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Nursing home care ensuring quality. (Health Policy Update).

There are more than 17,000 nursing homes in the United States providing care for 1.7 million disabled and elderly individuals. Medicare and Medicaid paid $28 billion in 1997 for nursing home services, more than one half of all nursing home expenditures. Improvements in the quality of care in these facilities and ensuring value for public expenditures has been a long sought after goal. Recent actions by the federal government are designed to strengthen state and federal authority and processes to accomplish this goal. Physician leadership in this area is essential to its success.

Key Concepts: Nursing Home Quality/Nursing Home Reform Act of 1987/Elder Care/Sanctions

Health care regulation of the nursing home industry is a joint state and federal function. Improving the quality in the nursing home industry was mandated by Congress through the Omnibus Budget Reconciliation Act of 1987: Nursing Home Reforms. This legislation modified survey procedures, revised care requirements to receive Medicaid and Medicare, added new sanctioning authority, and strengthened decertification procedures. It was enacted to enhance federal oversight of what was perceived as poor regulatory activity at the state level.

A one-year study commissioned by the Health Care Financing Administration (HCFA) showed that while care in these facilities has improved after these reforms, several opportunities remain. A recent report to the United States Senate Special Committee on Aging by the General Accounting Office (GAO) of California's nursing homes reinforced these findings.'

On July 21, 1998 President Clinton announced several additional steps designed to improve the quality of care received by patients in nursing homes.2 These steps include a series of regulatory changes and a call for new legislative action by the Congress.

New nursing home reforms

New reform efforts include increased quality assurance activities, enhanced enforcement, increased federal oversight of state activities, and more active public notification of facilities that fail to meet standards.

* Improvements in quality assurance: Three clinical conditions were targeted for special quality review. HCFA will be looking to ensure the nursing home industry has developed strategies to prevent dehydration, malnutrition, and decubitus ulcers. HCFA will also work with experts to develop best practices and penalize those facilities that do not meet these standards. Another quality improvement effort will be the development of a national automated data set known as the "Minimum Data Set" to help evaluate the quality of care provided in nursing homes. A third effort involves having states review each nursing home's plan to reduce patient abuse and requiring that this plan be shared with each patient and their families.

* Enhanced enforcement: HCFA is removing the grace period before a facility is sanctioned for a second violation causing harm to a patient, whereby a facility could come into compliance and avoid any penalty. States will also be able to impose monetary penalties for each instance of serious or chronic violation, instead of being limited to only those days the facility was out of compliance.

Inspections will be conducted at more unpredictable times, including nights and weekends- those facilities with serious or recurrent violations will be inspected more often. Nursing facilities that are part of a chain with a history of noncompliance with federal standards will be targeted for review. In the case of egregious violations that result in harm to a patient, prosecution of the responsible individuals under federal civil and criminal law may also occur.

* Increased federal oversight of state inspection systems: This effort entails working with state officials to improve training of inspectors. HCFA will increase its oversight of the state inspection process to ensure its adequacy and adherence to HCFA policy. HCFA also plans to prohibit the deeming process" which allows states to accept nursing facility accrediting assessments by organizations such as the Joint Commission on Accreditation of Healthcare Organizations as an alternative to state inspections directed by HCFA. This recommendation was made despite the potential savings associated with allowing deeming because of concerns about the quality of alternative reviews.

States will need to adhere to this policy carefully, because if they fail to comply with HCFA's policies they could loose all federal funding for survey activity. In such cases, HCFA would then designate an alternative organization to conduct the survey for the state.

* Public notification: HCFA will notify the public concerning nursing facilities that do not meet federal standards. Survey results will be disseminated via the Internet to allow consumers to make more informed choices when selecting a nursing home.

Congressional action

Congress has been asked to authorize the creation of a national registry of employees that are convicted of abusing patients in nursing homes. In addition, it has been requested to consider legislation to require criminal background checks on all job applicants. The GAO discovered that 5 percent of nursing homes in Maryland employed individuals with prior criminal histories. (3) This percentage appears to be a reduction from an estimated 20 percent that was believed to occur before the passage of a 1996 Maryland law requiring criminal background checks. In Illinois, a self reported review found a similar percentage of 5 percent.

Other enhancements requiring Congressional action include reauthorizing the Nursing Home Ombudsman Program and enlarging the scope of practice of some nursing home staff to allow them to give nutrition and hydration therapy. Legislation to collect a user's fee from Medicare providers has also been requested. Such a fee would vary by state and would be payable at the time of the survey.

Congressional action is not, however, assured, since the GOP led Congress has historically believed that nursing home regulations are a state function and has frequently attempted to reduce the federal government's role.

Cost implications

Administration estimates of the costs to provide these quality enhancements are up to $9 million a year. (4) The Presidents fiscal year 1999 budget request does include $13 million for this initiative. User's fee legislation, if enacted, may increase expenses minimally to the nursing home industry. The size of such costs would depend upon the scope of existing survey activities, the need to be resurveyed, and would vary by state.


Improvements in the quality of care in nursing homes has been a long sought after goal. New regulatory actions will result in enhanced enforcement and tighter inspections.

Physician executives in the nursing home industry must become knowledgeable of these regulations. New opportunities exist to address preventable diseases and strengthen the quality of long-term care for 1.7 million patients. Congressional action over the next year may add additional requirements on the nursing home industry.

Georges C. Benjamin, MD, FACP, is the Maryland Deputy Secretary for Public Health Services in Baltimore. He can be reached at 410/767-6510 or via fax at 410/767-6489.


(1.) California Nursing Home Care. Problems Persist Despite Federal and State Oversight, GAO/HEHS-98-202, July 1998.

(2.) Fact Sheet: Assuring the Quality of Nursing Home Care, U.S. Department of Health and Human Services, Health Care Financing Administration, July 21, 1998.

(3.) 5 percent of nursing home workers have criminal records. The Baltimore Sun, September 14, 1998.

(4.) Clinton Orders Better Nursing Home Care, The Washington Post, July 22, 1998.
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Author:Benjamin, Georges C.
Publication:Physician Executive
Geographic Code:1USA
Date:Nov 1, 1998
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