Improving the Quality of Care in Nursing Homes -- Copyright -- Preface -- Acknowledgments -- Contents -- 1 Introduction and Summary -- PURPOSE OF THE STUDY -- THE PUBLIC POLICY CONTEXT OF THE STUDY -- PERSPECTIVE ON THE ISSUES -- The Role of Nursing Homes -- Quality of Care and Quality of Life -- The Regulatory System -- Other Factors Affecting Quality of Care in Nursing Homes -- Other Regulatory Policies -- Consumers, the Community, and Nursing Home Management and Staff -- CONCLUSIONS -- SUMMARY OF RECOMMENDATIONS -- Regulatory Criteria -- Monitoring Nursing Home Performance -- Enforcing Compliance with Federal Standards -- Other Factors Affecting Quality of Care and Quality of Life in Nursing Homes -- Issues Requiring Further Study -- Information Systems -- Medicaid Payment Policies -- Nursing Home Bed Supply -- Staffing of Nursing Homes -- Single- Versus Multiple-Occupancy Rooms -- 2 Concepts of Quality, Quality Assessment, and Quality Assurance -- QUALITY OF CARE IN NURSING HOMES -- Characteristics of the Residents -- Care Needs -- The Care Setting -- Requirements for High-Quality Care -- Planning And Providing Care -- QUALITY OF LIFE -- QUALITY ASSESSMENT CRITERIA -- Structure -- Process -- Outcomes -- ASSESSING QUALITY OF CARE -- Functional Competency/Impairment -- Intellectual Impairment/Behavioral Problems -- PERSPECTIVE ON QUALITY ASSURANCE -- INTERPRETING AND USING INFORMATION FOR QUALITY ASSURANCE -- Measurement of Care Quality -- Standards -- Case Mix -- Standard Instruments -- National, Regional, and Local Uses -- QUALITY ASSURANCE AND THE REGULATORY SYSTEM -- 3 Regulatory Criteria -- THE ISSUES -- CONSOLIDATING THE TWO SETS OF CRITERIA -- RESIDENT ASSESSMENT -- REVISING AND STRENGTHENING THE CONDITIONS AND STANDARDS -- Quality of Life -- Quality of Care -- Residents' Rights -- Administration -- Training of Nurse's Aides.

Discrimination -- Notification -- Participation -- Access -- Physical Environment -- NOTE ON STAFFING STANDARDS -- General -- Social Services -- Licensed and Registered Nurses -- 4 Monitoring Nursing Home Performance -- THE ISSUES -- PROBLEMS WITH THE SURVEY PROCESS -- Predictability -- Inefficiency -- Paper Compliance -- Insensitivity to Resident Needs -- Inconsistency -- Isolation from Related Monitoring Processes -- Variable State Regulatory Capacity -- REDESIGNING THE SURVEY PROCESS -- Consolidation of Medicare and Medicaid Survey Procedures -- Timing and Frequency of Surveys -- Two-Stage Survey Approach -- The Resident Assessment Audit -- The Standard Survey -- The Extended Survey -- Case-Mix Referencing -- Key Indicators -- Triggering an Extended Survey: Scoring and Decision-Making -- Survey Data Sources -- Coordination with Complaint Programs -- Consumer Involvement -- Positive Incentives -- Continuing Improvement of the Survey Process -- Reliability and Validity of Instruments and Procedures -- Consistency of Survey Results -- PACS: AN NEW HCFA SURVEY PROTOCOL -- INCREASING STATE REGULATORY CAPACITY -- Federal Funding of Certification Activities -- State Surveyor Qualifications -- Federal Training Support -- Dissemination of Research and Evaluation Results -- Federal Oversight and Sanctioning Responsibilities -- ORGANIZATIONAL CHANGES -- Incorporation of Inspection of Care in the Survey Process -- Restructuring of State and Federal Roles and Responsibilities -- 5 Enforcing Compliance with Federal Standards -- THE ISSUES -- ENFORCEMENT ATTITUDES -- FEDERAL RULES AND PROCEDURES -- Consultation -- Survey Follow-up Procedures -- Plans of Correction -- Initiation of Formal Enforcement -- Sanctions -- Decertification and Termination of the Provider Agreement -- Voluntary Decertification -- Termination Without Decertification.

Automatic Cancellation Clause -- Suspension of Payment -- STATE RULES AND PROCEDURES -- State Sanctions -- ENFORCEMENT RESOURCES -- 6 Other Factors Affecting Quality of Care and Quality of Life in Nursing Homes -- INVOLVEMENT OF CONSUMERS AND CONSUMER ADVOCATES -- Consumer Involvement -- The Role of Consumer Advocacy -- Access to Information -- The Ombudsman Program -- COMMUNITY INVOLVEMENT -- MANAGEMENT AND STAFF MOTIVATION -- Development of Professionalism -- Incentive Systems for High-Quality Care -- 7 Issues Requiring Further Study -- INFORMATION SYSTEMS -- Data About Residents -- Other Data About Nursing Homes -- MEDICAID PAYMENT POLICIES -- DEMAND FOR AND SUPPLY OF NURSING HOME BEDS -- Demand -- Bed Supply -- STAFFING OF NURSING HOMES -- SINGLE- VERSUS MULTIPLE-OCCUPANCY ROOMS -- 8 Actions Required and Cost Implications of the Recommendations -- LEGISLATIVE ACTIONS REQUIRED -- Amendments to the Social Security Act -- Amendments to the Older Americans Act -- REVISION AND ADDITION OF SURVEY AND CERTIFICATION REGULATIONS -- DESIGN AND TESTING ACTIVITIES -- Resident Assessment Data -- Survey Instruments and Procedures -- COST IMPLICATIONS OF THE RECOMMENDATIONS -- Regulatory Costs -- Program Costs -- Notes -- Appendix A History of Federal Nursing Home Regulation -- THE ADVENT OF MEDICARE AND MEDICAID -- POST-1974 EFFORTS TO REVISE FEDERAL REGULATIONS -- NOTES -- Appendix B Existing Snf Conditions of Participation and Icf Standards -- A. SNF CONDITIONS OF PARTICIPATION (42 CFR 405.1120 -- 1. Condition Of Participation-Compliance With Federal, State, And Local Laws. -- 2. Condition Of Participation-Governing Body And Management. -- 3. Condition of Participation-Medical Direction. -- 4. Condition of Participation-Physician Services. -- 5. Condition of Participation-Nursing Services. -- 6. Condition of Participation-Dietetic Services.

7. Condition of Participation-Specialized Rehabilitative Services. -- 8. Condition of Participation-Pharmaceutical Services. -- 9. Condition of Participation-Laboratory and Radiologic Services. -- 10. Condition of Participation-Dental Services. -- 11. Condition of Participation-Social Services. -- 12. Condition of Participation-Patient Activities. -- 13. Condition of Participation-Medical Records. -- 14. Condition of Participation-Transfer Agreement. -- 15. Condition of Participation-Physical Environment. -- 16. Condition of Participation-Infection Control. -- 17. Condition of Participation-Disaster Preparedness. -- 18. Condition of Participation-Utilization Review. -- B. STANDARDS FOR INTERMEDIATE CARE FACILITIES (ICFS) OTHER THAN FACILITIES FOR THE MENTALLY RETARDED (42 CFR 442.300 THROUGH… -- Administration -- Safety Standards -- Environmental and Sanitation Standards -- Meal Service -- Medications -- Health Services -- Other Services -- C. STANDARDS FOR HOSPITALS AND SNFS PROVIDING ICF SERVICES (42 CFR 442.254) -- Appendix C Report of Survey of State Health Facility Licensure and Certification Agencies -- PURPOSE -- SUMMARY OF FINDINGS -- Organization of Nursing Home Regulation Activities -- Survey Agency Personnel and Budget -- Survey Agency Workload -- State Regulatory Standards -- Special Surveyor Training -- Survey Procedures and Coordination Arrangements -- Enforcement -- Views on Federal Regulations -- SURVEY QUESTIONNAIRE -- Appendix D Selected Data on Nursing Homes and Residents -- Appendix E Key Indicators of Quality of Care -- EXAMPLES OF KEY INDICATORS OF CARE QUALITY TO BE USED BY SURVEYORS -- OPERATIONAL USE OF KEY INDICATORS -- NOTES -- Glossary -- Acronyms and Initialisms -- Index.