tial care, and home health care) and the individuals receiving care in them. They may complement each other in various arrangements such as that of deemed status, complaint investigation and mediation, or independent confirmation of measures of satisfaction of individuals in long-term care and their families.

Beginning with the development of licensure for health workers in the nineteenth century to the current ongoing government initiatives to define and enforce quality standards, regulation and oversight have figured prominently in efforts to assess, protect, and improve the quality of health care. Basic quality standards define and specify the minimum acceptable qualifications for state licensure and for certification for participation in Medicare and Medicaid.1 This chapter focuses on the government's central role in setting and enforcing standards of quality for formal long-term care. It highlights the current status of the basic standards, the survey process for monitoring and assessing compliance, and the enforcement of the quality standards for nursing homes, residential care, and home health care. Throughout the chapter the committee provides suggestions and recommendations for further improvements at both the federal and the state levels.


Through legislation, regulation, and judicial decisions, federal and state governments play a central role in the definition and enforcement of basic standards of quality for long-term care, particularly for publicly funded services and institutional care. In addition, regulations involving such matters as contracts or disclosure of information to consumers and the public are components of quality strategies based on consumer choice and quality improvement.

Most federal regulations of long-term care are linked to federal funding of services through the Medicare and Medicaid programs, and are administered by the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services (DHHS). Both programs have requirements for participation that health care providers must meet to receive payment.2

Federal and state governments share regulatory responsibilities for long-term care. Overall, the federal government has a dominant presence in nursing home and home health regulation through certification for


Those who meet specified standards may also have to meet other conditions, for example, payment of a fee to actually secure a license.


Until recently, these requirements were known as “conditions of participation.”

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