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 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 , 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 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 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 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 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 Washington, D.C.: December 28, Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of Quality of Care. GAO 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 Washington D.C.: July 16, Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight. GAO 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 Washington, D.C.: October 31, Nursing Homes: Quality of Care More Related to Staffing than Spending. GAO R. Washington, D.C.: June 13, 2002.

GAO Nursing Home Studies since 1998 Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO Washington, D.C.: March 1, Nursing Homes: Federal Efforts to Monitor Resident Assessment Data Should Complement State Activities. GAO 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 Washington, D.C.: September 28, Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality. GAO/HEHS 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 R. Washington, D.C.: August 13, Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes Has Merit. GAO/HEHS Washington, D.C.: June 30, 1999.

GAO Nursing Home Studies since 1998 Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. GAO/HEHS Washington, D.C.: March 22, Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards. GAO/HEHS Washington, D.C.: March 18, California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. GAO/HEHS Washington, D.C.: July 27, 1998.

California Nursing Home Information CMS Nursing Home Compare: – 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. – California Nursing Home Search: –