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OCR for page 315
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
OCR for page 316
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
OCR for page 317
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.
OCR for page 319
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
OCR for page 320
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
OCR for page 322
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
OCR for page 323
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.
OCR for page 324
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
OCR for page 325
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
OCR for page 340
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.
OCR for page 341
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.
OCR for page 344
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
OCR for page 345
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.
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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)
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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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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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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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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
Representative terms from entire chapter:
nursing homes
