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 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. 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.
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. As Figure 1 illustrates, federal dollars pay for the majority of nursing home care.
Required Resident Services
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.
The Residents' Bill of Rights
The Nursing Home Reform Act established the following rights for nursing home residents:
- 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;
- 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.
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. The federal government did not issue regulations to implement the new survey process until 1995. 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.
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. For some violations, nursing homes have an opportunity to correct the deficiency before remedies may be imposed. Any or all of the following sanctions can be imposed to enforce compliance with the Nursing Home Reform Act:
- Directed in-service training of staff;
- Directed plan of correction;
- State monitoring;
- Civil monetary penalties;
- 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.
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.
The extent to which the Nursing Home Reform Act succeeds in actually improving nursing homes, however, depends on the effectiveness of its enforcement. Enforcement issues are addressed in PPI Fact Sheet: "Enforcement of the 1987 Nursing Home Reform Act."
Written by Martin Klauber and Bernadette Wright, AARP Public Policy Institute
May be copied only for noncommercial purposes and with attribution; permission required for all other purposes.
Public Policy Institute, Public Affairs, AARP, 601 E Street, NW, Washington, DC 20049