PPA 419 Aging Services Administration

1
PPA 419 Aging Services Administration

• Lecture 6b Nursing Home Reform Act of 1987
  (OBRA 87)

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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.

3
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.

4
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.

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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.

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The 1987 Nursing Home Reform Act
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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.

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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

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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.

10
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.

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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.

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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.

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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

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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.

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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.

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Conclusion

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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).

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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

34
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.

35
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.

36
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.

37
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.

38
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.

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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.

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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.

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California Nursing Home Information

• CMS Nursing Home Compare
• http//www.medicare.gov/NHCompare/Include/DataSect
  ion/Questions/SearchCriteria.asp?versiondefaultb
  rowserFirefox7C27CWinXPlanguageEnglishdefaul
  tstatus0pagelistHomeCookiesEnabledStatusTrue
• 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?itemI
  D107169.