicare and Medicaid beneficiaries?

No one knows the answer to these questions, but the General Accounting Office (GAO) of the United States Congress intends to find out. The GAO is conducting a study of the effectiveness of the nation's survey enforcement system. The GAO will issue a detailed report (perhaps around the time you read this), and then the Senate Select Committee on Aging plans to hold public hearings to discuss the report's conclusions.

I believe that we should all prepare for the inevitable, intense public attention that this report will likely draw.

So what exactly is the GAO studying? It is reviewing patterns of deficiencies and noncompliance related to 1995 enforcement actions. The study will look at the number and types of remedies the states and the Health Care Financing Administration (HCFA) pro posed and how many and which remedies were actually imposed. Included will be enforcement data from California, Michigan, Pennsylvania and Texas, representing four regions of the United States. The study will only evaluate those remedies that were referred to HCFA for action.

If HCFA or the state recommended imposing an enforcement remedy but did not actually do so, the GAO will examine the reasons for this. Possible reasons include: the facility attained compliance before the effective date of the remedy; the facility successfully contested the deficiency; the facility negotiated a settlement with the state and HCFA that included a lesser remedy; or the state elected to use a state-only remedy without referring the matter to HCFA.

To review, the currently available federal enforcement remedies include:

* Directed plan of correction;

* Directed in-service training;

* State monitoring;

* Denial of payment for new beneficiary admissions;

* Denial of payment for all beneficiaries;

* A civil monetary penalty of $50$3,000 per day;

* A civil monetary penalty of $3,050-$10,000 per day;

* Temporary management; and

* Closure of the facility and transfer of residents.

The intent of the original enforcement regulation was that "selection of specific alternative remedies would be based upon the nature of the deficiencies and the remedy(ies) that either HCFA or the states believes is most likely to result in correction of the deficiencies and is designed to encourage facilities to achieve and maintain compliance with federal regulations."

The enforcement regulation was published to implement the provisions of the Omnibus Reconciliation Act of 1987 (OBRA '87) and the Institute of Medicine (IOM) study in 1986, which examined the chronic problem of "yo-yo" compliance, in which marginal nursing facilities were frequently in and out of compliance with one or more of the federal requirements. The IOM study showed that many substandard facilities routinely avoided termination by coming into compliance long enough to be recertified, but exhibited no commitment to sustained compliance. Therefore, the IOM study concluded that imposing less severe, but swifter and surer, alternatives to termination would exert greater pressure on facilities to achieve and maintain compliance.

The original enforcement regulation instructs states to choose remedies based upon the following factors:

* The existence or nonexistence of an immediate and serious threat to resident health and safety;

* The severity and scope of the deficiency(ies);

* The nature of the deficiency(ies) or cluster of deficiencies;

* The relationship of one deficiency or group of deficiencies to other deficiencies;

* The facility's prior compliance history in general and specifically with reference to the cited deficiencies; and

* Whether the deficiencies are directly related to resident care requirements.

thing if it were not for our staff - and we ask a great deal of our staff.

Silverado strives to re-teach its residents to perform daily tasks - for instance, we don't simply dress the residents; the activity of dressing is broken down into small, manageable parts that residents work to accomplish on their own. Nonambulatory residents aren't wheeled up to the dining tables. With whatever assistance is required, the resident is walked from the wheelchair to the dining room chair, where he or she can sit with dignity. This creates extra work for the staff, but it is often literally the first step toward fully recovered mobility for the resident.

Not all staff understand the importance of this additional labor at first. We have to train them to rethink the way they perform their jobs. Soon, however, they begin to see the results. When you are working with a resident who is a grumpy, wheelchair-bound person, and you see him or her change into a person who walks the halls, interacting with the animals and staff, it is a life-altering experience.

Staff wages are set so they are within the top 25% for the local industry, and benefits are set within the top 10% or more. However, salary is not the reason we have a waiting list of people hoping to work at our facilities. Caregivers at every level await the chance to work for us because they have heard from their colleagues about the team-oriented, life-affirming atmosphere we provide.

An important part of our staffing is the 24-hour licensed nursing care. This provides a heightened level of medical care not normally found in an assisted living environment. This, along with hospice beds, is one reason we expect approximately 95% of our residents to spend the rest of their lives with us. Residents aren't moved as the disease progresses, which is a great relief to families and lessens confusion.

The 24-hour nursing, our affiliation with researchers at the University of San Diego and the overall complete nature of our medical care provides an added benefit. Silverado has never been turned down by a long-term care insurance provider, which in itself indicates how different a concept this is from traditional assisted living.

The Silverado Senior Living approach has been a success in Escondido, proving we could find an economically viable way to provide a better level of Alzheimer's care. Now we are taking that same concept into other regions. We have six California communities in various stages of development, and we are looking at new locations.

All of this adds up, in our view, to an answer to the question: "Is high-acuity Alzheimer's care compatible with assisted living?" It most definitely is.

Loren Shook is president and CEO of Silverado Senior Living. For further information, call [phone].