Management Agreement Nursing Home

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					PPA 419 – Aging Services
     Administration


           Lecture 6b – Nursing
           Home Reform Act of
           1987 (OBRA ’87)
The 1987 Nursing Home Reform Act

   In a 1986 study, conducted at the request of
    Congress, the Institute of Medicine found that
    residents of nursing homes were being
    abused, neglected, and given inadequate
    care. The Institute of Medicine proposed
    sweeping reforms, most of which became
    law in 1987 with the passage of the Nursing
    Home Reform Act, part of the Omnibus
    Budget Reconciliation Act of 1987.
The 1987 Nursing Home Reform Act

   The basic objective of the Nursing Home
    Reform Act is to ensure that residents of
    nursing homes receive quality care that will
    result in their achieving or maintaining their
    "highest practicable" physical, mental, and
    psychosocial well-being.
The 1987 Nursing Home Reform Act

   To secure quality care in nursing homes, the
    Nursing Home Reform Act requires the
    provision of certain services to each resident
    and establishes a Residents' Bill of Rights.
The 1987 Nursing Home Reform Act

   Nursing homes receive Medicaid and
    Medicare payments for long-term care of
    residents only if they are certified by the state
    to be in substantial compliance with the
    requirements of the Nursing Home Reform
    Act.
The 1987 Nursing Home Reform
Act
The 1987 Nursing Home Reform Act

   The Nursing Home Reform Act specifies what services nursing
    homes must give residents and establishes standards for these
    services.
   Required services include:
    –   Periodic assessments for each resident;
    –   A comprehensive care plan for each resident;
    –   Nursing services;
    –   Social services;
    –   Rehabilitation services;
    –   Pharmaceutical services;
    –   Dietary services; and,
    –   If the facility has more than 120 beds, the services of a full-time
        social worker.
OBRA ’87 - The Residents' Bill of
Rights

   The right to freedom from abuse,
    mistreatment, and neglect;
   The right to freedom from physical restraints;
   The right to privacy;
   The right to accommodation of medical,
    physical, psychological, and social needs;
   The right to participate in resident and family
    groups;
OBRA ’87 - The Residents' Bill of
Rights

   The right to be treated with dignity;
   The right to exercise self-determination;
   The right to communicate freely;
   The right to participate in the review of one's care
    plan, and to be fully informed in advance about any
    changes in care, treatment, or change of status in
    the facility; and
   The right to voice grievances without discrimination
    or reprisal.
OBRA ’87 – Survey and Certification

   To monitor whether nursing homes meet the
    Nursing Home Reform Act requirements, the
    law also established a certification process
    that requires states to conduct unannounced
    surveys, including resident interviews, at
    irregular intervals at least once every 15
    months.
OBRA ’87 – Survey and Certification

   The surveys generally focus on residents'
    rights, quality of care, quality of life, and the
    services provided to residents. Surveyors
    also conduct more targeted surveys, or
    complaint investigations, in response to
    complaints against nursing homes.
OBRA ’87 – Survey and Certification

   If the survey reveals that a nursing home is
    out of compliance, the Nursing Home Reform
    Act enforcement process begins.
   The severity of the remedy depends on
    whether the deficiency puts a resident in
    immediate jeopardy, and whether the
    deficiency is an isolated incident, part of a
    pattern, or widespread throughout the facility.
OBRA ’87 – Survey and Certification

   For some violations, nursing homes have an
    opportunity to correct the deficiency before
    remedies may be imposed.
   Other sanctions include:
    –   Directed in-service training of staff;
    –   Directed plan of correction;
    –   State monitoring;
    –   Civil monetary penalties;
OBRA ’87 – Survey and Certification

   Other sanctions include:
    –   Denial of payment for all new Medicare or
        Medicaid admissions;
    –   Denial of payment for all Medicaid or Medicare
        patients;
    –   Temporary management; and
    –   Termination of the provider agreement.
Conclusion

   The Nursing Home Reform Act established
    basic rights and services for residents of
    nursing homes.
   These standards form the basis for present
    efforts to improve the quality of care and the
    quality of life for nursing home residents.
Conclusion

   The extent to which the Nursing Home
    Reform Act succeeds in actually improving
    nursing homes, however, depends on the
    effectiveness of its enforcement.
Regulating Nursing Homes

   Major problems continue despite federal
    regulation.
    –   In 1998-1999, 25-33% had serious or potentially
        life threatening problems.
    –   26% had poor food hygiene, 21% provided
        inadequate care, 19% had environments that
        contributed to injuries in residents, 18%
        improperly treated pressure sores.
    –   About 77% of problem facilities had problems in
        subsequent surveys.
Regulating Nursing Homes

   Ownership and quality of care
    –   Greatest violations in for-profit homes (30% more violations
        of quality of care and quality of life)
   Federal Regulation
    –   State and licensing and certification with federal standards
    –   Standardized comprehensive assessments on admission
        and yearly. Care plans
    –   Annual surveys of 185 quality requirements.
    –   Central data collection on compliance
    –   Enforcement procedures with intermediate sanctions.
Regulating Nursing Homes

   Federal regulation
    –   1987 law, intermediate sanctions: fines, payment
        denial, managers.
   Flaws
    –   Inadequate staffing
    –   Poor mix of skills
    –   Ineffective system of survey and enforcement
        (GAO)
    –   Poor levels of Medicaid payment decrease
        staffing.
Federal and State Enforcement of the
1987 Nursing Home Reform Act

   BACKGROUND
    –   The Nursing Home Reform Act of 1987 established quality
        standards for nursing homes nationwide, established
        resident rights, and defined the state survey and
        certification process to enforce the standards (See PPI Fact
        Sheet Number 84: "The Nursing Home Reform Act of
        1987.")
    –   Ten years after the passage of the Nursing Home Reform
        Act, however, a series of research studies and Senate
        hearings called attention to serious threats to residents'
        well-being. These problems were attributed to weaknesses
        in federal and state survey and enforcement activities.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   In 1997, the Senate Committee on Aging,
    chaired by Senator Charles Grassley,
    received reports of widespread death and
    suffering in California nursing homes caused
    by inadequate care.
   In response to these reports, the Committee
    held a hearing on California nursing homes
    in July 1998.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   A General Accounting Office (GAO) report presented at the
    hearing revealed that, despite the requirements of the Nursing
    Home Reform Act, weak enforcement put many residents at
    risk of substandard care.
   Between 1995 and 1998, state surveyors cited 30 percent of
    nursing homes in California for violations that put residents in
    immediate jeopardy or caused actual harm to residents.
    Another 33 percent of facilities were cited with substandard
    conditions that caused less serious harm, and another 35
    percent had more than minimal deficiencies. Only 2 percent of
    California facilities were found to have minimal or no
    deficiencies.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   While state surveyors identified widespread
    serious problems, the report suggested that
    many other care problems went undetected
    due to weaknesses in federal and state
    nursing home oversight. Even when serious
    problems were identified, enforcement
    actions often failed to ensure that they were
    corrected and did not recur.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   Although the study focused on California, the
    findings were indicative of broader problems
    in the nursing home enforcement system.
    Based on their findings, GAO recommended
    strengthening federal and state oversight of
    nursing homes to better protect residents
    throughout the country.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   THE SURVEY PROCESS COMPARED WITH THE
    ALTERNATIVES
    –   Also in July 1998, the Health Care Financing Administration
        (HCFA) published a report that examined the effectiveness
        of the current survey and certification process and the
        proposed alternatives of private accreditation and
        incentives. While the study indicated that the Nursing Home
        Reform Act of 1987 had resulted in improved resident
        outcomes, it also concluded that many of the enforcement
        processes were not working as intended. Despite the flaws
        in the survey and certification process, however, the study
        found federal enforcement to be more effective in protecting
        residents than either private accreditation or incentives.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act
   THE 1998 NURSING HOME INITIATIVE
    –   Concurrent with the Senate Committee on Aging hearing, the GAO
        report on California nursing homes, and the HCFA study, the Clinton
        Administration announced the 1998 Nursing Home Initiative. The
        Initiative included a series of proposed steps designed to improve
        enforcement of nursing home quality standards. To implement the
        Nursing Home Initiative, HCFA has begun a series of steps to improve
        nursing home enforcement procedures. These include:
            Staggering nursing home inspections, with a set number occurring on
             weekends and evenings;
            Inspecting more frequently nursing homes that are repeat offenders with
             serious violations, without decreasing frequency of inspections for other
             facilities;
            Enhancing the HCFA review of nursing home surveys conducted by the
             states;
            Terminating federal nursing home survey funding to states that fail to
             perform adequate surveys;
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   THE 1998 NURSING HOME INITIATIVE
    –   HCFA has begun a series of steps to improve nursing home
        enforcement procedures. These include:
            Imposing immediate sanctions on nursing homes found guilty
             of a second offense for violations harming residents; such
             facilities will not receive a "grace period" allowing them to
             correct problems and avoid penalties;
            Allowing states to impose civil monetary penalties for each
             instance of a serious or chronic violation; and
            Ensuring that state survey agencies enforce sanctions against
             nursing homes with serious violations and that sanctions are
             not lifted until after an onsite visit has verified compliance.
    –   Some states have also implemented their own efforts to
        improve nursing home quality enforcement.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act
   FUNDING FOR ENFORCEMENT
    –   State survey, certification, and enforcement activities are funded through
        the Medicare and Medicaid programs. The federal government finances
        100% of the Medicare budget and 75% of the Medicaid budget for state
        survey and certification activities. States provide the remaining 25% of the
        Medicaid survey and certification budget. Currently, HCFA distributes
        federal funds to states based on past state practices and costs, thereby
        perpetuating low budgets in states that have spent less for survey and
        certification activities. HCFA is now exploring options for better distribution
        of future survey and certification funding.
    –   In the meantime, recognizing the increased costs associated with the
        Nursing Home Initiative, the Administration and Congress have significantly
        increased the federal Medicare and Medicaid budget for state survey and
        certification activities. Federal funding grew from $290.2 million in fiscal
        year 1998 to $310.1 million in 1999, and to $358.7 million in fiscal year
        2000.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act
   NURSING HOME QUALITY NATIONWIDE
    –   Following the California study and the announcement of the 1998 Nursing
        Home Initiative, GAO and HCFA conducted additional research that
        included nursing homes nationwide. The findings were presented at a
        series of additional hearings on nursing home quality held by the Senate
        Committee on Aging in 1999 and 2000. These reports and hearings
        confirmed that problems of substandard quality, weak survey procedures,
        and ineffective enforcement were not limited to California, but were
        widespread throughout the nation. Key findings include:
    –   In 1997 to 1998, over one-fourth of nursing homes nationwide (27%) were
        cited with violations that caused actual harm to residents or placed them at
        risk of death or serious injury. Another 43 percent of homes were cited with
        violations that created a potential for more than minimal harm.
    –   During annual surveys, state surveyors often missed significant care
        problems, such as pressure sores, malnutrition, and dehydration. This
        problem reflected both weaknesses in state survey methods and the
        predictable timing of the surveys.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act
   NURSING HOME QUALITY NATIONWIDE
    –   Complaints made by residents, family members, or nursing home staff
        often went uninvestigated for weeks or months. In addition, states
        frequently had procedures that discouraged the filing of complaints.
    –   When serious quality deficiencies were detected, enforcement
        mechanisms frequently failed to ensure that the problems were corrected
        and remained corrected.
    –   Federal procedures for overseeing state monitoring were limited in their
        scope and effectiveness.
    –   Over half (54%) of nursing homes had fewer than the minimum number of
        nurse aide time per resident to avoid harming residents. These facilities put
        residents at increased risk of hospitalization for avoidable causes, pressure
        sores, and significant weight loss due to inadequate staffing.
    –   As a result of these findings, GAO recommended additional steps to
        improve enforcement of quality standards, many of which are being
        addressed by HCFA's new efforts at enforcement.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act
   EFFECTS OF THE NURSING HOME INITIATIVE
    –   In September 2000, the Senate Committee on Aging held a hearing on the
        outcomes of the Nursing Home Initiatives. A GAO official testified at the
        hearing that the Initiatives had resulted in improvements to state survey
        and federal oversight procedures, including:
            Several states have increased, or plan to increase, the number of surveyors;
            Several states are automating their information systems to track complaints more
             effectively;
            States have begun to use new methods introduced by the initiatives to spot
             serious deficiencies when conducting surveys; and
            HCFA has made organizational changes to improve nursing home oversight
             activities and to help ensure consistency across regions.
    –   At the same time, a GAO report noted that many of the new policies and
        practices have only recently begun and will need time to be fully
        implemented. Moreover, HCFA is in the process of implementing the
        Nursing Home Initiative, some parts of which may not be introduced until
        2002 or 2003. Hence, it may take a few more years before the full effects
        of the efforts to improve quality of care can be known.
Federal and State Enforcement of
the 1987 Nursing Home Reform
Act

   CONCLUSION
    –   Inadequate implementation and enforcement have seriously
        limited the effectiveness of the Nursing Home Reform Act of
        1987. To address this problem, the Senate Committee on
        Aging began holding hearings on nursing home quality, and
        the Clinton Administration introduced the 1998 Nursing
        Home Initiative. While these efforts have resulted in some
        improvements, more work needs to be done to improve
        quality in the nation's nursing homes. As a recent GAO
        report concludes, "Sustained efforts by HCFA and the
        states are essential to realize the potential of the quality
        initiatives" (GAO, 2000).
GAO Nursing Home Studies since 1998

   Nursing Homes: Efforts to Strengthen
    Federal Enforcement Have Not Deterred
    Some Homes from Repeatedly Harming
    Residents. GAO-07-241. Washington, D.C.:
    March 2007
GAO Nursing Home Studies since 1998

   Nursing Homes: Despite Increased Oversight,
    Challenges Remain in Ensuring High-Quality Care
    and Resident Safety. GAO-06-117 . Washington,
    D.C.: December 28, 2005.
   Nursing Home Deaths: Arkansas Coroner Referrals
    Confirm Weaknesses in State and Federal Oversight
    of Quality of Care. GAO-05-78 . Washington, D.C.:
    November 12, 2004.
GAO Nursing Home Studies since 1998

   Nursing Home Fire Safety: Recent Fires
    Highlight Weaknesses in Federal Standards
    and Oversight. GAO-04-660 . Washington
    D.C.: July 16, 2004.
   Nursing Home Quality: Prevalence of Serious
    Problems, While Declining, Reinforces
    Importance of Enhanced Oversight. GAO-03-
    561 . Washington, D.C.: July 15, 2003.
GAO Nursing Home Studies since 1998

   Nursing Homes: Public Reporting of Quality
    Indicators Has Merit, but National
    Implementation Is Premature. GAO-03-187 .
    Washington, D.C.: October 31, 2002.
   Nursing Homes: Quality of Care More
    Related to Staffing than Spending. GAO-02-
    431R . Washington, D.C.: June 13, 2002.
GAO Nursing Home Studies since 1998

   Nursing Homes: More Can Be Done to
    Protect Residents from Abuse. GAO-02-312 .
    Washington, D.C.: March 1, 2002.
   Nursing Homes: Federal Efforts to Monitor
    Resident Assessment Data Should
    Complement State Activities. GAO-02-279 .
    Washington, D.C.: February 15, 2002.
GAO Nursing Home Studies since 1998

   Nursing Homes: Sustained Efforts Are
    Essential to Realize Potential of the Quality
    Initiatives. GAO/HEHS-00-197 . Washington,
    D.C.: September 28, 2000.
   Nursing Home Care: Enhanced HCFA
    Oversight of State Programs Would Better
    Ensure Quality. GAO/HEHS-00-6 .
    Washington, D.C.: November 4, 1999.
GAO Nursing Home Studies since 1998

   Nursing Home Oversight: Industry Examples
    Do Not Demonstrate That Regulatory Actions
    Were Unreasonable. GAO/HEHS-99-154R .
    Washington, D.C.: August 13, 1999.
   Nursing Homes: Proposal to Enhance
    Oversight of Poorly Performing Homes Has
    Merit. GAO/HEHS-99-157 . Washington,
    D.C.: June 30, 1999.
GAO Nursing Home Studies since 1998

   Nursing Homes: Complaint Investigation Processes
    Often Inadequate to Protect Residents. GAO/HEHS-
    99-80 . Washington, D.C.: March 22, 1999.
   Nursing Homes: Additional Steps Needed to
    Strengthen Enforcement of Federal Quality
    Standards. GAO/HEHS-99-46 . Washington, D.C.:
    March 18, 1999.
   California Nursing Homes: Care Problems Persist
    Despite Federal and State Oversight. GAO/HEHS-
    98-202 . Washington, D.C.: July 27, 1998.
California Nursing Home Information

   CMS Nursing Home Compare:
    –   http://www.medicare.gov/NHCompare/Include/DataSection/
        Questions/SearchCriteria.asp?version=default&browser=Fir
        efox%7C2%7CWinXP&language=English&defaultstatus=0&
        pagelist=Home&CookiesEnabledStatus=True
   California Department of Health Services Licensing
    and Certification Program.
    –   http://www.dhs.ca.gov/lnc/default.htm.
   California Nursing Home Search:
    –   http://www.calnhs.org/nursinghomes/index.cfm?itemID=107
        169.

				
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