Structural and operational factors affecting quality of patient care in nursing homes

This article inquires into structural and operational characteristics of nursing homes that have predictive power for the quality of direct patient care provided to their residents. Data are from nursing homes in the Phoenix, Arizona, metropolitan area. The data were analyzed using multivariate linear regression. Findings of policy interest are that, other things equal: (1) for-profit facilities provide lower levels of care than do nonprofit facilities; and (2) distantly headquartered chain operations provide lower care levels than locally owned facilities. These factors should be considered in long-term care planning and regulation.     

Nursing home quality-of-care cases after Mikes v. Straus

The quality of care rendered to residents of nursing facilities continues to gain attention from legislators, regulators, and the courts. Advocates for improvements in the quality of care by government-funded healthcare providers have identified the False Claims Act (FCA) as a potent tool. The Second Circuit decision in Mikes v. Straus might be viewed as a barrier to FCA claims against nursing facilities. Any impediment imposed by this decision, however, is limited by the facts of the case; the authors believe that carefully-crafted pleadings can enable litigants to rely upon the FCA in pursuing quality-of-care claims against nursing facilities.     

Medicare and Medicaid programs; nurse aide training and competency evaluation programs--HCFA. Final rule

This rule amends the Medicare and Medicaid regulations pertaining to facilities to incorporate Federal requirements that States have training and competency evaluation by Medicare participating skilled nursing facilities and Medicaid participating nursing facilities and also have a nurse aide registry. The purpose of these provisions is to ensure that nurse aides have the education, practical knowledge, and skills needed to care for residents of facilities participating in the Medicare and Medicaid programs. These requirements implement, in part, sections 4201(a) and 4211(a) of the Omnibus Budget Reconciliation Act of 1987, section 6901(b) of the Omnibus Budget Reconciliation Act of 1989, and sections 4008 and 4801 of the Omnibus Budget Reconciliation Act of 1990.     

Medicare and Medicaid programs; preadmission screening and annual resident review--HCFA. Final rule; correction

In the November 30, 1992 issue of the Federal Register, we established requirements for preadmission and annual review of individuals with mental illness or mental retardation who are applicants to or residents of nursing facilities that are certified for Medicaid. We also established an appeals system for individuals who may be transferred or discharged from facilities or who wish to dispute a determination made in the preadmission screening and annual review process. This notice corrects typographical errors made in that document.     

Medicare and Medicaid programs; preadmission screening and annual resident review--HCFA. Final rule with comment period

This rule sets forth State requirements for preadmission and annual review of individuals with mental illness or mental retardation who are applicants to or residents of nursing facilities that are certified for Medicaid. It also sets forth an appeals system for persons who may be transferred or discharged from facilities or who wish to dispute a determination made in the preadmission screening and annual review process. These provisions implement several provisions of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), Public Law 100-203 and the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), Public Law 101-508.     

Medicare and Medicaid programs; advance directives--HCFA. Interim final rule with comment period

This interim final rule amends the Medicare and Medicaid regulations governing provider agreements and contracts to establish requirements for States, hospitals, nursing facilities, skilled nursing facilities, providers of home health care or personal care services, hospice programs and prepaid health plans concerning advance directives. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when an individual's condition makes him or her unable to express his or her wishes. The intent of these provisions is to enhance an individual's control over medical treatment decisions. This rule implements sections 4206 and 4751 of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90), Public Law 101-508.     

Legal anxieties and end-of-life care in nursing homes

Many persons spend their final days as nursing home residents. It has been suggested that one set of factors powerfully and unfavorably influencing the quality of end-of-life (EOL) care provided in American nursing homes involves the anxieties that nursing home providers experience regarding potential negative legal entanglements and repercussions associated with the provision of EOL care to their residents. This article critically examines the hypothesis that the quality of EOL medical care provided in nursing homes often is skewed in a perverse way because providers are driven unduly by legal apprehensions. The author offers practice and policy recommendations for trying to resolve or mitigate the tension present between legally defensive practice (real or perceived) by nursing homes, on one hand, and ethically optimal EOL care, on the other.     

Medicare and Medicaid programs; advance directives--HCFA. Final rule

This final rule responds to public comments on the March 6, 1992 interim final rule with comment period that amended the Medicare and Medicaid regulations governing provider agreements and contracts to establish requirements for States, hospitals, nursing facilities, skilled nursing facilities, providers of home health care or personal care services, hospice programs and managed care plans concerning advance directives. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when an individual's condition makes him or her unable to express his or her wishes. The intent of the advance directives provisions is to enhance an adult individual's control over medical treatment decisions. This rule confirms the interim final rule with several minor changes based on our review and consideration of public comments.     

Medicare and Medicaid programs; revaluation of assets--HCFA. Final rule

This final rule revises the Medicare and Medicaid regulations that are affected by section 2314 of the Deficit Reduction Act of 1984 and sections 9110 and 9509 of the Consolidation Omnibus Budget Reconciliation Act of 1985. Those provisions amended sections 1861(v)(1) and 1902(a)(13) of the Social Security Act. This rule describes new limitations on the valuation of assets acquired as the result of changes in ownership occurring on or after July 18, 1984. These changes affect hospitals and skilled nursing facilities under the Medicare program and hospitals, nursing facilities, and intermediate care facilities for the mentally retarded under the Medicaid program.     

Medicare and Medicaid programs; survey, certification and enforcement of skilled nursing facilities and nursing facilities--HCFA. Final rule and correction to final regulations

In the November 10, 1994 issue of the Federal Register (FR Doc. 94-27703) (59 FR 56116), we established rules for survey of skilled nursing facilities that participate in the Medicare program, and nursing facilities that participate in the Medicaid program. We also established remedies that we impose on facilities that do not comply with Federal participation requirements, as alternatives to program termination. This document corrects errors made in that document.     

Medicare and Medicaid programs; revaluation of assets; correction--HCFA. Correcting amendments

This document contains corrections to final regulations (BPD-311-F) that were published September 23, 1992 (F.R. Doc. 92-22582) (57 FR 43906). The regulations describe new limitations on the valuations of assets acquired as the result of changes in ownership occurring on or after July 18, 1984. These changes affect hospitals and skilled nursing facilities under the Medicare program, and hospitals, nursing facilities, and intermediate care facilities for the mentally retarded under the Medicaid program.     

Medicare and Medicaid programs; survey, certification and enforcement of skilled nursing facilities and nursing facilities--HCFA. Final rule

This final rule implements certain provisions of the Omnibus Budget Reconciliation Act of 1987, as further amended by subsequent 1988, 1989, and 1990 legislation. These provisions make significant changes in the process of surveying skilled nursing facilities under Medicare and nursing facilities under Medicaid and in the process for certifying that these facilities meet the Federal requirements for participation in the Medicare and Medicaid programs. They also set forth a number of alternative remedies which may be imposed on facilities that do not comply with the Federal participation requirements (instead of or in addition to termination), and specify remedies for State survey agencies that do not meet surveying requirements.     

Health Care Financing Administration--Adoption of the National Bureau of Standards fire safety evaluation system for health care facilities. Final notice

The Department of Health, Education, and Welfare proposed extending the new Fire Safety Evaluation sSystem (FSES) to all hospitals participating in the Medicare and Medicaid programs in a Notice of comment period publishedon June 28, 1979 in the Federal Register (44 FR 37818). The Department also sought public comment on whether to apply the FSES to skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) in this same Notice. After a careful review and analysis of the public comments received, the Department has decided to adopt the FSES as a means of evaluating alternative arrangements used to achieve compliance with the provisions of the Life Safety Code for hospitals, skilled nursing facilities, and intermediate care facilities participating in the Medicare and Medicaid programs.     

Medicaid program; use of restraint and seclusion in psychiatric residential treatment facilities providing psychiatric services to individuals under age 21. Health Care Financing Administration (HCFA), HHS. Interim final rule with comment period

This interim final rule with comment period establishes a definition of a "psychiatric residential treatment facility" that is not a hospital and that may furnish covered Medicaid inpatient psychiatric services for individuals under age 21. This rule also sets forth a Condition of Participation (CoP) that psychiatric residential treatment facilities that are not hospitals must meet to provide, or to continue to provide, the Medicaid inpatient psychiatric services benefit to individuals under age 21. Specifically, this rule establishes standards for the use of restraint or seclusion that psychiatric residential treatment facilities must have in place to protect the health and safety of residents. This CoP acknowledges a resident's right to be free from restraint or seclusion except in emergency safety situations. We are requiring psychiatric residential treatment facilities to notify a resident (and, in the case of a minor, his or her parent(s) or legal guardian(s)) of the facility's policy regarding the use of restraint or seclusion during an emergency safety situation that occurs while the resident is in the program. We believe these added requirements will protect residents against the inappropriate use of restraint or seclusion.     

Medicare and Medicaid programs; requirements for long term care facilities; nursing services; posting of nurse staffing information. Final rule

In this rule, we finalize provisions specified in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) that establish new data collection, posting, and recordkeeping requirements for skilled nursing facilities (SNFs) and nursing facilities (NFs). It requires that on a daily basis for each shift, SNFs and NFs must post nurse staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. Facility census information must also be posted. This final rule is also part of a broader communication outreach initiative by CMS to provide beneficiaries, their families, and the public with access to updated data and other information that can assist them in making healthcare decisions.     

Updating fire safety standards. Final rule; affirmation

This document affirms as final, without changes, a provision included in a final rule with request for comments that amended the Department of Veterans Affairs (VA) regulations concerning community residential care facilities, contract facilities for certain outpatient and residential services, and State home facilities. That provision established a five-year period within which all covered buildings with nursing home facilities existing as of June 25, 2001, must conform to the automatic sprinkler requirement of the 2009 edition of the National Fire Protection Association (NFPA) 101. This rule helps ensure the safety of veterans in the affected facilities.     

Perceived Conditions of Confinement: A National Evaluation of Juvenile Boot Camps and Traditional Facilities

In a national study of juvenile correctional facilities, the perceived environment of 22 juvenile boot camps was compared to the perceived environment of 22 traditional facilities. Self-report surveys completed by 4,121 juveniles recorded information on demographics, risk factors, and perceptions of the facility's environment. Compared to juveniles in traditional correctional facilities, boot camp residents consistently perceived the environment as significantly more controlled, active, and structured, and as having less danger from other residents. Boot camp juveniles also perceived the environment as providing more therapeutic and transitional programming. Overall, from the perspective of the juveniles, boot camps appear to provide a more positive environment conducive to effective rehabilitation considering almost allof the conditions measured. A major concern is that in both types of facilities, juveniles perceived themselves to occasionally be in danger from staff (rated as rarely to sometimes).     

Medicare program; prospective payment system and consolidated billing for skilled nursing facilities--update. Health Care Financing Administration (HCFA), HHS. Notice

This notice sets forth the updates required in section 1888(e) of the Social Security Act (the Act), as added by section 4432 of the Balanced Budget Act of 1997, related to Medicare payments and consolidated billing for skilled nursing facilities.     

State nursing home enforcement systems

This study presents interview and statistical data from a telephone and fax survey of state agency officials and statistical data from the Centers for Medicare & Medicaid Services' Online Survey Certification and Reporting (OSCAR) system. State survey activities for nursing facilities were reviewed and the number and types of intermediate sanctions issued by states in 1999 were reported, along with barriers to the use of such sanctions. Using five selected enforcement measures to create a summary score, states were classified by quartiles based on the stringency of their nursing facility enforcement activities. Controlling for the number of complaints as a proxy for quality, the predictors of a summary of state enforcement actions were: percentage of population at age eighty-five and above. Democratic governors, higher percentages of chain facilities, and lower facility occupancy rates. Regional differences in enforcement patterns also were shown. Many federal policies and resource constraints were identitied as barriers to effective regulation. The findings identified nursing facility survey and enforcement issues that need to be addressed by policy makers.     

Medicare program; optional payment system for low Medicare volume skilled nursing facilities--HCFA. Final rule

This final rule allows skilled nursing facilities (SNFs) that provide fewer than 1,500 days of care to Medicare beneficiaries in a cost reporting period to have the option of receiving prospectively determined payment rates in the following cost reporting period. The prospectively determined payment rates are based on components of SNF costs such as routine operating costs, capital-related costs, and a return on equity for proprietary facilities for routine services furnished before October 1, 1993. This rule also specifies that the return on equity provision for proprietary SNFs is eliminated for services furnished on or after October 1, 1993.