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Glossary Accredited Facility: a hospital accredited by the Joint Commission on the Accreditation of Hospitals (JCAH) or the American Osteopathic Association (AOA), or a SNF, ICE, or HHA accredited by the JCAH. Activities of Daily Living (ADL): basic self-care activities, including eating, bathing, dressing, transferring from bed to chair, bowel and bladder control, and independent ambulation, which are widely used as a basis for assessing individual functional status. Acute Care: medical care designed to treat or cure disease or injury, usually within a limited time period. Acute care usually refers to physician and/or hospital services whose duration is less than 3 months. Adult Day-Care: social and health services provided for physically or mentally impaired individuals in a nonresidential, day-care setting. Aged: persons aged 65 and over. Age-Specific Rate: the rate of occurrence of an event (for example, death, marriage, birth, illness) for a specified age group in a population. Aging of the Population: the increasing proportion in the total population of older (age 65 and over) relative to younger (less than age 65) persons. It is generally 389
390 / GLOSSARY measured in percentage distribution by age group, but also measured in median age, the age at which 50 percent of the population is older and 50 percent is younger. A-Key Deficiencies: violations of certain Conditions of Participation that were identified as being of primary importance by the HCFA in 1981. Violations of these conditions were, at that time, considered more serious than the remaining, or B-level, deficiencies. Allowable Costs: costs of operating a facility, which are reimbursable by the state under the state Medicaid program. Alzheimer's Disease: the most common form of dementia, an organic brain disease leading to progressive loss of brain function and eventual death. The cause is unknown and there is no effective standard medical treatment. Annual Survey: the process of inspecting a health care facility for compliance with state licensing regulations and/or Federal Conditions and Standards of Participation. Assessment Technology: testing instruments or procedures to measure and evaluate. In long-term care, instruments or procedures used to measure the physical, mental, and social functioning of individuals. Assistive Device: a tool, prosthesis, or adaptive equipment that helps an individual compensate for certain functional impairments, such as a hearing aid for hearing loss, glasses for vision loss, a cane to aid walking, or a universal cuff for difficulty in eating. Average Per Diem State Rates: the average amount spent by a state for each Medicaid long-term-care resident each day. Bed-Fast, Bed-Bound: a condition in which one is confined to bed and not able to walk, sit, or move about independently. Bed-to-Population Ratio: the number of beds certified fo a specific health care service to every 1,000 persons in the group intended to use the service. For example, the number of SNF beds per 1,000 persons aged 65 and over.
GLOSSARY / 391 Board and Care Homes: nonmedical facilities that provide room and board and some degree of protective supervision on a 24-hour basis. Examples include adult foster homes, group homes, larger residential care facilities, and retirement homes. Case Mix: the combination of diagnoses, medical care, and social care needs present in the population of a health care facility. Case-Mix Payments: a reimbursement system based on the principle that payment for services should take into account the illness level of the resident. Each resident is assessed at some standard time interval and receives services appropriate to those determined needs. The case mix model develops an average patient profile for each facility. The state then pays that average rate for all Medicaid residents in that facility. The case mix system moole! establishes a rate for each patient which is determined at each assessment. Categorically Needy: under Medicaid, categorically needy cases are aged, blind, or disabled individuals or families and children who are otherwise eligible for Medicaid and who meet financial eligibility requirements for Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI), or an optional state supplement. Ceiling, Cap: highest allowable cost payable by the state under the state Medicaid program. Certificate of Need (CON): a certification made by the state under P.L. No. 92-641 that determines that a certain health service is needed and authorizes a specific operator, at the operator's request, to provide that service. Certification for Medicaid: the survey's determination regarding a Medicaid provider's compliance with health and safety requirements. Certification for Medicare: a recommendation made by the state survey agency to the federal agency regarding the compliance of providers with the Conditions of Participation and Conditions of Coverage. Charge Nurse: a person who is (1) licensed by the state in which practicing as a registered nurse or practical
392 / GLOSSARY (vocational) nurse who (a) is a graduate of a state-approved school of practical (vocational) nursing, or (b) has 2 years of appropriate experience following licensure by waiver as a practical (vocational) nurse, and has achieved a satisfactory grade on a proficiency examination approved by the state's Secretary of Health, or on a state licensure examination which the Secretary finds at least equivalent to the proficiency examination (such determinations of proficiency do not apply with respect to persons initially licensed by a state or seeking initial qualifications as a practical (vocational) nurse after December 31, 1977~; and (2) is experienced in nursing service administration and supervision in areas such as rehabilitative or geriatric nursing, or acquires such preparation through formal staff development programs. Charges: the dollar rates that a provider of the services places on the services provided. The provider's cost and charges are not necessarily identical, because the charge may also contain a handling and/or profit rate. Chronic Condition: a physical or mental illness or disorder characterized by a long duration (usually more than 3 months) or frequent recurrence. Class-Based or Flat-Rate Reimbursement Systems: rates set statewide or for groups of facilities in a particular state, based on the cost history of the entire group. The state may determine groups by geographic regions, size, ownership status, or any other characteristics it chooses. Cohort: a population group that shares a common property, characteristic, or event, such as a year of birth or year of marriage. The most common cohort is the "birth cohort," a group of individuals born within a defined time period, usually a calendar year or a 5-year interval. Complaint Visit: a brief visit made by the state survey agency to a health care facility in response to a complaint made about the facility to the agency. Conditions of Participation: the regulatory criteria, as outlined in 42 CFR 405.1122 and the following, by which a state survey agency determines whether a skilled nursing facility is eligible to participate in the
GLOSSARY / 393 Medicare or Medicaid program. Conditions are composed of a number of items (standards), which may be composed of several additional items (elements). Standards and elements are intended to explicate Conditions. Cost: actual expenses incurred for inputs. For example, the cost of nursing home care includes direct costs such as staff salary, facility, equipment, supplies, and indirect costs such as mortgage, general and administrative fees, and cost of capital. Cost-to-Charge Ratio: a constant used by researchers and policymakers to calculate the charges or cost of a given input when only partial or incomplete charge or cost figures are readily available. Decertification or Termination: the process of suspending or revoking a health care facility's certification to participate in the Medicare and/or Medicaid programs. Decubitus Ulcer, Decubiti: a break in the surface of the skin that appears in areas under pressure in reclining or sitting because of a circulatory defect in the area under pressure. Also called bed sores, pressure sores. Deficiencies: the designation a surveyor makes on finding a facility out of compliance with Conditions and Standards of Participation. Dementia: the loss of intellectual mental function, due to many different acute and chronic diseases, including Alzheimer's disease, which may affect the white matter and blood supply of the cerebrum. Diabetes Mellitus: a familial constitutional disorder of carbohydrate metabolism that is characterized by inadequate secretion or utilization of insulin, by excessive amounts of sugar in the blood and urine, and by thirst, hunger, and loss of weight. Diagnosis-Related Groups (DRGs): a classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. In October 1983, Medicare instituted a prospective reimbursement system based on 467 DRGs. Under this system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. Dietetic Service Supervisor: a person who (1) is a qualified dietician; or (2) is a graduate of a dietetic
394 / GLOSSARY technician or dietetic assistant training program (corresponding or classroom), approved by the American Dietetic Association; or (3) is a graduate of a state-approved course that provided 90 or more hours of classroom instruction in food service supervision and has experience as a supervisor in a health care institution with consultation from a dietician; or (4) has training and experience in food service supervision and management in a military service. Dietician: a person who (1) is eligible for registration by the American Dietetic Association under its requirements in effect on January 17, 1974; or (2) has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management, has 1 year of supervisory experience in the dietetic service of a health care institution, and participates annually in continuing dietetic education. Director of Nursing Services: a registered nurse who is licensed by the state in which practicing, and has 1 year of additional education or experience in such areas as rehabilitative or geriatric nursing, and participates annually in continuing nursing education. Disability: the inability to perform an activity in the manner or in the range considered normal because of physical or mental impairment. Discharge: a formal release from a hospital or a skilled nursing facility (SNF). Discharges include persons who died during their stay, or were transferred to another facility. Distinct Part Facility: a nursing home which is certified by the state agency to provide both skilled and intermediate care in separate designated areas of the facility. Drug Administration: an act in which a single dose of a prescribed drug is given to a patient by an authorized person In accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper patient, and promptly recording the time and dose given.
GLOSSARY / 395 Drugs and Biologicals: substances included (or approved for inclusion) in the United States Pharmacopoeia, the National Formulary, or the United States Homeopathic Pharmacopoeia, or in New Drugs or Accepted Dental Remedies (except for any drugs and biologicals unfavorably evaluated therein), or as approved by the pharmacy and drug therapeutics committee (or equivalent committee) of the medical staff of the hospital furnishing such drugs and biologicals for use in such hospital. Dually Certified Facility: a nursing home which is certified by the state agency to provide both skilled and intermediate care in all areas of the facility. Elements: regulatory certification requirements which explicate standards and conditions of participation. See Conditions of Participation and Standards of Participation. Expenditure: under Medicaid, an amount paid out by a state agency for the covered medical expenses of eligible participants. Extended Care Services: items and services furnished to an inpatient of a skilled nursing facility including (1) nursing care provided by or under the supervision of a registered professional nurse; (2) bed and board in connection with the furnishing of such nursing care; (3) physical, occupational, or speech therapy furnished by the skilled nursing facility or by others under arrangements with them made by the facility; (4) medical social services; (5) such drugs, biologicals, supplies, appliances, and equipment furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients; (6) medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement, under a teaching program of such hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect; and (7) such other services necessary to the health of the patients as are generally provided by skilled nursing facilities; excluding, however, any item or service if
396 / GLOSSARY it would not be included if furnished to an inpatient of a hospital. Extencled Survey: a comprehensive survey requiring surveyor to review all conditions, standards, and elements, and to interview a large number of residents. Facility-Specific Reimbursement Rates: rates set for each facility based on that facility's cost history. Follow-up Visit: a brief return visit made by the state survey agency to a health care facility within 90 days of an annual survey in order to determine a facility's progress on correcting violations found by the survey agency during the annual survey. Functional Dependence: the inability to attend to one's own needs, including the basic activities of daily living. Dependence may result from the changes that accompany natural aging, or from a disease or related pathological condition. Functional Impairment: inability to perform basic self-care functions such as eating, dressing, and bathing, or instrumental activities of daily living, including home management activities such as cooking, shopping, or cleaning, because of a physical, mental, or emotional condition. Handicap: a disadvantage resulting from a physical or mental impairment or disability that limits or prevents the fulfillment of a role that is normal (for that individual) in a given environment. Heavy-Care Residents: residents of skilled or intermediate care facilities who require a great deal of attention for medical care, nursing care, and/or assistance with activities of daily living. Bed-fast or severely demented residents are examples of heavy-care residents. Home Care: medical, social, and supportive services provided in the home, usually intended to maintain independent functioning and avoid institutionalization. Home Health Agency (HHA): a public or private organization providing skilled nursing services, other therapeutic services and other assisting services in the patient's home, and which meets certain conditions to ensure the health and safety of the individuals who receive the services.
GLOSSARY / 397 Hospital-Based Facility: a designated area of a hospital certified by the state to provide skilled and/or intermediate care. Impairment: a physical or mental abnormality that can be readily identified or diagnosed. Independent Professional Review: see Inspection of Care. Input Measurement: examination of resources, activities, or tools used to provide a service in order to determine the quality of service provided. Inspection of Care: a regular program of medical review (including medical evaluation) by one or more medical review teams (composed of physicians or registered nurses and other appropriate health and social service personnel) to determine (1) the care being provided in nursing facilities; (2) the adequacy of the services available in particular nursing facilities (or institutions) to meet the current health needs and promote the maximum physical well-being of patients receiving care in the home (or institution); (3) the necessity and desirability of the continued placement of patients in the nursing home (or institution); and (4) the feasibility of meeting the patient's health care needs through alternative institutional or noninstitutional services. Instrumental Activities of Daily Living (IADL): home management and independent living activities such as cooking, cleaning, using a telephone, shopping, doing laundry, providing transportation, and managing money. Intermediate Care Facility (ICE): an institution furnishing health-related care and services to individuals who do not require the degree of care provided by hospitals or skilled nursing facilities as defined under Title XIX (Medicaid) of the Social Security Act. Intermediate Sanctions: penalties short of termination of a facility's Medicaid or Medicare contract, which are imposed by states against health care facilities found out of compliance with state or federal regulations. Key Indicators: measures of quality of care and quality of life which focus on care given to residents, the results (outcome) of such care, and the manner (process)
398 / GLOSSARY in which the care is given, for example, use of certain drugs, and incidence of infections and decubiti. Level of Care: the amount of medical care and assistance with activities of daily living needed by individuals in a group. Traditionally, level of care refers to the SNF and ICE groups. Licensed Nursing Personnel: registered nurses or practical (vocational) nurses licensed by the state in which they practice. Life Care/Continuing Care Communities: communities that provide a range of services for elderly residents, including homes or apartments for independent living, home care services, infirmary, and sometimes nursing home services. Payment of an initial membership or entrance fee and a monthly fee guarantees the individual most types of health and social services for the rest of his/her life. Life Expectancy: a measure of the average remaining years of life at specified ages for different subgroups (for example, by sex and race) of a population. Life Safety Code (LSC), Fire Safety Code: regulatory criteria used by the state health agency or fire marshal! to determine whether a physical plant is structurally safe and adequately prepared against fire. Long Stayers: nursing home residents who are no longer able to live outside of institutions and who generally reside in nursing homes for many months or years, often until they die. Long-Term Care: a variety of ongoing health and social services provided for individuals who need assistance on a continuing basis because of physical or mental disability. Services can be provided in an institution, the home, or the community, and include informal services provided by family or friends as well as formal services provided by professionals or agencies. Long-Term-Care Facility: any skilled nursing facility, intermediate care facility, nursing home, adult care home, or similar institution regulated by a state. Medicaid: a federal/state program, authorized by Title XIX of the Social Security Act, to provide medical care for low-income individuals. Federal regulations specify mandated services, but states can determine optional
GLOSSARY / 399 services and eligibility standards. The federal government's share of costs ranges from 50 to 78 percent and is based on per capita income in the state. Medicaid Retrospective Reimbursement Systems: state reimbursement systems in which a facility's costs are reimbursed after the expenditure. Each state may have different allowable costs and ceilings, and may vary costs by factors such as region or size of facility. Medically Needy: under Medicaid, medically needy cases are aged, blind, or disabled individuals or families and children who are otherwise eligible for Medicaid, and whose income resources are above the limits for eligibility as categorically needy (AFDC or SSI) but because of their medical problem are considered within limits set under the Medicaid state plan. Medicare: a federally funded health insurance program authorized by Title XVIII of the Social Security Act to pay for medical care for elderly and disabled beneficiaries. Medicare reimburses part of the costs for acute care and some types of long-term care. Beneficiaries pay an annual deductible and co-payments for most covered services. The program is divided into two sections: Part A, which covers hospital and inpatient physicians' services, and an optional Part B. which covers outpatient physician and some other outpatient services. Medicare Cost-Based Reimbursement: a uniform federal payment system that is based on a facility's costs for providing that service. Medicare Medicaid Automated Certification System (MMACS): a data base system operated by the Health Care Financing Administration to collect data from state survey agencies on certification activities. Nurse-Bed Ratio: the number of full-time equivalent nursing personnel to the number of beds. The ratio can be presented at the facility, local national level. state, regional, or Nurse's Aide, Nursing Aide, Nursing Assistant: people who, under the supervision of a licensed nurse, provide medical care and assistance with activities of daily living to residents, and who are not themselves licensed to independently provide care.
400 / GLOSSARY Nursing Home: a residential long-term-care facility that provides 24-hour care, skilled nursing care, and personal care on an inpatient basis. The definition of a nursing home varies by state. Nursing Services: services provided under the direction or supervision of one or more registered nurses or licensed practical or vocational nurses. Ombudsman: a state representative or a representative of a public agency or a private nonprofit organization (which is not responsible for licensing or certifying long-term care services) who (1) investigates and resolves complaints made by or on behalf of older individuals who are residents of long-term-care facilities relating to administrative action that may adversely affect the health, safety, welfare, and rights of such residents; (2) monitors the development and implementation of federal, state, and local laws, regulations, and policies with respect to long-term-care facilities in that state; (3) provides information as appropriate to public agencies regarding the problems of older individuals residing in long-term-care facilities; (4) provides for training volunteers and promotes the development of citizen organizations to participate in the ombudsman program; and (5) carries out such other activities as the State Health Commissioner deems appropriate. Outcome Measurement: examination of the results of a service in order to determine the quality of the service provided. Out-of-Pocket Expenditures: amounts not covered by any third-party payer that must be paid directly by the consumers, out of their own pockets. Patient Assessment Computerized (PAC) System: a standard resident assessment system developed and used by a private nursing home chain, the National Health Corporation, located in Murfreesboro, Tennessee. Patient Care and Services (PaCS): a new survey protocol developed by the Health Care Financing Administration. Patient Care Profile: a standard resident assessment system developed by Mr. William Thoms, a nursing home administrator in New Hampshire. It is now being used by
GLOSSARY / 401 the Hillhaven Corporation, a national nursing home chain. Payment: the dollar amount that is transferred on behalf of the recipient from one or more agents to the provider of the service. Physicians' Services: professional services performed by physicians, including surgery, consultation, and home office and institutional calls. Plan of Correction: the form by which a facility documents its procedures and time frame for correcting violations of certification regulations cited by the state survey agency. Process Measurement: the examination of methods of providing a service in order to evaluate the quality of the service provided. Professional Standards Review Organization (PSRO): a physician or other professional medical organization (consisting of physicians and other health professionals with independent admitting hospital privileges) that enter into an agreement with the U.S. Department of Health and Human Services to assume the responsibility for the review of the quality and appropriateness of services covered by Medicare, Medicaid, and the Maternal and Child Health program. PSROs determine whether services are medically necessary, provided in accordance with professional standards, and, in the case of institutional services, rendered in the appropriate setting. Prospective Reimbursement Systems: systems in which the day rate or line item rate is set beforehand, based on a formula that takes into account historical expenditures. Typically these systems are adjusted annually and use an inflation or similar factor as the basis for future adjustment. Rehabilitation: social or medical care designed to restore patients to their former capacity or to a condition of health or independent activity. Resource Utilization Groups (RUGS): a standard method of grouping nursing home residents in accordance with the services they require (and, therefore, with the staff and other resources needed to supply those services).
402 / GLOSSARY Retrospective Reimbursement Systems: systems in which the amount of reimbursement is based on the cost of the services already provided. These amounts are usually controlled or limited by a cap, a ceiling, or percent of actual costs incurred. Risk Factors: characteristics, behaviors, substances, or environmental and other factors that are statistically associated with an increased likelihood of developing a given condition. Short Stayers: nursing home residents who generally come from hospitals ant! wit be discharged home or will die in a very short time. Skilled Nursing Facility (SNF): defined by the federal government as an institution that has a transfer agreement with one or more participating hospitals, and that is primarily engaged in providing to inpatients skilled nursing care and rehabilitative services, and that meets specific regulatory certification requirements. Social Worker: a person who is licensed, if applicable, by the state in which practicing, is a graduate of a school of social work accredited or approved by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. Spend-Down: under the Medicaid program, a method by which an individual establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income (after medical expenses) meets Medicaid financial requirements. A resident spends down when she/he is no longer sufficiently covered by a third-party payor (usually Medicare) and has exhausted all personal assets. The resident then becomes eligible for Medicaid coverage. Standard Survey: a semiannual inspection based on review of a facility's performance with regard to key indicators and interviews with a stratified sample of residents. Standards of Participation: the regulatory criteria, as outlined in 42 CFR 442.300 and the following, by which a state survey agency determines whether an intermediate care facility is eligible to participate in the Medicaid
GLOSSARY / 403 program. Standards are composed of elements. See also Conditions of Participation. State Plan: a comprehensive written commitment by a Medicaid agency to administer or supervise the administration of a Medicaid program in accordance with federal requirements. State Survey Agency: the state health agency or other appropriate state or local agency that performs survey and review functions for Medicare and Medicaid. Substate Ombudsman: a representative of the state ombudsman who performs ombudsman responsibilities in a given area of the state. See also Ombudsman. Supplemental Security Income (SSI): a program of income support for low-income aged, blind, and disabled persons, established by Title XVI of the Social Security Act. Supplementary Medical Insurance (SMI): a voluntary insurance program (also known as Medicare Part B) that provides insurance benefits for physician and other medical services in accordance with the provisions of Title XVIII of the Social Security Act, for aged and disabled individuals who elect to enroll under such program. The program is financed by premium payments by enrollees, and contributions from funds appropriated by the federal government. Swing-Beds: beds located in a hospital that are certified by the state for use by patients in need of acute or skilled care. Title III of the Older Americans Act: federal legislation that provides funding to states for development and coordination of services for the elderly. The Administration on Aging allocates Title III funds to states primarily on the basis of the proportion of each state's population aged 60 and over. 24-Hour Nursing Services: services for which nursing personnel are on duty 24 hours a day. The term "nursing personnel" includes registered nurses and licensed practical or vocational nurses. Urinary Incontinence: inability to control urinary f unction. Utilization Review: a review, on a sample or other basis, of admissions to the institution, the duration of stays
404 / GLOSSARY therein, and the professional services (including drugs and biologicals) furnished, to determine the medical necessity of the services and the most efficient use of available health facilities and services. It is made by either a staff committee of the institution composed of two or more physicians with or without participation of other professional personnel, or by a group outside the institution that is similarly composed and that is established by the local medical society and some or all of the hospitals and skilled nursing facilities in the locality, or (if there has not been established such a group serving such institution) that is established in such other manner as may be approved by the state's Secretary of Health. Waivers: exemption from meeting a particular regulatory requirement. Waivers for certification requirements may be given by states to facilities. Waivers for program requirements may be given by the federal government to states.