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APPENDIX C Report of Sur vey of State Health Facility Licensure and ~ ~ ~ ~ ~ ~ertl~catlon Agencles PURPOSE The Institute of Medicine Committee on Nursing Home Regulation conducted a mail survey of 50 state and the District of Columbia health facility licensure and certification agencies to 1. obtain data about the resources committed by each jurisdiction to inspect and certify nursing homes under the Medicaid and Medicare programs, and 2. obtain data on the statutory availability and use by states of various types of intermediate sanctions for enforcing compliance with nursing home standards. The survey was designed with the cooperation and assistance of the officers and board members of the National Association of State Health Facility Licensure and Certification Directors. The survey questionnaire was developed, and pretested in September 1984 on three health facility licensure and certification directors. On the basis of the pretest, 18 questions were modified. The final version covered eight topics: 315

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316 / APPENDIX C (1) organization of nursing home activities, (2) survey agency personnel and budget, (3) survey agency workload, (4) state standards, (5) special surveyor training, (6) survey procedures and coordination agreements, (7) enforcement, and (8) survey directors' views on federal regulation. A copy of the questionnaire is attached to this Appendix. Clearance to conduct the survey was received from the Office of Management and Budget on November 2S, 1984. The questionnaires were mailed, with an endorsement from the Association of State Health Facility Licensure and Certification Directors, on November 29, 1984. The recipients were the 51 current Health Facility Licensure and Certification directors. Forty-seven responded. From January to March 1985, staff collected and analyzed the data, which were then used to produce descriptive and inferential statistics, to make interstate comparisons, and to observe changes in survey agency resources and enforcement activities from 1980 to 1984. The survey data were also merged with existing state demographic and nursing home data available from the Medicare/Medicaid Automated Certification System (MMACS), and with other data from the HCFA Office of Research and Development and from published literature, so that factors contributing to state variations could be determined. Because of the population size, and the nominative level of most of the data, the major analyses performed were (1) frequencies for all variables, and (2) two-by-two and two-by-three contingency table comparisons of major variables such as survey agency budgets, staff, numbers of surveys completed, surveyor training, and survey and enforcement procedures. Frequencies, medians, and ranges of various responses of variables are reported in the attached copy of the actual survey. Significant associations and correlations are discussed in the "Summary of Findings" section. Data validity was assessed. Because the committee intentionally designed the survey to gather information

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APPENDIX C / 317 that could not be obtained from other sources, Medicare and Medicaid budget data supplied by the HCFA were the only external data available to check the validity of the information collected by the survey. Staff compared the total federal Medicare and Medicaid 1983/1984 allocations as reported in the survey with federal Medicare and Medicaid allocations to the states as reported by the HCFA. Of the comparisons (43 Medicare and 39 Medicaid), 16 of the survey figures and those provided by the HCFA were identical; 44 were within a tolerable error. Of the remaining 22 discrepancies, only 4 could not be corrected. With these corrections, the data demonstrated external validity. The survey data also were checked for their power to discriminate. Questions that received the same answer from all, or nearly all, of the respondents, and questions that had received little or no response, were not used for correlational analyses. In the first case, the informa- tion collected does not discriminate among respondents. In the second, insufficient information was collected. Although the consistency or the unavailability of data were themselves interesting and noted in the frequency analyses, the responses received were not useful as variables for comparative analyses and were therefore excluded from further analysis. Questions were considered nondiscriminating if 37 or more (80 percent) of the 47 respondents answered the question in the same way. Questions were considered to provide insufficient information if 37 or more (80 percent) of the respondents failed to answer the question. The survey data provided the committee with factual information concerning the feasibility and desirability of changing the current survey and certification system. Many of the committee's conclusions on the survey process, on state agency resources, and on state enforcement activities are based on survey findings. SUMMARY OF FINDINGS Major findings for each of the eight topics covered by the survey are summarized below. In each case, the number

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318 / APPENDIX C of respondents is given as a proportion of the total respondents. Organization of Nursing Home Regulation Activities All 47 responding agencies conduct Medicare certification inspections; 46 conduct licensure, Medicaid certification inspections, and complaint investigation visits to nursing homes. Two-thirds conduct life safety code inspections (32/47) and just over a third (17/47) also are responsible for inspection of care visits. Very few make certificate-of-need determinations (7/47) or set Medicaid nursing home reimbursement rates (2/47~. The majority of the agencies are also responsible for licensing and certification activities for other types of health facilities. All but three handle acute care hospitals, all but two handle home health agencies and hospices, and most also are responsible for board-and-care facilities (33/47~. Survey Agency Personnel and Budget State agencies vary greatly in the size of their budget and staff per nursing home. The percentage of total survey agency resources allocated to nursing-home-related activities ranges from a high of 93 percent to a low of 14 percent; the median is 56 percent. The amount of money allocated for regulatory activities per nursing home ranges from a minimum of $1,296 to a maximum of $13,018, with a median of $4,700. The number of nursing homes per available full-time equivalent (FTE) licensing and certification field surveyor varies from a low of 0.78 to a high of 41.96, with a median of 13.00. Nineteen states reported that their licensing funds increased by less than 50 percent from 1980 to 1984; 17 reported that their funds increased by more than 50 percent. About half the states reported that their total budget decreased between 1980 and 1984; the other half reported that their budget increased between 1980 and 1984. Half the states reported that the number of field surveyors had decreased between 1980 and 1984; the other half reported that the number had increased.

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APPENDIX C / 319 Twenty-two reported that total staff decreased between 1980 and 1984; 19 reported that total staff increased. Survey Agency Workload Of the 17 state survey agencies performing inspection-of-care (IOC) reviews in addition to licensure and certification surveys, 9 indicated that these reviews are done by the same team at the same visit as the certification survey. In the other states, IOC is done by a different team or during a separate visit. Thirty-four states reported that complaints are investigated by the regular surveyors; 10 reported that they have a separate survey staff to investigate complaints. The length of facility certification visits varies by state, by facility classification, and by type of visit. Combined licensing and certification surveys for the average-quality 100-bed nursing home ranged from 1.0 to 12.0 person-days for ICFs (with a median of 5.9), and from 1.5 to 18 person-days for SNFs (with a median of 6.~. Post-certification follow-up visits ranged from 0.5 to 4.0 person-days for ICFs (with a median of 1.5), and from 0.5 to 6.0 person-days for SNFs (with a median of 2.0~. Post-certification visits average about one per facility. Complaint visits vary in length by state, but not by type of facility. The longest average visit is 2.0 and the shortest 0.4 person-days, with a median of 1.0 for both SNFs and ICFs. Eleven states reported that the total number of visits to facilities decreased between 1980 and 1984; 20 reported that the total number of visits to facilities increased. The change in the number of follow-up visits made between 1980 and 1984 ranged from a decrease of 1,013 to an increase of 631 (or a 96 percent decrease to a 215 percent increase). State Regulatory Standards Just over half (24/47) of the respondents judged that their state's licensure requirements for ICFs are more

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320 / APPENDIX C stringent than those of the federal government, one- quarter (11/47) said they were the same, and one-quarter (12/47) said they were less stringent. One-third (17/47) of the directors asserted that their state's licensure requirements for SNFs are more stringent than the federal requirements, one-third (14/47) said they were about the same, and one-third (14/47) said they were less stringent. Special Surveyor Training Thirty-three states reported that they conduct special enforcement training for surveyors. The median number of hours of training is 7.5, but ranged in different states from 1 to 96 hours. Nine states reported that training is conducted by internal staff, 1 said training is conducted by external staff, 2 use outside consultants, and 22 said that they use a combination of the above. Twenty-six pay for training in a line item in the agency budget, seven include training funds in another line item, one uses funds external to the agency, and two use a combination of internal and external funds. All of the states that have special enforcement training think that it has improved the surveyor's work and that training should continue. Survey Procedures and Coordination Arrangements Most of the agencies conduct licensure inspections once every 12 months (40/47) and certification inspections once every 12 months (42/47~. All states reported that licensure and certification surveys are combined, with roughly three-quarters always doing combined surveys (33/47~; the remainder combine surveys only some of the time. Seven states indicated that they use a screening or abbreviated survey to determine which facilities should receive a full-licensure or certification survey. Most agencies reported that their surveyors review previous licensure (45/47), previous certification (47/47), inspection-of-care reports (34/47), and complaint

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APPENDIX C / 321 reports (42/47) before conducting a survey. Thirty-three states indicated that surveyors always conduct "hands-on" assessments of residents during certification surveys. Most surveyors complete HCFA Form 2567 at the office, most within 10 days of the inspection (41/47~. The number of days varies from 2 to 18. Thirty-three states indicated that some aspect of their licensure and/or certification procedures has been changed in recent years. Enforcement Nearly all state survey agencies responding indicated that they have at least several intermediate licensure sanctions available to them, but very few are applying any formal sanctions, federal or state. Eighty-five percent of the total actions are taken in 13 states. Most respondents, however, did rate their state's enforcement efforts favorably. Thirty-nine states said that any surveyor has the authority to cite a deficiency; three said that the team leader must make the decision to cite; two said that a supervisor must make the decision; and three states listed "other" authorities. Thirty-six states reported that the number of standards out of compliance that would cause the nursing services condition to be marked out-of-compliance "depends." Usually they said it depended on "the severity" of the violation. Five states listed specific standards which would put the nursing services condition out of compliance: standards 124, 134, and 181 (director of nurses, 24-hour nursing, and administration of drugs, respectively). Two states said any standard out of compliance would put the condition out of compliance; one said one standard was sufficient; two said two; and one said three. Thirty state directors thought that one onsite visit to a facility is adequate to verify a plan of correction; 13 said that several visits are necessary; 3 said that none are necessary. Most states do a routine follow-up visit for each full survey; it lasts one-third as long as the

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322 / APPENDIX C original visit. Most survey agency directors think this is a reasonable procedure. Twenty-three states reported that they do not have attorneys on staff who are specially designated to deal with enforcement actions. Ten states have one attorney who specializes, five have more than one. Only 6 reported that they have hearing officers designated for nursing home enforcement; 28 do not. Four have special investigators, 30 do not. Two have special assignment surveyors. When the states take court action, 13 have a staff attorney available to defend them; 31 have a departmental attorney available, and 3 have no attorney available. Twenty said that their attorney carried out their request to file an action all of the time, 11 said most of the time, 12 said some of the time, and 2 have never requested an action. States have, on the average, ~ available sanctions under their state licensure laws. The survey inquired about 14. Some states had all 14, and some had only a few. Most states have the authority to revoke a facility's license (44/47), to decertify a facility (40/47), and to seek a court injunction (37/47~. Additionally, 36 states reported having authority to relocate residents from substandard facilities; 35 have the authority to issue conditional licenses; 32 have the authority to suspend all new admissions: 30 have the . ~ . . ~ authority to Impose criminal penalties t~or patient abuse; 26 have administrative fining authority; 25 have the authority to take licensure records into consideration in certificate-of-need recommendations; 21 have the authority to place a facility into receivership; 19 report having the authority to withhold Medicaid payments to noncompliant facilities; 15 have the authority to issue probationary licenses; 9 have the authority to reduce the Medicaid reimbursement rates of noncompliant nursing homes; and 7 have the authority to appoint a monitor to a facility (see attached copy of survey questionnaire). In states that have the sanction, the survey agencies usually have the authority to recommend a sanction but not necessarily the authority to decide whether to carry out a sanction. In 9 of the 14 categories, most of the state agencies that have the sanction have the authority to

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APPENDIX C / 323 recommend the sanction, but less than half have the authority to decide whether to use the sanction. The availability of sanctions in a state seems to be associated with (1) whether surveyors receive special enforcement training, (2) the agency budget per nursing home, (3) the total number of state agency visits to nursing homes, and (4) the survey agency director's opinion of the survey process regulations. States that have special enforcement training are more likely to have more types of sanctions available. States with high budgets per nursing home also have high numbers of sanctions available. States that make a lot of visits are likely to have more sanctions available. And agency directors who are content with the procedural regulations are more likely to have more sanctions available to them.* States that have committed significant efforts to strengthening nursing home regulation, whether in special staff training, increased survey agency budgets, or frequency of inspection visits, are also those that have elected to have a variety of sanctions available. Perhaps political pressures have stirred all of these interests simultaneously, or perhaps the greater training and resource allocations have uncovered the need for more sanctions. Regarding enforcement actions, 20 states report that they have written guidelines for when and how to take a formal enforcement action; 27 do not. The total numbers of enforcement actions taken by states in each category in 1983 ranged from one to dozens, to several hundred in a few categories (civil fines, criminal penalties, and withholding of payments). However, at least 75 percent of the actions taken in each category were taken by one, two, or three states. (It was not necessarily the same state in each category; states seem to favor one or two sanctions.) The median number of types of enforcement actions used by an agency was two. The median total number of actions taken was 11. The number of reported actions taken increased in all but one category (conditional licensing) from 1980 to *Findings are significant at the .10 level of confidence.

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324 / APPENDIX C 1983-1984. In 1983, 15 states revoked the license of at least 1 facility; 15 suspended admissions to one or more facilities; 14 relocated residents from a facility; 14 issued conditional licenses; 13 issued fines; 13 decertified facilities; 10 took licensure records into account on certificate-of-need recommendations; 9 obtained injunctions; ~ placed a facility into receivership; 5 issued probationary licenses; 3 withheld Medicaid payments to a facility; 3 appointed a monitor to a facility; and 1 reduced Medicaid rates to a facility. Of those reporting having taken enforcement actions, the number of types of actions taken and the total number of actions taken seem to be correlated with (1) special enforcement training, (2) whether recent changes in the survey process have taken place, (3) minimum number of required nursing hours, (4) percentage of agency resources allocated to nursing homes, (5) survey agency budget per nursing home, (6) total numbers of visits in 1983-1984, (7) changes in state licensing funds, (8) number of sanctions available, and (9) statewide per capita income. More training was positively linked with using more types of enforcement actions, as well as implementing more actions. Changes in the survey process were also positively linked with numbers of types and numbers of actions taken. States with higher nursing requirements, and those with more monetary resources and more staff/time resources allocated to nursing homes, implement more kinds of sanctions and more sanctions. Larger increases in state licensing funds from 1980 to 1983-1984 are related to fewer enforcement actions; smaller increases are related to more types and numbers of enforcement actions. The number of available sanctions is directly related to their use. And a higher per capita income is related to a higher number of types of sanctions applied. The correlations with enforcement activity seem to be a reflection of the amount of political interest states take in nursing homes. Those that have higher nursing requirements, special training, more available sanctions, that have made recent changes in the survey process, and that allocate more resources to nursing home surveying seem to be more active in enforcement. Or perhaps these factors make it easier for states to bring enforcement

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APPENDIX C / 325 actions. States that take more enforcement actions have more knowledge, better rules, and more resources for monitoring the situation. Agencies tend to rate sanctions favorably. In 11 of the categories, well over half of those using the sanction rated it as very effective or effective. Fifteen agencies said that their overall enforcement efforts were very effective, 29 said their efforts were effective, and 3 said their efforts were not effective. These opinions did not correlate with availability and use of sanctions. Agencies may be reluctant to downgrade the effectiveness of the sanctions available to them, or their own efforts. When actions were taken to court, three agency directors said that the court supported the agency's position all of the time, 20 said most of the time, 15 said some of the time, and 9 have never taken a facility to court. Again, these opinions were not related to use of sanctions. Twenty states said that particular sanctions are effective because they affect the income of the provider. Other reasons given included the ability to implement the action quickly (7), the ability to remove an operator (4), and publicity (5~. The obstacle to enforcement that was mentioned most often was time delays in implementing a sanction, both administrative and legal (11~. Others mentioned the difficulty of administering some of the sanctions (3), potential harm to residents (transfer trauma, decreases in funds being taken out on patients) (4), and too little impact on the provider's income (2~. More states listed reasons for the success of sanctions than listed obstacles (37 as opposed to 19~. This is because several did not rate unfavorably any of the sanctions they used. Views on Federal Regulations The majority of respondents believe that current federal certification regulations could ensure nursing home services of adequate quality with certain modifications. A few forwarded specific suggestions for changes. Eight state agency directors reported that they believe that current federal SNF Conditions of Participation can

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340 / APPENDIX C OMB No. 0938-0395 STATE: 42. If your agency conducts inspection of care reviews, they are done: a. ( 2 ) At the same visit as the certif ication survey. b. ( 3) At a different visit. c . ( 0 ) By the same team which conducts the certif icat ion survey. d. ( 2 ) By a separate team. Both a and c: 9 Both a and d: 0 Both b and c: 1 Both b and d: 3 43. Are inspection of care review f indings cited as part of the documentation of def iciencies on the HCFA 2567 form? a. ( 14) Yes (if yes, how frequently?): b. ( 17) No. HCFA-466 i. ( 8) often/all the time. ii. ( 5) sometimes/about half the t ime . iii. ( 1 ) rarely/almost never.

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APPENDIX C / 341 OMB No. 0938-0395 STATE: G. Enforcement 44. Different states have different legal provisions for enforcing their nursing home standards. Below is a table that lists down on the f irst column several provisions. There are six other column headings labeled A through F.* As instructed please complete columns A through F. For Column A, "State Has Provision, " if your state has the provision, place a "y" on the appropriate line. If it does not, place an "n" on the appropriate line. Column B. "Recommending Agency, " we are also interested if the survey agency and/or some other agency recommends the legal action. If your agency recommends the action, place a "y" on the appropriate line. If another agency recommends, write the name of the agency on the provided line. In many states different agencies determine whether the legal provision will be carried out depending on the sanction. For each sanction please list the appropriate agency or individual in Column C, "Deciding Agency. " In Column D, "Number of Recommendations Carried Out," we would like to know the number of times the recommended actions were carried out in 1980 and 1983. Please write the numbers on the provided lines. In Column E, "Order of Importance, " please rank order your perspective of the importance to the regulatory process of each of the provisions using the numbers 1, 2, 3 or 4 where 4 = Very important 3 = Important 2 = Unimportant 1 = Very unimportant Finally, in Column F. "Order of Effectiveness," please rank order how effective you feel these provisions are in assuring compliance. Please rank each of the provisions using the numbers 1,2,3 or 4 where 4 = Very effective 3 = Effective 2 = Uneffective 1 = Very unef f ect ive If you do not use some of these sanctions, place an "X" on the line. *The following table is a modified version of the table used in the original survey. A few columns have been changed to show more clearly the composite response from the 47 states that replied to the survey. Columns A, B. and C are the same here as in the original survey. Col- umns D, E, and F constitute an expansion of the original column D, which simply requested the number of actions taken by each state in 1980 and 1983. (The new columns D, E, and F deal with 1983 only; figures for 1980 were dropped because of a low response rate.) The new column G shows the number of states that ranked the sanction ef- fective and the number that ranked it ineffective and is similar to original column F ("Order of Effectiveness"). The original column E ("Order of Importance") was dropped because the responses were ba- sically the same as those in column G.

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342 / APPENDIX C OMB No. 0938-0395 LeRal Provis ion C ivi 1 or admin i strative f ines 26 Court-appointed receiver State-appointed monitor STATE: A B C D E F G State Recommending Agency Deciding ARency it States Carrying 1983 Range 1983 Effective/ Has Survey Other Out 1983 of # Actions Total It Ineffective Agency ( identify) Taken Actions 24 1 17 2- 90 _ 19 3 8 8 1-4 12_ __ 7 8 7 4 3 1 3 19/5 15/3 4/2 Suspens ion of all admissions 32 24 6 17 15 1-29 96 26/5 Cons iderat ion of past record in evaluation of cer tificate of need application 25 17 12 7 10 1-36 105 26 Court injunctions against substan dard operation 37 36 1 17 9 1 3 13 19/11 State- initiated relocat ion of res idents f ram substandard homes 36 31 5 21 14 1 8 27 22/8 Reduced Med i caid rates for inferior performance 9 6 12 3 1 10 10 4/2 Conditional or provis tonal licensing 35 34 2 22 14 1-72 268 23/8 Probat ionary license 15 14 6 8 5 1-72 154 9/3 Cr iminal penalties f or pat lent abuse _ 16 14 9 5 1-300 376 13/11_ License revocation 44 41 0 28 15 1-13 59 33/4 Involuntary decert i fication _ 39 1 22 13 1-55 129 26/7_ _ _ _ _ Withho lding of payments 19 8 14 5 3 4-263 272 3/2 Per State: Total sanctions available: Median = 8; Range = 1-14 Number of tvDes of sanctions applied: Median = 2; Range = 1-12 Total number of sanctions applied: Median = 11; Range = 1-457 HCFA-466

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APPENDIX C / 343 OMB No. 0938-0395 STATE: 45. Does your agency have written guidelines on when or how formal enforcement action should be taken against a facility with def iciencies? a. (20) Yes. (If yes, please return a copy of the guidelines with this questionnaire . ) b. (27) No. 46. Does your state have a law requiring mandatory reporting of patient abuse? a. (38) Yes. b. ( 9) No. 47. Does your state have a law permitting residents to sue facilities to protect their rights? a. (24) Yes. b. (18) No. 48. Does your state have other legal provisions which can be used to enforce quality of care standards? a. (30) No. b. (16) Yes. Send copy or list: 49. Does your state have a system which rates nursing homes and publicly discloses the ratings? a. (41) No. b. ( 6) Yes, it is operated by Survey Agency. 50. Do nursing homes with good compliance records (e.g., few deficiencies) receive higher Medicaid reimbursement rates or receive an incentive payment? a. ( 6) Yes. b. (41 ) No. skip to question 52 51. What proportion of the homes in your state are currently receiving the higher rate( s ) ? Median = 30% RanRe = 28-32% 52. When you recommend court action, is there an attorney on staff to take care of this? a . ( 13 ) Yes, the attorney is part of my agency' s stat f b. (31) Yes, the attorney is part of the state or district attorney's staff but is assigned to my unit. HCFA-466 c. ( 3) No. d. ( 0 ) Don' t know; we have never requested court action.

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344 / APPENDIX C OMB No. 0938-0395 STATE: 53. When you recommend court action, does the state attorney general carry out your request by filing suit? a. ( 20 ) All of the time b. ( 11 ) Most of the time c . ( 12 ) Some of the time d. ( 2 ) Don' t know; we have never requested court action. When you have taken a facility to court, do you think the courts have supported the agency's position? a. ( 3 ) All of the time b. (20) Most of the time c. (15) Some of the time d. ( 9) Don't know; we've never taken a facility to court. The next several questions address the effectiveness of various enforcement efforts. For these questions effectiveness is defined as getting the facilities to comply with nursing home regulations, terminating contracts with facilities that fail to comply, as well as the speed and thoroughness with which the sanction is carried out; e. g. new admissions to the facility were stopped immediately on court order. You need to refer to your answers to question 44. 55. In general, would you say your agency or state enforcement efforts have been a . ( 15 ) Very ef fective? b. (29) Effective? c . ( 3 ) Not effective? 56. Why are the sanctions you ranked "number 4" listed in question 44, Column F. "Order of Effectiveness," effective? Affect income of provider (20) Quick implementation ( 7 ) PublicitY ( 5 ) Ability to remove operator (4) 57. What are the obstacles to effective use of the sanctions you ranked "number 1" in question 44, Column F. "Order of Effectiveness?" Delays Difficulty of Administering ( 3) Potential harm to residents ( 4) Small impact on provider income ( 2 ) (11) HCFA - 466

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APPENDIX C / 345 OMB No. 0938-0395 STATE: H. Views on Federal Regulations 58. The current federal Conditions of Participation for skilled nursing facilities: a. ( 8 ) Can ensure nursing home services of adequate quality as they are. b. ( 9) Can ensure nursing home services of adequate quality, if they deleted some unnecessary or unmeasurable provisions. c. (20) Could ensure adequate quality services if they included certain additions and modifications. d. (10) Cannot ensure adequate quality services without a major overhaul and reorientation. 59. The current federal standards for intermediate nursing facilities: a. ( 6) Can ensure nursing home services of adequate quality as they are. b. ( 8) Can ensure nursing home services of adequate quality, they deleted some unnecessary or unmeasurable provisions. c . ( 20 ) Could ensure adequate quality services if they included certain additions and modif ications . d. (13) Cannot ensure adequate quality services without a major overhaul and reorientation. Which of the following statements do you feel is an accurate description of the situation in your state? 60 . The current f ederal survey Procedures: a. (11) Work reasonably well as they are in assuring that Medicare- and Medicaid-funded residents do not receive substandard services . b. ( 7 ) Would work as well if certain unnecessary or unmeasurable items were dropped. c . ( 7 ) Would work reasonably well if HCFA gave the states Bore support when they move to terminate substandard facilities. d. ( 20 ) Would work adequately if some changes and additions were made . e. ( 2 ) Need to be completely revised. HCFA-466

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346 / APPENDIX C OMB No. 0938-0395 STATE: 61. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations ) inhibit quality patient care? Utilization Control (2) 62. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations ) are currently ineffective and should be dropped completely? Utilization Control ( 11 ) Quarterly Staff Reports ( 5) 63. Which, if any, federal survey and certification regulations (including both the Conditions of Participation and the Subpart S regulations) should be retained in a modif fed or alternative form? Nursing Services (52 Medical Director (4) Physician Services (4 ) 64. Which, if any, federal survey and certification regulations ( including both the Conditions of Participation and the Subpart S regulations ) are neither effective nor worth the time and cost? Utilization Control ( 11 ) 65. List what you feel are the f ive most important federal survey and certif ication regulations ( including both the Conditions of Participation and the Subpart S regulations ) for ensuring adequate quality patient care? 1. Nurs ing Services (36) 2. Dietetic Services (30) 3. Pharmaceutical Services (24) 4. Physician Services 5. Physical Environment ( 19) (13) 66. What, if anything, should be in the federal survey and certification regulations ( including both the Conditions of Participation and the Subpart S regulations ) that is not there now? Resident Assessment Outcomes (13) Intermediate Sanctions ( 6 ) Staff Ratios ( 5) HCFA-466

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APPENDIX C / 347 OMB No. 0938-0395 STATE: 67. The current requirement for annual surveys of all federally certified nursing homes should be made more flexible to permit less frequent surveys of facilities with histories of compliance and more than annual surveys of facilities with histories of noncompliance. a. ( 12 ) Strongly agree b. ( 11 ) Agree c. ( 10 ) Disagree d. ( 14 ) Strongly disagree ) 23 ) 24 68. The time-limited agreement requirement should be dropped because its usefulness as an enforcement tool is outweighed by the consequent ability of facilities to predict the timing of survey visits. ( 14 ) Strongly agree c. b. ( 14 ) Agree (12) Disagree d. ( 7 ) Strongly disagree ) 28 19 69. A short screening instrument should be used in conjunction with more flexible survey cycles to identify which facilities should receive more f requent full surveys . a. ( 11 ) Strongly agree b. ( 23 ) Agree somewhat c . ( 6 ) Disagree d. ( 7 ) Strongly disagree ) 34 ) 13 70. It is desirable and practical to include a patient-centered assessment in the certif ication survey process. a. ( 30 ) Strongly agree b. (15) Agree c . ( 0 ) Disagree d. ( 1 ) Strongly disagree HCFA-466 45 1

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348 / APPENDIX C OMB No. 0938-0395 STATE: 71. A sample of alert nursing home residents should be interviewed and their opinions be included as part of the survey process. a. ( 10) Strongly agree b . ( 8 ) Agree c . ( 3 ) Disagree d . ( 0 ) Strongly disagree ) 18 3 72. How many on-site visits should be required to verify correction with all items identified as deficiencies in a Statement of Deficiencies/Plan of Correction form? a. (30) One on-site revisit is adequate and more practical in most cases. b. ( 13) Several; there should be a series of on-site visits if there are multiple deadlines for corrections. c . ( 3 ) None, because on- s ite vis its are expens ive and some common def iciencies can be adequately verif fed by telephone or mail . 73. Accreditation by JCAH or some other accrediting body should be permitted to stand in place of state surveys for federal certif ication purposes . a. ( 1 ) Strongly agree b . ( 0 ) Agree c. ( 11 ) Disagree d. (35) Strongly disagree 1 ) 46 74. The federal regulations should require posting of survey results. The posting should include whether or not the facility is in compliance in general and list the specif fed elements found not to be in compliance. This posting should be in a prominent location in each facility. a . ( 17 ) Strongly agree b. ( 13 ) Agree c. ( 13 ) Disagree d. ( 4 ) Strongly disagree HCPA-466 ) 30 17

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APPENDIX C / 349 OMB No. 0938-0395 STATE: 75. The regulations, procedures, and forms for surveying skilled and intermediate level facilities should be combined in to one comprehend ive survey . a. ( 18 ) Strongly agree b. ( 18 ) Agree c. ( 9 ) Disagree d. ( 1 ) Strongly disagree ) 36 ) 10 76. Should the inspection of care review system be integrated with the process of surveying nursing homes for certification? a. (26) Yes, they both should be done at the same visit by different teams so that significant inspection of care problems can be cited and corrected in the survey process while the burden on providers is reduced. b. ( 6) Yes, and to save costs and avoid duplication, they should be done by the same team as well as during same visit. c . ( 7 ) No, the two functions should be conducted by separate agencies or departments, because they have different foci (patient vs. facility) and/or two visits allow better surveillance of facilities. d. ( 7 ) No, they are separate functions, but they should be under the same supervisor in the state health or health and human services department so that the pertinent f indings of each process can be shared. 77. Federal regulations should contain a requirement for state certif ication of nurses aides . a. ( 14 ) Strongly agree b. ( 20 ) Agree c . ( 10 ) Disagree d. ( 2 ) Strongly disagree HCFA-466 ) 34 ) 12

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350 / APPENDIX C OMB No. 0938-0395 STATE: 78. Specific minimum nursing staff to patient ratios should be adopted in the federal regulations. a. (13) Strongly agree ) ) 32 b. ( 19 ) Agree c . ( 13 ) Disagree d. ( 2 ) Strongly disagree HCFA-466 ) 15