Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Improving Quality Through External Oversight
Improving Quality Through External Oversight
Pages 135-179
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From page 135... ...
The approaches of regulatory oversight, advocacy, and accreditation are somewhat different. Their relative strengths and weaknesses may make them differentially suited to different long-term care settings (e.g., nursing homes, residen135
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From page 136... ...
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.
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From page 137... ...
In order to assess compliance with federal Medicare and Medicaid requirements, HCFA relies on a survey and certification process, which is administered by state licensing and certification agencies. HCFA's ten regional offices are charged with the oversight and monitoring of the state survey and certification efforts for nursing homes and home health agencies.
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, it has a responsibility to hold providers accountable for fiscal integrity and for the quality of care provided to beneficiaries. Medicare and Medicaid requirements of participation for nursing homes and home health care services serve both goals.
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Other values such as the quality of life or autonomy of those receiving care may be underemphasized. With regard to federal regulation of nursing homes, however, the nursing home reforms in the Omnibus Reconciliation Act of 1987 (OBRA 87)
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From page 140... ...
The discussion that follows focuses on nursing homes, residential care facilities, home health care, and home care and other home and community-based services. Nursing Homes Both federal and state governments employ regulation as a strategy to protect quality of care in nursing homes.
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It identified "large numbers of marginal or substandard nursing homes that are chronically out of compliance when surveyed .
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Continuing past practice, OBRA 87 required HCFA to contract with state agencies to survey nursing homes to certify their compliance with Medicare and Medicaid requirements. Consistent with the changes in the standards, enforcement was to focus on both processes and outcomes of care.
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From page 143... ...
Definitive, rigorous evaluation of their continuing impact on quality of care and outcomes is necessary. State Survey Process To monitor and assess compliance by nursing homes with Medicare and Medicaid requirements for participation, HCFA relies on a survey and certification process administered under contract by state agencies.
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HCFA has developed standardized forms, sampling methods, and survey procedures to ensure the reliability, accuracy, and comparability of state surveys of nursing homes. In a further effort to achieve consistency, HCFA's State Operations Manual (HCFA, l999c)
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Several studies support the conclusion that the current survey process fails to identify important quality-of-care problems. A study conducted by the University of Wisconsin in 1996, which involved 6 concurrent surveys and 23 survey observations performed by independent investigators, showed that state surveyors consistently cited fewer deficiencies in care and rated problems as less severe than did the researchers (Abt and CHSRA, 1996~.
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From page 148... ...
In 1998, as a part of the President's initiative to ensure the health and safety of nursing home residents, federal and state regulators began to target a small list of about 100 nursing homes that had poor records of compliance with quality standards to ensure these facilities receive more frequent inspections. Targeting poor-performing facilities for more frequent surveys is consistent with OBRA 87.
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Another potentially high-risk situation that HCFA and state survey agencies should consider tracking and targeting for special surveys includes changes in key administrative and clinical staff. One recent report cited annual turnover rates of nursing home administrators at 30 percent (AHCA, 1998~.
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has announced steps in this direction by proposing to have the database of state survey results include major state enforcement actions (e.g., decertification) against individual and corporate owners of nursing homes.
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As described earlier, states vary substantially in their survey and enforcement findings, and no evidence suggests that this variation is a function of corresponding variation in the quality of care provided in states. The implementation of OBRA 87 was only partly successful in improving protocols for assessing compliance, monitoring state survey agencies, and training and support for surveyors.
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From page 152... ...
3) also reviewed the nursing home complaint investigation process and found that "HCFA reporting systems for nurs
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The GAO (1998a) report on quality problems in California nursing homes noted suspicious gaps in information and implausible entries in the sample of records it reviewed.
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Beginning in fuly 1995, state surveyors were required to rate all violations based on their scope and severity, and then to link sanctions to the scope and severity of the violation identified (HCFA,1995b)
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Category 3: · temporary management, · termination of certification, and/or · optional: civil money penalties of $3,050-$10,000 per day or $1,000-$10,000 per instance.
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. In cases of immediate jeopardy, the sanction can be put into effect after a two-day notice.8 Civil money penalties can be assessed retroactively for noncompliance that occurred between surveys.
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examined the enforcement of federal nursing home regulations and concluded that although HCFA has taken steps to improve the oversight of nursing homes, it is unable to ensure that nursing homes maintain compliance with federal health care standards. According to GAO, more than one-fourth of the facilities had deficiencies that caused actual harm to residents or placed them at risk of death or serious injury and many others had serious deficiencies.
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when they received a per-instance civil money penalty; (3) when the deficiencies were for immediate jeopardy; or (4)
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In 1996, HCFA issued guidelines that urged states to limit the imposition of civil money penalties (CMPs) to situations of immediate jeopardy to the health and welfare of residents or uncorrected deficiencies at the time of a revisit of a poor-performing facility (Edelman, 1998a-c)
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From page 161... ...
HCFA has established this information about nursing homes on its Web site at www.hcfa.gov/Medicare/NHCompare. This is an important first step toward making information more accessible to the public.
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From page 162... ...
HCFA has not evaluated the informal dispute resolution process, but such an evaluation should be conducted. Recommendations for Nursing Home Assessment and Enforcement The above discussion of federal and state enforcement of nursing home regulations in this chapter has identified problems with both the identification of quality care and the enforcement of compliance with quality standards.
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From page 163... ...
State standards for these care arrangements including assisted living facilities, a relatively recent subset of residential care, are highly variable (Mollica, 1998; Hawes et al., 1999~. As described in Chapter 2, this variability begins with the very definition of
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The complexity of the situation facing state regulators is illustrated by the fact that there are numerous levels and types of residential care including group homes, foster homes, assisted living facilities, residential care facilities, mental health facilities, mental retardation facilities, personal care homes, supportive living facilities, and habilitation facilities. Moreover, they are called by more than 25 different names with multiple categories and titles within states (Lewin/ICF and lames Bell Associates, 1990; Hawes et al., 1993~.
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Unresolved questions remain about the acceptable role and extent of regulatory standards in residential care settings. Weaknesses in State Regulation of Residential Care Very little has been done to evaluate the effectiveness of current policy and regulatory practices in residential care.
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The same GAO (1999a) study of four states found that assisted living facilities showed wide variation in state standards and the procedures for surveying facilities, which ranged from annual to biennial inspections.
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Although residential care settings pose quality concerns, some committee members believe that consumers are choosing residential care over nursing homes because of quality-of-life issues and the greater flexibility these facilities provide to residents. Little study of state enforcement actions has occurred and variation across states is enormous.
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From page 168... ...
Because the public and policy makers are searching for an adequate understanding of the range of residential care options and appropriate boundaries for these options, they would benefit from more systematic information about state experiences with different care options and with different regulatory strategies and labels. Standard definitions and boundaries across states need to be developed in order to collect national systematic and comprehensive data on residential care settings, their characteristics, staffing, and care provided.
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30~. HOME HEALTH AGENCIES Standards for Home Health Care Agencies Each area of long-term care presents different surveying and monitoring challenges.
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The survey guidelines for home health agencies require an initial or standard survey to assess whether the home health agency has the capacity to deliver services that meet minimum standards. Once an agency passes its initial survey, it should be recertified every 12 to 26 months following the same survey process, with the frequency varying depending on the results of prior surveys.
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From page 171... ...
Deemed Status In addition to certification based on state surveys, federal law provides that home health agencies may meet Medicare participation requirements by receiving accreditation from either of two private organizations, the Joint Commission on Accreditation of Healthcare Organizations (ICAHO) or the Community Health Accreditation Program of the National League for Nursing.
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From page 172... ...
found that agencies can continue as Medicare providers even if they have multiple deficiencies as long as they have an approved plan of correction. The same yo-yo pattern described earlier for nursing homes also characterizes home health agencies.
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In particular, as with nursing homes, federal and state survey efforts should focus more on chronically poor-performing providers by surveying them more frequently, increasing penalties for repeated violations of standards, and decertifying persistently substandard providers. Federal and state survey efforts should focus more on high-risk events such as rapid caseload growth and management changes.
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From page 174... ...
Historically, advocacy by consumers, family members, and committed community members has played a critical role in shaping long-term care policy and services (Shapiro, 1993~. Consumer activists spearheaded the passage of key legislation, such as the Nursing Home Reform Act (OBRA 87)
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The advocacy models include the publicly funded Long-Term Care Ombudsman Program; resident representatives and councils in nursing homes, assisted living facilities, and other residential settings; family councils for both congregate residential and other settings; and indenendent state and national advocacy organizations. Long-Term Care Ombudsman Program (, , Probably the best-known advocacy effort in long-term care is the Long-Term Care Ombudsman Program, which was mandated under the Older Americans Act in 1978.
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In recent years, family councils have taken a more active role in improving conditions in nursing homes because of the residents' impairments. Independent Advocacy Organizations Since the late 1960s, citizen groups have organized in many communities to improve conditions in nursing facilities.
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From page 177... ...
Despite their strengths, citizen groups are often limited by their reliance on volunteers and charitable contributions and their lack of guaranteed access to nursing homes and residential care settings. Fear of retaliation against residents often keeps families and other interested parties from protesting poor conditions and otherwise acting to improve quality of care (Monk et al., 1984; IOM, 1995~.
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From page 178... ...
In the long-term care arena, accreditation programs currently exist for some nursing homes, home health care, adult day care, hospice, assisted living, and long-term care pharmacies. Accreditation standards are usually intended to "raise the bar" by promoting and recognizing performance beyond basic, legally established levels, including through programs of continuous quality improvement.
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From page 179... ...
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.
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