Regulation in nursing homes has been a work in progress since the 1960s when the Federal government first set out to improve conditions nationwide. Statutory frameworks continue to evolve as the need for facilities expands with the American population increase. This evolution of nursing home rules and regulations, as well as their enforcement, has significantly changed how nursing home facilities operate, how residents are cared for and how governing bodies are able to oversee this massive industry.
Medicare coverage for hospital services was enacted in 1965 when Congress mandated that hospitals be accredited in order to be accepted for participation in the Medicare program. This was fairly easy for hospitals that provided critical care for acute patient needs like surgery and recovery from illness and injury.
Bringing nursing homes under the same coverage was more difficult. Nursing homes provide long-term care for chronic ailments and no regulatory or enforcement model existed for skilled extended care homes or intermediate care facilities. The challenge for Federal regulators was to take the fundamentals of hospital care and build from them in developing a new set of regulations that were specific to the requirements of nursing homes.
Primarily, the Federal requirements for nursing homes have two concerns:
- Physical Safety: At the most basic level, nursing home facilities should be safe and clean. This included addressing fire safety as well as the need to protect residents from physical and sexual abuse as well as set rules dealing with neglect. At a time where patient abuse, devastating fires, and excessive filth were common, this was a major improvement needed in America’s nursing homes.
- Adequate Services: Services and treatment of patients in nursing homes needed to be addressed and the basic requirements set out in legislation. This was different from hospital situations where the outcome was straightforward. Hospitals focused on returning a patient to health. Nursing homes had a different goal—maintain patient function and slow deterioration down as much as possible.
Regulations for nursing home focused on three general principles:
- Staff Qualification: Workers having contact with patients were properly selected in a screening process, were properly trained for their care duties and were provided the climate to carry out their duties for the best care of residents.
- Policies: Frameworks which nursing homes were to operate under and adhere to.
- Procedures: Step-by-step processes were prescribed for the operation, maintenance and inspection of nursing home facilities.
Enforcement of government regulations was also addressed by law. To participate in Medicare, nursing homes were licensed and inspected, however, this was an underfunded and overlooked part of the program to improve nursing home operations and living conditions.
By the mid-1980s, the United States Federal Government recognized the need to overhaul regulations governing the nursing home industry. This resulted in the Nursing Home Reform Act which is the guiding statute governing nursing homes across America. Although it’s a federal act, each state is required to administer and enforce it.
Nursing Home Reform Act (1987)
The Federal Nursing Home Reform Act of 1987 is essentially a bill of rights for nursing home patients that guarantees by law that residents receive a basic care level.
Nursing home facilities that receive funding from the Federal Medicare and Medicaid programs must “provide services and activities to maintain or attain the highest practical physical, mental and psychological well-being of each resident in accordance with a written plan”.
Under the Nursing Home Reform Act, all facilities must:
- Maintain sufficient staff to meet residents’ needs
- Accurately assess each patient’s health status and individual needs
- Develop a written plan specific to each resident
- Prevent deterioration of patient health as much as possible
- Provide the necessities of life such as nutrition and cleanliness
- Ensure residents have access to assistance devices
- Pay specific attention to bedsores and other immobility effects
- Provide treatment and services for incontinence
- Provide adequate supervision and devices to prevent falls
- Provide proper nutrition
- Provide proper hydration
- Ensure medications are correctly administered
- Promote each resident’s quality of life
- Maintain the dignity and respect of every resident
- Ensure residents have the ability to be active and choose activities
- Administer the facility in an effective and resourceful manner
- Maintain accurate and accessible records documenting each resident
Other legislative acts also govern the nursing home industry. These also address the common purpose of protecting elderly and disabled persons from abuse, neglect, and exploitation. They also address financial support for people who are unable to look after themselves.
U.S. Federal Acts which address nursing homes as well as assisted living and hospice care facilities include:
Medicare is the federal health insurance program that funds seniors over the age of 65 who have worked full-time for over ten years. Premiums are deducted through state-administered payroll services and assessed at a mandatory 2.9% across the nation. Medicare has four parts:
- Part A which is free and covers basic nursing home care
- Part B which has a monthly fee and covers extended services
- Part C known as Medicare Advantage includes partial private insurance
- Part D which covers prescription medication
Medicaid is a health insurance program partially funded by the federal government but administered by the states. It’s generally an insurance of last resort for low-income seniors and disabled persons. There are strict conditions guiding who is eligible for Medicaid and people who qualify must have “spent down” their personal assets and have no other means of health coverage.
Veterans who have been honorably discharged from the U.S. Military may qualify for funding and care in nursing homes. This may also include spouses and family members of veterans.
Older Americans Act
The Older Americans Act (OAA) is a group of federal laws dating back to 1965 that guarantees certain services for the elderly including nursing home care. Grants are available for:
- Funding nursing homes and seniors centers
- Social services and community planning
- Protection of vulnerable seniors
- Meals and medication for seniors
Long-Term Care Ombudsman Program
Although a federal act, the Long-Term Care Ombudsman Program is administered by each state. The purpose is to resolve complaints and issues of individual nursing home residents.
Adult Protective Services
Every state has their own department that administers adult protective service programs that are in place to protect the elderly from neglect and abuse. Complaints laid to the state APS agencies are investigated and intervention is coordinated if violations of federal or state laws are founded.