Governments have a central role in defining and enforcing basic standards of quality for long-term care. Professional, trade, consumer, and other organizations generally make a different contribution by going beyond minimum performance levels to set requirements that encourage excellent care.
Although OBRA 87 has achieved advances in the quality of care and life in some areas, the implementation of its survey and enforcement efforts has been less than satisfactory, as HCFA, the agency with primary responsibility for its implementation, has recognized. Although HCFA has moved to strengthen its oversight of state survey and enforcement activities and to improve their effectiveness and efficiency, these activities need to be sustained and revised in collaboration with state officials, providers, and consumers. This report was not intended as a full review of the implementation of OBRA 87; this chapter has focused selectively on problem areas in regulatory standards and made recommendations that would improve the reliability and validity of federal and state enforcement efforts primarily affecting quality of care.
Little information is available about federal or state performance in monitoring the quality of long-term care provided under Medicaid 's home and community-based services waiver program. To guide decisions, policy makers need more information about how this program is working and, more generally, about how states are defining and regulating community-based long-term care services and supportive housing for different populations. The committee is concerned about reports of quality problems in community-based residential care. At the same time it believes that because of the complexity of the various settings, the inadequate information about quality, and the fragmentation of the various state regulations, the creation of a detailed federal regulatory system at this time is unlikely to bring about better quality of care and quality of life for users of these services. The committee believes that people using long-term care should, within certain broad limits, be able to make choices among alternatives that offer varying balances of autonomy, safety, and other values that sometimes conflict.