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Improving
He Quality of
J
C.
- are in ~
urging
OCommittee on Nursing Home Regulation
Institute of Medicine
NATIONAL ACADEMY PRESS
Washington, D.C. 1986
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NATIONAL ACADEMY PRESS
2101 Constitution Avenue, NW
Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the
Governing Board of the National Research Council, whose members are drawn from
the councils of the National Academy of Sciences, the National Academy of
Engineering, and the Institute of Medicine. The members of the committee
responsible for the report were chosen for their special competences and with
regard for appropriate balance.
This report has been reviewed by a group other than the authors according
to procedures approved by a Report Review Committee consisting of members of
the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of
Sciences to enlist distinguished members of appropriate professions in the
examination of policy matters pertaining to the health of the public. In this,
the Institute acts under both the Academy's 1863 congressional charter
responsibility to be an advisor to the federal government, and its own
initiative in identifying issues of medical care, research, and education.
This volume is the final report of a study conducted under Contract No.
500-83-0054 with the Health Care Financing Administration.
Publication IOM-85-10
Library of Congress Catalog Card Number 86-70373
International Standard Book Number 0-309-03646-1
First Printing, March 1986
Second Printing, February 1987
Third Printing, March 1988
Fourth Printing, September 1989
Printed in the United States of America
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Committee on Nursing Home Regulation
SIDNEY KATZ (Chair), Associate Dean of Medicine, Brown
University, Providence, Rhode Island
CARL E. ADAMS, Director, National Health Corporation,
Murfreesboro, Tennessee
ALLAN BEIGEL, Professor of Psychiatry and Vice President
for University Relations and Development, University
of Arizona, Tucson
JUDITH F. BROWN, Vice President of Professional Services,
ARA Living Centers, Houston, Texas
PATRICIA A. BUTLER, Attorney, Boulder, Colorado
IRIS FREEMAN, Director, Nursing Home Residents'
Advocates, Minneapolis, Minnesota
BARRY J. GURLAND, Director, Columbia University
Center for Geriatrics and Gerontology, New York City
CHARLENE A. HARRINGTON, Associate Professor, School
of Nursing, University of California, San Francisco
CATHERINE HAWKS, Research Triangle Institute, Research
Triangle Park, North Carolina
ROSALIE ANN KANE, Center for Health Services Research,
University of Minnesota, at Minneapolis St. Paul
JUDITH R. LAVE, Professor of Health Economics,
University of Pittsburgh, Graduate School of Public
Health, Pittsburgh, Pennsylvania
MAURICE I. MAY, Chief Executive Officer, Hebrew
Rehabilitation Center for Aged, Roslindale,
Massachusetts
· · ~
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DANA L. PETROWSKY, Chief, Division of Health Facilities,
Iowa State Department of Health, Des Moines
SAM SHAPIRO, Professor, Department of Health Services
Administration, The Johns Hopkins University, School
of Hygiene and Public Health, Baltimore, Maryland
PETER W. SHAUGHNESSY, Director, Center for Health
Services Research, University of Colorado, Health
Sciences Center, Denver
JUNE L. SIDES, Consultant, Regency Health Centers, Inc.,
Clemmons, North Carolina
HELEN L. SMITS, Associate Vice President for Health
Affairs, University of Connecticut Health Center,
Farmington
DAVID ALAN WAGNER, Vice President for Planning and
Marketing, Trimark Corporation, West Orange,
New Jersey
BRUCE C. VLADECK, President, United Hospital Fund of
New York, New York City
MAY LOUISE WYKLE, Associate Professor, Frances Payne
Bolton School of Nursing, Case Western Reserve
University, Cleveland, Ohio
Staff
David Tilson, Staff Director
Jane Takeuchi, Staff Officer
Robert E. Burke, Staff Officer
Michael G. H. McGeary, Staff Officer
Susan E. Sherman, Research Associate
Peter Reinecke, Research Assistant
H. D. Tiller, Administrative Secretary
1V
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Preface
The Institute of Medicine Committee on Nursing Home
Regulation was given a complex and controversial task: to
recommend ways to improve nursing home regulation. The
regulation of nursing homes is a matter on which many
knowledgeable people in all parts of the country have very
strong and by no means unanimous views.
I was privileged to serve as chairman of the committee
appointed by the president of the Institute of Medicine to
conduct the study. The committee consisted of 20
individuals with substantial knowledge of and experience
in nursing homes and with the perspectives of ownership,
management, consumer advocacy, state regulation, and
professional staff in both for-profit and not-for-profit
nursing homes. Members of the committee have had
substantial training and practical experience in medicine,
health law, nursing, social work, public administration,
public policy analysis, economics, statistics, sociology,
health services research, and health care management.
They come from 15 states and are familiar with the nursing
homes in most parts of the country.
v
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The study was prompted by controversy over changes in
nursing home certification procedures, proposed by the
Health Care Financing Administration (HCFA) in 1982. When
the committee commenced its work it agreed that a serious
look at many factors bearing on nursing home regulation
was necessary if the study was to contribute significantly
toward enhancing the quality of care and of life in
nursing homes by improving the regulatory system. The
range of relevant issues is large and the relationships
are complex. Not all could be addressed by the committee,
but an effort was made to at least recognize and discuss
them and to point some directional arrows for future
policy development.
To address its charge properly, the committee decided
that the study should collect and analyze data and other
information as follows:
1. Views of interested parties. Knowledgeable,
interested parties in various parts of the country--
residents and their families, long-term-care ombudsmen,
nursing home owners and administrators, professional and
other staff who work in nursing homes, and state and
federal regulatory agency officials--were asked to give
their views of the problems.
This information was obtained in several ways. First,
the staff conducted semistructured interviews with state
and federal regulatory officials, nursing home
administrators, professional staff, and consumer
advocates, and they visited nursing homes in several
states. Second, they reviewed the voluminous hearings
conducted by the HCFA in 1978 and the congressional
hearings on, and the written responses to, the HCFA's
proposed changes in the federal certification regulations
(the action that led, ultimately, to this study). Third,
the committee held five public meetings during September
1984, in Philadelphia, Atlanta, Dallas, Minneapolis, and
Los Angeles. The meetings were announced and publicized
well in advance and all interested parties were invited to
offer oral and/or written statements to the committee.
Over 200 persons spoke at the meetings and
V1
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had informal discussions with committee members and
staff. Many others submitted written statements. The
discussions at the public meetings and the written
materials were reviewed, analyzed, and summarized in a
working paper used by the committee in shaping some parts
of the study and. as a basis for some statements made in
this report. Finally, in the course of conducting the
case studies in six states (discussed below), there was an
opportunity to discuss in depth the perceptions of state
regulatory officials, state agency staff, federal regional
office staff, consumer advocates, nursing home operators,
and professional staff.
2. How states actually regulate nursing homes.
Information was obtained in four ways. First, case
studies of nursing home regulation were conducted in six
states. The states (Connecticut, Maryland, Georgia,
Texas, Minnesota, and California) were chosen because they
represented widely varying local circumstances, different
regions of the country, and different approaches to
regulating nursing homes. In each state, three staff
members conducted semistructured interviews with state
regulatory agency officials, with state surveyors and
those who conducted inspection-of-care reviews in nursing
homes, with representatives of the state nursing home
operators' associations, with for-profit and nonprofit
nursing home administrators and professional staff, with
state and local ombudsmen and other consumer
representatives, with state legislative committee staff,
and with representatives of the attorney generals' and
governors' offices. They also talked to federal regional
office staff.
Second, a mail survey of all 51 (including the District
of Columbia) state licensure and certification directors
was conducted. Its purpose was to get information on the
resources being used by the states in carrying out their
nursing home survey and certification responsibilities, on
the intermediate sanctions they had available, the extent
to which the sanctions were used, and the directors'
opinions on several aspects of regulatory policy.
Responses were received from 47 directors, although not
all items were answered by all respondents.
vat
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Third, staff reviewed and analyzed the contents of 15
state nursing home investigatory commission reports issued
in the last 10 years, to determine the kinds of regulatory
problems that prompted these investigations.
Fourth, a workshop was conducted to examine problems of
enforcing the certification regulations and to formulate
recommendations to improve enforcement. Several papers by
experts were commissioned, and a group of over 30
enforcement experts from state and federal government
agencies (including attorney generals' offices), lawyers
who represented providers and their associations, and
consumer advocacy (including legal service) groups,
discussed the issues for 2 days.
3. Quality and quality assessment. The work
consisted mainly of a review of the published literature,
some unpublished studies including evaluations of
HCFA-sponsored demonstration projects, plus commissioned
papers. A great deal of research has been conducted and
published on these subjects in the past 10 years or so,
and this was digested by a subcommittee of the full
committee.
4. 31eclicaid reimbursement policies. A conference
was convened to explore what is known about the
relationships between various types of state Medicaid
reimbursement policies and both quality of care of, and
access to nursing homes by, Medicaid-financed residents
and those requiring extensive care. A paper was
commissioned that reviewed the published literature on
this subject, and extensive discussions were held by
knowledgeable participants representing all pertinent
perspectives. Additional literature was also reviewed by
staff and committee members. The committee believes this
to be an important subject that merits deeper exploration,
but it was beyond the scope of this study.
5. Demand for and supply of nursing home beds. In
addition to a literature review conducted by staff, two
papers were commissioned to examine this question. One
projected population and morbidity and disability trends
by age category. The other reviewed the published and
unpublished information and analyses on the effects of
nursing home loed supply on regulation, enforcement, and
quality of care.
· · ~
vail
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6. Staffing. A paper was commissioned to address
the issues of training and accreditation (including
licensure and/or certification) of four categories of
nursing home staff: administrators, registered nurses,
licensed practical nurses, and nurse's aides or nursing
assistants. Another paper was commissioned on the role of
physicians in nursing homes, and HCFA data on current
staffing of nursing homes were analyzed.
7. Consumer role and con~rn~'nity relations. A
workshop was organized to explore the role of consumers
(residents) and their advocates in quality assurance and
to determine how this role should be enhanced by public
policy changes. The same workshop also addressed the
issue of nursing home/community relations. Several papers
were commissioned that reviewed the ombudsman program, the
development of nursing home residents' advocacy organiza-
tions, the development of residents' councils and family
councils, and nursing home/community interactions.
8. Management incentives. The committee organized
a workshop to explore the feasibility of introducing
positive incentives into the regulatory system. The
regulatory system now works almost entirely on negative
incentives: There is punishment for inadequate
performance, but no recognition or rewards for good or
excellent performance. Nine papers were commissioned for
the workshop.
I would like to call attention to two important
considerations that affect the content of the report.
First, although we used data and objective evidence as
much as possible, many conclusions and recommendations
rest largely on professional judgment. The committee was
made up of people with diverse backgrounds and
experience. Achieving consensus within this group after
extensive discussion of the available evidence clearly is
an appropriate and responsible way to recommend necessary
adjustments in public policy. Of course, individual
members did not agree in all cases with every conclusion
and recommendation. But they all support the report as a
whole.
1X
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Second, for a number of reasons we did not address every
issue that might be considered relevant. Two are of
particular importance: Medicaid reimbursement policy and
policy governing bed supply (that is, the administration
of certificate-of-need for nursing homes). Both are
state-administered policies and both clearly affect
nursing home operations. Some members of the committee
believed we should have addressed these issues directly,
but the majority believed--for the reasons explained in
Chapters 1 and 7 of the report--that we should not.
The results of our efforts are contained in this
report. We hope they will contribute to achievement of
the goals of improving the quality of care and the quality
of life for nursing home residents and of producing a more
efficient and effective regulatory environment.
Sidney Katz, Chairman
Committee on Nursing Home
Regulation
x
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Acknowledgments
The committee wishes to express appreciation for the
excellent cooperation and assistance it has received from
hundreds of individuals and dozens of organizations
throughout the country. The staffs of the Health Care
Financing Administration, the American Health Care
Association, the National Citizens' Coalition for Nursing
Home Reform, the National Senior Citizens Law Center, the
American Association of Homes for the Aging, the
Association of Health Facility Licensure and Certification
Directors, and the American College of Health Care
Administrators were especially helpful. They received
numerous requests from us for various types of information
and documents. They always responded promptly and
courteously. Other organizations, including the American
Association of Retired Persons, the National Council of
Senior Citizens, and the National Council on Aging, also
were helpful.
Government officials in the six states in which we
conducted case studies were generous in allotting time for
interviews with our staff. The same was true of
representatives of provider associations, consumer groups,
ombudsmen, and staff in federal regional offices. We
particularly appreciate the cooperation of the 47 state
licensure and survey agencies who responded to our survey
x.
.
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questionnaire. For many, a major effort was entailed to
obtain the information needed to respond to our questions.
A study as complex and technically demanding as this
requires competent professional staff. The committee was
singularly fortunate in being supported by such a staff,
effectively organized and directed by David Tilson. In
addition to its deep appreciation for Mr. Tilson's
leadership, the committee gratefully acknowledges the work
of the other members of the professional staff: Robert
Burke, Michael McGeary, Susan Sherman, Jane Takeuchi, and
Peter Reinecke (who worked on the staff through January
1985~. Don Tiller provided exceptionally effective
administrative support. Staff members organized and
coordinated conferences and workshops. They reviewed and
abstracted hundreds of publications and technical
documents. They carried out the survey of state licensure
and certification agencies and analyzed the data. They
prepared staff papers and drafted this report. In
addition to long hours, the IOM professional staff
displayed a sensitive commitment to nursing home
residents. They never lost sight of the study's principal
focus on residents as human beings with special needs for
living and for care.
x~
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Contents
PREFACE
1 INTRODUCTION AND SUMMARY
Purpose of the Study
The Public Policy Context of the Study
Perspective on the Issues
Conclusions
Summary of Recommendations
2 CONCEPTS OF QUALITY, QUALITY
ASSESSMENT, AND QUALITY ASSURANCE
Quality of Care in Nursing Homes
Quality of Life
Quality Assessment Criteria
Assessing Quality of Care
Perspective on Quality Assurance
Interpreting and Using Information
for Quality Assurance
Quality Assurance and the Regulatory System
x~
2
8
21
25
45
45
51
53
56
60
61
67
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3 REGULATORY CRITERIA
The Issues
Consolidating the Two Sets of Criteria
Resident Assessment
Revising and Strengthening the Conditions
and Standards
Note on Staffing Standards
4 MONITORING NURSING HOME PERFORMANCE
The Issues
Problems with the Survey Process
Redesigning the Survey Process
PaCS: A New HCFA Survey Protocol
Increasing State Regulatory Capacity
Organizational Changes
5 ENFORCING COMPLIANCE WITH
FEDERAL STANDARDS
The Issues
Enforcement Attitudes
Federal Rules and Procedures
State Rules and Procedures
Enforcement Resources
6 OTHER FACTORS AFFECTING QUALITY
OF CARE AND QUALITY OF LIFE
IN NURSING HOMES
Involvement of Consumers and Consumer
Advocates
Community Involvement
Management and Staff Motivation
7 ISSUES REQUIRING FURTHER STUDY
Information Systems
Medicaid Payment Policies
Demand for and Supply of Nursing Home Beds
Staffing of Nursing Homes
Single- Versus Multiple-Occupancy Rooms
x~v
69
69
71
74
77
98
104
104
106
109
130
132
140
146
146
147
150
162
169
171
172
184
185
190
191
193
196
200
201
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8 ACTIONS REQUIRED AND COST IMPLICATIONS
OF THE RECOMMENDATIONS
Legislative Actions Required
Revision and Addition of Survey and
Certification Regulations
Design and Testing Activities
Cost Implications of the Recommendations
NOTES
APPENDIX A History of Federal Nursing Home
Regulation
APPENDIX B Existing SNF Conditions of
Participation and ICE Standards
APPENDIX C
Report of Survey of State Health
Facility Licensure and
Certification Agencies
APPENDIX D Selected Data on Nursing Homes
and Residents
APPENDIX E Key Indicators of Quality of Care
GLOSSARY
ACRONYMS AND INITIALISMS
INDEX
xv
203
204
206
207
210
213
238
254
315
351
378
389
405
407
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