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Nursing Homes and the Public Trust

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by Sarah Slocum and Anne Montgomery
Altarum Center for Eldercare & Advanced Illness

Often — including every time we fly — we entrust our lives to others. A necessary precondition is that we have very high expectations of safety and quality. So while few of us have the training to assess an aircraft’s performance, we board with the understanding that inspections and safety are paramount. We trust that quality measurement and essential maintenance are embedded in ongoing, routine operations, and that all personnel (on and off the plane) are trained and highly competent. In much the same way, we must be able to trust in the safety and quality of the health care services we receive.

In today’s nursing home sector, thousands of facilities across the country provide reliable, high-quality services. Yet a troubled subset has chronic safety and quality problems. Unfortunately, this has been true for years, and is not the fault of the standards. While chronic underperformance is difficult to address, whenever severe, sudden failures occur, regulators have a responsibility to quickly re-examine existing standards, adjusting them as necessary, and implementing them as expeditiously as possible.

One such failure occurred in mid-September in Hollywood, Florida, where 14 deaths have now been attributed to a power failure caused by Hurricane Irma, which led to sweltering temperatures inside the Rehabilitation Center at Hollywood Hills. According to media reports, while staff made efforts to try to keep frail elders cool, they did not relocate the residents to a safer, cooler location – a nearby hospital. Gov. Rick Scott expressed outrage and anger, and state regulators suspended the facility’s license.

Congresswoman Debbie Wasserman-Schultz (D-FL) represents the 23rd District where Hollywood Hills is located. At an Oct. 23rd event, Rep. Wasserman-Schultz made a good case that both tougher standards and enforcement are needed. “Facilities need to understand that failing to meet CMS requirements puts their residents in danger, and it will not be tolerated,” she said. Wasserman-Schultz will shortly introduce a bill focusing on various elements of emergency preparedness for nursing homes following a disaster. The measure:

  • requires facilities to maintain an alternative source of energy capable of powering heating, ventilation, and air conditioning systems for at least 96 hours after a disaster;
  • establishes a loan fund to help smaller facilities, or those serving more low-income residents, come into compliance;
  • mandates that nursing homes be considered on par with hospitals in terms of priority for restoring power after a storm, known as critical infrastructure;
  • increases civil monetary penalties levied against a facility when it is in noncompliance;
  • codifies the emergency preparedness rules applicable to nursing homes.

Those emergency preparedness regulations, scheduled to take effect in mid-November, stem from Hurricane Katrina, which resulted in the death of 139[1] nursing home residents in 2005. Following years of work and extensive consultation and study by state, local and federal officials, a major regulation covering 17 types of health care providers and suppliers, including nursing homes, was issued in 2013. The standards cover four major domains:

  • risk assessment and emergency planning;
  • policies and procedures that support successful execution of response to the emergency and address the risks identified;
  • communication plans — both internal and with key external local partners like hospitals, ambulance, local public health, and law enforcement; and
  • training and testing — at least annually – to prepare staff for different types of emergency events (e.g., floods, earthquakes, infectious disease outbreaks), accompanied with drills to rehearse responses and to demonstrate competency.

The full set of emergency preparedness requirements can be found here, and they are a major step forward.

Yet they are far from the only essential safety and quality regulations that are needed. More than a million Americans – mostly frail and disabled elders– receive both medical and long-term care in nursing homes, and rely on them to meet their daily needs for medical care, personal care, and an enjoyable life. Starting with regulations issued in the late 1980’s through the mid-1990’s in response to the Nursing Home Reform Act of 1987, the Centers for Medicare & Medicaid Services (CMS) has striven to meet the law’s aspirational goal, which is to assist residents to “attain and maintain the highest practicable physical, mental, and psychosocial well-being.”[2]

This is the intent behind the regulations released in October 2016 – the first rewrite of Conditions of Participation since 1991. The new standards, which codify advances in care practices and performance improvements made during the last 25 years, include:

  • provisions allowing residents more participation in their own care planning and treatment decisions;
  • policy strengthening residents’ rights to access more modes of communication, including email;
  • policy to clarify residents’ rights to contact outside services and agencies;
  • improved staff training;
  • required infection prevention;
  • stronger protections against abuse, neglect and exploitation;
  • a ban on charging residents additional fees for hospice services, and
  • a requirement that the facility notify the State Long Term Care Ombudsman of all involuntary discharges.

Together, these new and modified provisions aim to provide a more person-centered experience residents, and particularly for long-stay residents, for whom facilities are, in many cases, their final home. To learn more, the National Consumer Voice for Quality Long Term Care has resources here.

Evidence over the years shows that regulations have helped, not hindered, the ability of nursing homes to provide better care. Among the gains are a vast reduction in the use of physical restraints that were once commonplace. CMS has also done outstanding work in incentivizing nursing homes to reduce inappropriately high use of antipsychotics, which have been characterized by some as chemical restraints. Looking ahead, many more advances are possible, including in how staff are trained and how they work together. Starting in November, the first batch of more accurate staffing reports, based on payroll data, are due to be released. These data stem from a provision included in the bipartisan Nursing Home Transparency and Improvement Act, enacted in 2010.

When it comes to safety and quality, regulatory standards matter. Many good nursing homes set goals for quality and resident satisfaction that go above and beyond the requirements, including those facilities that work in the “culture change” movement to provide person-centered care in a more home-like environment. These efforts should be applauded and supported. Over time, we can take additional steps to demonstrate how nursing homes across the country can create processes and protocols that effectively de-institutionalize them. And as care practices improve, standards can be adjusted to motivate better performance – and increase trust.

Countering these trends, both the for-profit and non-profit nursing home associations are asking for broad rollback of safety and quality regulations, which could cause harm. No reduction in regulations should allow nursing homes to drift back to being inattentive to resident safety or resident rights. If you want to help ensure better lives for nursing home residents, go to Consumer Voice’s website to sign on to a letter opposing delay and termination of key safety and quality standards:

To sign on, if you represent a group/organization/program — click here
To sign on, if you are an individual. — click here

Sign-ons are due by November 15.

As aging Americans, we have a right to expect that a certain basic level of safety and quality will always be afforded to us and to our loved ones. As taxpayers, we need to know we are providing funding for care that is trustworthy. We would not accept removal of airline safety requirements, and we must not accept removal of basic standards governing nursing homes that are meant to keep us well and safe when we are old and frail.

[1] http://www.chron.com/news/nation-world/article/Katrina-s-toll-on-the-sick-elderly-emerges-1939354.php

[2] 4242 U.S. Code § 1395i–3(b)(2)

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