II. HOW NURSING FACILITIES REGULATIONS KEY POINTS The U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) is the governing agency that ensures compliance with more than 1,000 regulations for all nursing facilities that are certified to participate in either program. These requirements include, but are not limited to, regulations related to care and service areas such as: environment, resident rights, quality of life, quality of care, facility administration and many more. The Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Health Systems is responsible for a nursing facility s compliance with all federal and state regulatory requirements. Annually, LARA conducts an on-site visit of all nursing facilities in the state. These are commonly referred to as annual standard surveys and are unannounced. Improving the quality of care is a constant, continual process that involves a number of aspects: continuously improving clinical and administrative practices; involving residents and families in planning their care and ensuring they are satisfied with the care they receive; developing a skilled and caring work force through participation in continuing education programs; and managing a facility in an ethical, transparent and accountable way.
REGULATIONS Dear Ashley Family, I am writing to express my gratitude for the care you gave my mother, Vivian Hornak. The residents, nurses, patient aides, social workers, rehab staff, administrators, cooks and maintenance staff at your facility function as a family unit. During my mother s stay, I visited her daily and observed many expressions of caring, compassion, understanding and personal attention to all residents. I was most impressed by the patience that was shown toward my mother and others in need of care. The facility is spotless and well cared for and the atmosphere is cheerful and colorful. The dining area is clean and comfortable with a variety of tasty, nutritious food. The helpful aids were always available to assist with the resident s needs. The resident activities gave my mother something to look forward to. After living alone for 13 years, she told me how much she enjoyed the bingo games and the beauty shop. The weekly schedule offered many other recreational activities that welcomed everyone. I can t say thank you enough to the administration for the time, patience and information that helped us understand and complete the necessary paperwork. Thank you for all of your help. Because of the compassion, caring and helpful deeds from the Ashley family, we were able to get through the last days peacefully and comfortably. I thank you on behalf of myself, my wife Judy and my children Ken Jr. and Becky. God Bless all of God s Angels at Ashley. Sincerely and Appreciatively, Ken and Judy Hornak
REGULATORY STRUCTURE Throughout the 20th century, care of the elderly and disabled has evolved from an extended family structure and county Almshouse to the onset of the Medicare and Medicaid programs when federal and state governments initiated funding and oversight for the provision of 24/7 nursing support care. In the 1960s the Social Security Act-Titles XVIII (Medicare) and XIX (Medicaid) mandated the establishment of minimum health and safety standards that must be met by skilled nursing facilities participating in the Medicare and Medicaid programs. The federal Department of Health and Human Services designated the Centers for Medicare and Medicaid Services (CMS) to administer the standards and compliance aspects of these programs. These programs led to the evolution of the nursing facility industry, from enhancements to the county Almshouse of the early- and mid-1900s to the highly-skilled, residentcentered nursing communities of today. Federal Oversight Medicare is a federal insurance program providing a wide range of benefits for specific periods of time through providers participating in the Medicare Part A program. The act designates those providers that are subject to federal health care quality standards. The federal government makes payment for services through designated fiscal intermediaries and carriers to the providers. Medicaid is a state program that provides medical services to clients of the state public assistance program and, at the state s option, other needy individuals. When services are furnished through facilities that must be certified for Medicare, the standards must be met for Medicaid as well. The CMS is the governing agency that ensures compliance with more than 1,000 regulations for all nursing facilities that are certified to participate in either program. These requirements include, but are not limited to, regulations related to care and services such as: environment LEGISLATIVE GUIDE TO TODAY S NURSING AND REHABILITATION FACILITY 9
Medilodge Olympics 2010 (temperature of water in the dishwasher/refrigerator, lighting levels), resident rights (protection of resident funds, free choice, mail), quality of life (activities, social work, accommodation of needs), quality of care (pressure sores, vision and hearing, range of motion), facility administration (nurse aide training, staff qualifications, laboratory services) and many more. CMS is divided into federally-designated regions. Michigan, Wisconsin, Minnesota, Ohio, Illinois and Indiana are provided oversight by the CMS Region V Office in Chicago, IL. State Oversight The Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Health Systems is responsible for a nursing facility s compliance with all federal and state regulatory requirements. Annually, LARA conducts an on-site visit of all nursing facilities in the state. These are commonly referred to as annual standard surveys. Standard surveys are 10
unannounced and conducted by an interdisciplinary team of state surveyors. They may be conducted at any time including weekends and typically last several days. The nursing facility survey protocol is expansive, containing elements which measure quality of care, quality of life, resident rights and facility administration. A report of survey findings is produced and made available to the public. Facilities are granted a brief period of time to correct deficiencies cited during the survey process. Revisit surveys are conducted to either confirm compliance has been achieved or to identify continued non-compliance. A regulatory deficiency in practice or service in any requirement results in a citation that is evaluated based on scope (number of residents affected) and severity (the potential level of harm to a/any resident). The average number of deficiencies cited per facility in Michigan at annual survey was 7.3 out of approximately 1,000 for calendar year 2010, with the vast majority of citations at or below a level where a very limited number of residents were affected and no actual harm with potential for more than minimal harm occurred with any resident. Regency at Waterford LEGISLATIVE GUIDE TO TODAY S NURSING AND REHABILITATION FACILITY 511
LARA also responds to complaints related to nursing facility services. These may be facility-reported or reported by residents or others on behalf of residents. Complaint investigations are, to the extent possible, combined with other standard survey activity. However, they may be conducted between annual surveys. These surveys are conducted under the same regulatory requirements as the standard surveys and deficiencies cited are subject to similar enforcement actions. CMS also established guidelines for enforcement actions against nursing facilities that fail to achieve compliance with all federal regulatory requirements. There is, however, some discretion granted to states in terms of the application of such actions. A facility is required to develop and implement a plan of correction for all deficiencies cited during any survey. Additional enforcement options are based upon the scope and severity of survey findings. Enforcement options include, but are not limited to, directed plans of correction, directed in-service training, denial of payment for admissions or re-admissions, temporary management or closure. Enforcement actions remain in effect until surveyors confirm a facility has achieved full compliance with federal and state regulatory requirements. Revisit surveys, at which continued non-compliance is identified, generally result in application of progressive enforcement actions. Our Quest for Quality Quality is the first priority for HCAM and its members. Many effective quality measures have been defined for and by our profession during the last twenty years. From these measures, tools have been developed to analyze and evaluate operational performance. Comparative data is available that serves as a foundation for facility-based quality improvement activities. Some quality improvement activities for our profession are required by law and evaluated through the regulatory process. Some have been developed by the profession itself. Following are examples of quality improvement processes for our profession, both mandatory and voluntary. 12
Quality Assurance/Quality Improvement Committees Under federal regulation, each nursing and rehabilitation facility must have an active Quality Assurance/Quality Improvement Committee. It is this committee s responsibility to identify facility-specific opportunities to improve care and services through operational and organizational change and to enhance staff skills and performance through the development and implementation of corrective action plans. Facility Staffing Levels Research indicates that staffing is an important factor in nursing facility quality. Michigan s staffing levels from 2000-2010 have steadily increased from 3.21 hours/day to 3.62 hours/day, a level that far exceeds minimum staffing levels required by law. Quality Indicators/Quality Measures As required by the Centers for Medicare and Medicaid (CMS), all residents in nursing facilities receive a comprehensive needs assessment (Minimum Data Set/ MDS) at least every quarter. CMS compiles this data and generates a Quality NexCare Health Systems, Vacation Program LEGISLATIVE GUIDE TO TODAY S NURSING AND REHABILITATION FACILITY 513
Indicator (QI) Report that summarizes a facility s performance in 34 quality indicators of care and organization. Data is arranged such that a facility can compare its own performance over time, with other facilities in the state, and against other states both regionally or nationally. Facilities review and analyze this data as an essential part of their internal interdisciplinary quality improvement process to establish performance benchmarks and define goals for ongoing improvement. Quality Indicators include such care areas as: weight loss, physical restraints, dehydration, activity, incontinence, infection control practice, nutrition/eating, pain management, skin care, accidents, mobility, quality of care and others. Like the Quality Indicators, the MDS resident assessments also produce Quality Measures. These measures are computed, updated quarterly and publicly reported. Trends in Michigan nursing facility care throughout the last three years continue to demonstrate improvement. Survey Performance Trends: 2000-1010 Michigan s average number of citations per annual standard survey has decreased from approximately 16 (back in the 1990 s) to 7.3 at year-end FY2010. CMS created a comprehensive database, the Online Survey and Certification Reporting System (OSCAR), of all survey findings across the nation. Facilities may access facility-specific OSCAR data or comparative OSCAR data to evaluate their performance against other facilities in their state, region or nationally. Consumer and Workforce Satisfaction The vast majority of nursing facilities in Michigan have voluntarily incorporated consumer and workforce satisfaction as a tool in their quality improvement process. Overall, the number of consumers who would recommend a long-term care facility remains high at or above 85 percent. Also, workforce satisfaction increased in every job category between 2007 and 2009. LEGISLATIVE GUIDE TO TODAY S NURSING AND REHABILITATION FACILITY 14
Improving Performance through Person-Centered Care Over the last twenty years, the nursing facility profession has been gradually implementing culture change toward person-centered care. This initiative is transforming nursing and rehabilitation facilities from medical institutions treating patients to facilities serving and supporting residents. An accumulating body of empirical research supports the value of personcentered care as a viable strategy to improve organizational performance across a broad set of parameters. Approximately 90 percent of Michigan s nursing facilities have voluntarily implemented elements of person-centered care. The Advancing Excellence Campaign In 2005, a strategic national approach to improvement was created. More than 100 Michigan nursing facilities participated in Phase 1 of the Advancing Excellence Program, showing dramatic improvement in quality of care areas such as pain management, reduction in the use of physical restraints and minimizing the risk of pressure ulcers. Phase 2 of Advancing Excellence was launched in 2010. More than 187 Michigan facilities are voluntarily participating in Phase 2, improving quality in clinical areas such as pressure ulcer prevention, physical restraint reduction and pain management as well as addressing improvements in organizational practice such as establishing individual targets for improving quality, more in-depth assessment of resident and family satisfaction, increasing staff retention and workforce stability, and increasing consistent assignment so that residents more regularly receive care from the same caregiver. LEGISLATIVE GUIDE TO TODAY S NURSING AND REHABILITATION FACILITY 15