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Sarah C. Massengale Files (Ford Administration)
Sarah Massengale's Health, Social Security and Welfare Files
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Federal aid
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The original documents are located in Box 17, folder "Long Term Care (1)" of the Sarah C.
Massengale Files at the Gerald R. Ford Presidential Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the
United States of America her copyrights in all of her husband's unpublished writings in National
Archives collections. Works prepared by U.S. Government employees as part of their official
duties are in the public domain. The copyrights to materials written by other individuals or
organizations are presumed to remain with them. If you think any of the information displayed
in the PDF is subject to a valid copyright claim, please contact the Gerald R. Ford Presidential
Library.
Some items in this folder were not digitized because it contains copyrighted
materials. Please contact the Gerald R. Ford Presidential Library for access to
these materials.
THE JOURNAL OF
Long-Term Care
LIBRARY GERALD ? FORD
Adminstration
Long-Term Care
AMERICAN
COLLEGE
Facility Improvement-A Nationwide
Research Effort
Long-Term Care Program
Management-An Intersystem Approach
roce 196° NURSING TRATORS VIRTUS, HOME
Nursing Home Administrator Roles:
An Overview
<<<<<<
QUALITY
COMMUNICATING
COORDINATING
CARE
TEAC
STUDY
PLAN
ADVOCATING
MANAGING
LEADING
POLICY MAKING
CONVOCATION ATLANTA-76
A quarterly publication of the American College of Nursing Home Administrators
WINTER 1976
VOLUME IV, NO. 1
TABLE
The Journal of Long-Term Care Administration
THE JOURNAL OF
OF
Long-Term Care
CONTENTS
Adminstration
J. Albin Yokie, Editor
Robert Burmeister, Ph.D., Managing Editor
Suzanne Wood, Assistant Editor
Ellen Korth, Assistant Managing Editor
Susan Hutsell, Assistant Editor
Editorial
EDITORIAL ADVISORY BOARD
J. Albin Yokie
iii
Frederick H. Gibbs
Samuel Levey
George Washington University
City University of New York
Guest Editorial: Long-Term Care's Finest Hour
Washington, D.C.
New York, New York
Gerald A. Bishop
1
Patricia Cahill
W. Dean Mason
Association of University Programs
Kennedy Memorial Christian Home
in Health Administration
Martinsville, Indiana
Long-Term Care Facility Improvement - A Nationwide
Washington, D.C.
Charles Parmalee
Research Effort
Harvey Wertlieb
De Paul and Mt. St. Vincent
Faye G. Abdellah, R.N., Ed.D., L.L.D., F.A.A.N. and
Randolph Hills Nursing Home
Retirement and Nursing Centers
Wheaton, Maryland
Seattle, Washington
Rita K. Chow, R.N., Ed.D., F.A.A.N.
5
Robert Able
Robert S. Rebalsky
University of Colorado Medical Center
Saunders House
This article is adapted from the presentation at the First
Denver, Colorado
Philadelphia, Pennsylvania
North American Sypmposium on Long-Term Care Adminis-
Louise Broderick
Stuart Wesbury, Jr.
University of Missouri School of
tration held July 28 30, 1975, in Toronto, Ontario, Canada.
Broadway Home
San Diego, California
Medicine
Its content provides a basis for the development and imple-
Columbia, Missouri
Nicholas Demisay
mentation of a national strategy for long-term care in the
Clove Lakes Nursing Home
Muriel B. Wilbur
areas of gerentology, mental retardation and developmental
Staten Island, New York
Babson College
Babson Park, Massachusetts
disabilities.
Sidney Friedman
Jewish Home for the Aged
Charles Yeilding
Millbrae, California
Lewisville Nursing Home
Long-Term Care Program Management -
Annabelle Kleppick
Lewisville, Texas
An Intersystem Approach
University of Pittsburgh
Jonathan M. Metsch, Dr. P.H.
20
Pittsburgh, Pennsylvania
Volume IV, Number 1
This paper discusses the manner in which a specific subset of
The Journal of Long-Term Care Administration is published quarterly by the
systems concepts, the intersystem model and program man-
American College of Nursing Home Administrators ©1976 by the President and
agement, are applicable to the planning and management of a
Board of Governors of the College. All rights reserved. Permission to reproduce
comprehensive health care program in the long-term care in-
and quote material is granted only to scholars for legitimate use in learning en-
stitution.
vironments. This waiver does not extend to use of material in anthologies or col-
lections.
Annual subscription is $9.00 per year in the U.S.A. and Canada; all other coun-
tries $12.00. Single copy of current issue is $2.50. Direct change of address and
subscription correspondence to The Journal of Long-Term Care Administration,
Subscription Services, American College of Nursing Home Administrators, 4650
East-West Highway, Washington, D.C. 20014.
Winter 1976
Second class postage paid at Washington, D.C. and additional mailing offices.
NOTE.-DO NOT USE THIS ROUTE SLIP TO
DATE
SHOW FORMAL CLEARANCES OR APPROVALS
4/27/76
TO:
AGENCY BLDG. ROOM
Sarah Massengale
APPROVAL
REVIEW
X
PER CONVERSATION
SIGNATURE
NOTE AND SEE ME
V
AS REQUESTED
COMMENT
NOTE AND RETURN
NECESSARY ACTION
FOR YOUR INFORMATION
PREPARE REPLY FOR SIGNATURE OF
REMARKS:
(Fold here for return)
To
From
Decker Anstrom
PHONE
BUILDING
ROOM
245-2205
Donohoe
4030
FORM HEW-30 REV. 11/56 ROUTE SLIP
*U.S. GOVERNMENT PRINTING OFFICE: 1974 620-399/3503 1-3
LONG-TERM CARE
FACILITY IMPROVEMENT STUDY
LIBRARY
Introductory Report
July 1975
HEALTH.
OF
DELICATION.
PARTNENT ANCHORA AND
U.S.A.
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
Office of Nursing Home Affairs
LONG-TERM CARE
FACILITY IMPROVEMENT STUDY
Introductory Report
July 1975
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
Office of Nursing Home Affairs
ГОИС-ДЕВИ
Statement by the
YOUTS ТИЗМЭѴОЯЧМІ YTIJIOA7
Assistant Secretary for Health
The quality of care being provided in the Na-
The preparation and distribution of this sta-
tion's skilled nursing facilities is quite properly a
tistical report and recommendations does not
matter of serious concern to a great many individ-
mark the end of the efforts underway. Validation
uals, to the health professions, and to agencies of
surveys will continue through 1975 and will in
Government that both regulate these facilities and
fact be increased. Like the initial survey reported
channel vast amounts of public moneys to pay for
here, these validation site visits will be unan-
their services. That concern, obviously, is height-
nounced. In addition, a departmental management
ened by disclosures of seriously deficient care, by
information system is being designed SO that in-
sometimes tragic evidence of inadequate fire and
formation obtained either through surveys or
safety protection, and by allegations of fraud the
through periodic certification inspections can
victims of which are not only the patients them-
quickly identify those facilities that are not in
selves but also the taxpayers whose dollars are
compliance with existing regulations.
supposed to be providing high quality care in
Obviously, the States carry the primary burden
safe, comfortable, and properly managed facili-
of monitoring the performance of skilled nursing
ties.
facilities, thus the State surveyor has a critical
In response to a Presidential initiative and to
and continuing responsibility to evaluate not
the will of the Congress as expressed in Public
merely the physical surroundings and facilities of
Law 92-603, the Department of Health, Educa-
nursing homes but also the health status of the
tion, and Welfare is engaged in a broad campaign
people residing in them. For this reason the De-
aimed at improving the performance of long-
partment has placed strong emphasis on the train-
term care facilities. This report presents the re-
ing, credentialing, and licensing of State survey-
sults of a key element in the campaign, namely a
ors and on the training of providers and health
survey of skilled nursing facilities that was con-
personnel at all levels. In addition, the nursing
ducted to obtain a clearer picture of the care actu-
home ombudsman demonstrations that the De-
ally being provided, the health status of patients
partment has funded, and the results of which
and residents, and the physical environment and
are now being evaluated, appear to offer nursing
managerial setting as they affect both the quality
home residents a much-needed voice in the care
and the cost of skilled nursing care.
and services being provided them.
While the primary purpose of the survey was
I hope that this report will receive wide circula-
data collection, a purpose that has, I believe, been
tion both because the information it contains of-
fully met, the longer range and more significant
fers a uniquely perceptive view of the health of
goal involves identifying the need for change in
persons residing in skilled nursing facilities, and
the roles and responsibilities of the Department
more important because it can provide the basis
for constructive cooperation among all of us who
and other agencies and organizations that have a
are seeking the best possible life for present and
legal or professional responsibility for the serv-
future residents of skilled nursing facilities.
ices and care rendered in the Nation's skilled
nursing facilities.
THEODORE COOPER, M.D.
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402 Price $2.15
Stock Number 017-001-00397-2
iii
We are grateful for the extraordinary contributions of the many dedicated individuals who made
Foreword
this Long-Term Care Facility Improvement Survey possible. This collaboratively prepared report is
the result of Federal key staff listed here and in appendix B.
"Nursing home care is a field with a brief past
Part of this plan will be to develop a uniform
and an important future. We have come a long
scorecard for grading nursing home care. An "A"
DEPARTMENTAL RESOURCE PERSONS
way in a short time."¹
would then mean the same thing in any State in
One forward step was accomplished when the
the country.
Caspar W. Weinberger
Theodore Cooper, M.D., Ph.D.
President signed Public Law 92-603 to establish a
This report is limited to the presentation of the
Secretary
Assistant Surgeon General
common definition of care and mandate a single
findings of the Long-Term Care Facility Im-
DHEW
Assistant Secretary for Health
set of nursing home standards for health, safety,
provement Study. The findings are different from
Washington, D.C.
DHEW
environment, and staffs in skilled nursing homes.
those of other studies particularly because for the
Washington, D.C.
These Federal standards were issued January 1974.
first time a patient assessment form specifically
Frank C. Carlucci
On June 21, 1974, the Department announced
designed for long-term care facilities was used on
Under Secretary
John D. Young
the special long-term care improvement campaign,
a national basis.² Most existing survey forms cur-
DHEW
Assistant Secretary, Comptroller
consisting of four projects.
rently used to survey nursing homes are designed
Washington, D.C.
DHEW
The first was a visit to a sample of skilled nurs-
for short term, acute care facilities such as hos-
Washington, D.C.
ing homes across the Nation by teams from the
pitals. Further, since the main purpose of the sur-
Peter Franklin, M.Ed., M.B.A.
Department's 10 regional offices and headquarters.
vey was fact finding no effort was made to utilize
Special Assistant to the Secretary
Faye G. Abdellah, R.N., Ed.D., LL.D., F.A.A.N.
The purpose was to identify the needs and deter-
the survey findings for certification purposes. Only
DHEW
Assistant Surgeon General
mine where the Department's emphasis should be
skilled nursing facilities were included in the
Washington, D.C.
Chief Nurse Officer, Public Health Service (PHS)
to improve the quality of care and provide a safe
survey.
and
environment in nursing homes.
The staff of the National Center for Health
Director, Office of Nursing Home Affairs
A second element of the campaign involved
Statistics provided continuing consultation and
DHEW
setting up a Long-Term Care Management In-
assistance in selecting the sample and in designing
Rockville, Maryland
formation System with a rapid response capability.
the sampling procedures. These are described in
The system must be capable of responding to the
detail in the report.
steady demand for quick information about sur-
The Federal regulations governing Skilled Nurs-
STAFF
veys, certification status, Life Safety Code inspec-
ing Facilities published in the January 17 and
tions and other matters. This system will link up
October 3, 1974, regulations were used as a basis
Rita K. Chow, R.N., Ed.D., F.A.A.N.
Claire F. Ryder, M.D., M.P.H.
the data-gathering apparatus at headquarters, re-
for comparing the survey findings. These Federal
Deputy Chief Nurse Officer, PHS and
Chief, Division of Policy Development
gional, and State offices.
regulations represent minimum standards and ap-
Deputy Director, Office of Nursing Home Affairs
Office of Nursing Home Affairs, PHS
A third project will be to establish a monthly
pear in appendix F.
DHEW
cost of care index for long-term care. The plan is
It was not the intention of the survey to sub-
DHEW
Rockville, Maryland
Rockville, Maryland
to arrive at a national index and 10 regional in-
stantiate the common allegations made about lack
dices-and one for Skilled and another for Inter-
of care in nursing homes. The survey process did
Helen V. Foerst, R.N., M.A.
mediate facilities. The indices will gauge admin-
not permit the collection of data and information,
Editorial Assistance:
Assistant Chief Nurse Officer, PHS
istration, nursing, food, and costs and will help to
for example, about patients left sitting in chairs
DHEW
Kenneth H. Flieger
guide Federal and State reimbursement policies.
for extended periods of time nor the extent of use
Rockville, Maryland
Special Assistant to the Assistant Secretary for
Another project in this campaign will be to
of various types of physical restraints and locked
Health
develop uniform inspections and uniform ratings
rooms for patient control. No assumptions or
DHEW
for nursing homes.
Wayne Richev, Jr., M.A.
Washington, D.C.
U.S. Department of Health, Education, and Wel-
Associate Director
1 Remarks by Under Secretary Frank C. Carlucci, De-
fare, Health Administration. Patient Classification for
Office of Nursing Home Affairs, PHS
partment of Health, Education, and Welfare, before the
Long-Term Care: Users Manual. DHEW Pub. No. (HRA)
DHEW
Meeting of State Surveyors, St. Petersburg, Fla., June 21,
74-3107. (Washington, D.C.: U.S. Government Printing
1974.
Rockville, Maryland
Office, December 1973).
V
iv
judgments can be made about the physical and
should be based on what the individual needs, and
mental abuse of patients. A realistic picture of
not be limited to institutional care.
patient's needs for care associated with their
We are truly grateful to the large number of
pathophysiologic and psychosocial conditions and
persons who contributed to this survey research
the related practice and service requirements to
project, especially the Department's Office of
satisfy these needs was sought.
Nursing Home Affairs staff and the Regional Di-
In many cases, the social and economic needs of
rectors of the Offices of Long-Term Care Stand-
Contents
older people can be met much better through pro-
ards Enforcement. (See appendix E.)
grams that permit self-sufficiency for older people
in their own homes. It is important to make it pos-
sible for older people to keep functioning in their
Page
Page
own homes. We have not yet begun to realize the
FAYE G. ABDELLAH,
Statement by the Assistant Secretary for
Health and safety of the environ-
full possibilities-human and economic-of ex-
Assistant Surgeon General
Health
1
ment
13
panding home health services. Long-term care
U.S. Public Health Service.
Social services
14
Departmental Resource Persons
4
Training
14
Needed action
14
Foreword
6
4. Characteristics of Facilities and
Patients
17
Chapter
Number of facilities
17
1. Historical Overview of DHEW'S
Facilities in the study
17
Efforts in Long-Term Care
10
Number of patients
18
2. Survey Methodology
16
Demographic characteristics
18
Survey purpose and format
3
Age
18
Research plan
3
Sex
19
Race
19
The sample and how it was se-
lected
5
Marital status
19
Selection of nursing homes
5
Educational and economic character-
Selection of residents
6
istics
20
20
Reliability of the estimates
7
Educational attainment
Methods and procedures
7
Occupation
20
The study team
7
Family income
20
Selection of team members
8
5. Health Status
22
Orientation and training of team
members
8
Activities of daily living
22
Survey instruments
9
Bathing
23
Content of the instruments
Dressing
23
9
Eating
23
How survey instruments were de-
veloped
9
Toileting
23
Survey procedures
9
Mobility
24
Bladder and bowel function
24
3. Summary of Findings and Im-
Orientation and behavior
25
plications
Communication of needs
25
Health care needs of patients and
Condition of the skin
26
residents
11
Impairments in sensory perception
28
Nutritional needs
12
Patient diagnoses
29
Pharmaceutical services
12
Dentition
32
Physician services
12
Rehabilitative services
12
6. The Patient Care Setting
Other health professional involve-
Administrative and fiscal manage-
ment
13
ment
33
Administrative and fiscal manage-
The governing body
33
ment
13
Nursing home administrator
34
vi
vii
Page
Page
Table
Page
Table
Page
Patient care policies
35
Social services and activities pro-
5. Number and percent of patients by
30. Distribution, number and percent of
Personnel management
36
grams
62
sex and race
19
decubitus ulcer sites among pa-
Use of outside resources for con-
Social work programs
62
6. Number and percent of male patients
tients who do not walk, who are
sultative services
37
Activities programs
64
by race
19
not transferred, and who are not
Summary of findings
38
Conclusions and implications
67
7. Number and percent of female
wheeled
27
Conclusions and implications
38
19
31. Number and percent of patients with
39
8. Historical Development of Sur-
patients by race
Fiscal management
8. Number and percent of patients by
exudative ulcers and the frequency
Health and safety of the environ-
veyor and Provider Training
marital status
20
of treatment of the ulcers.
28
ment
39
Programs
69
9. Last year of schooling completed by
32. Classification of patients according
Conclusions and implications
41
Implications for provider training
71
patients in skilled nursing fa-
to visual perception
28
Training issues
72
cilities
20
33. Classification of patients according
7. Patient Care Services
43
Training costs
74
10. Usual occupation of patients in
to hearing acuity
29
Physician services
43
skilled nursing facilities
20
34. Classification of patients according
Admission data
44
Bibliography
75
11. Current employment status of pa-
to speaking ability
29
Continuing care
44
tients in skilled nursing facilities
21
35. Primary diagnoses recorded on ad-
Summary of findings
46
Appendix
12. Number and percent of patients by
mission by diagnostic group and
Conclusions and implications
46
sex and family income
21
by age
30
A Instructions for Selecting a Sample
Rehabilitative services
48
of Residents for the Long-Term
36. All diagnoses recorded on admission
Specialized rehabilitative services
48
13. Number and percent of male pa-
Care Facility Improvement
21
by diagnostic group and by age
30
Utilization of specialized rehabili-
tients by family income
Campaign
78
37. Most prevalent diagnostic groups
tative services
49
14. Number and percent of female pa-
(recorded postadmission) by age
31
Frequency of treatments
49
B Estimation and Variance Specifica-
tients by family income
21
38. Rank order of most common diag-
Characteristics of the services
49
tions for the Long-Term Care Fa-
15. Bathing ability of patients
23
nostic groups by time of recording
Space and equipment
50
cility Improvement Campaign
84
16. Dressing ability of patients
23
and age group
31
Summary of findings
51
c Preparation of the Data for
17. Eating ability of patients
23
39. Patients' status of dentition
32
Conclusions and implications
51
Analysis
86
18. Toileting ability of patients
23
40. Number and percent of SNFs
Pharmaceutical services
51
D General Instructions for Members
19. Bladder function of patients
24
which have adopted rules and
Drug prescribing
52
of the Survey Team
88
20. Bowel function of patients
24
regulations pertaining to the health
Drug ordering
52
21. Patient's orientation as to time,
care of patients
35
Dispensing of medications
52
E Acknowledgements
90
place, and person-spheres
25
41. Number and percent of SNFs in
Drug distributing
53
F Social Security Amendments of
22. Patients classified according to ap-
which the administrator enforces
Administering and recording
53
1972 (Public Law 92-603) (Sum-
propriate behavior
25
rules and regulations pertaining to
Drug monitoring
54
mary of Sections Affecting Long-
the level of health care provided
35
23. Patients' ability to communicate
Storing and inventorying
54
Term Care Facilities)
103
needs
26
42. Number and percent of SNFs in
Supervising pharmaceutical serv-
which the governing body has
ices
55
134
24. Number and percent of decubitus
Glossary
adopted rules and regulations for
ulcers among patient population
Coordinating pharmaceutical serv-
the general operation of the fa-
56
Table
and site frequency among those
ices
cility
35
patients with decubitus ulcers
26
Drug counseling
56
1. Number of facilities classified ac-
43. Number and percent of SNFs that
Summary of findings
56
cording to whether pharmacist
25. Walking status of patients with
verify the licensure and registra-
decubitus ulcers
26
Conclusions and implications
57
provides written comments con-
tion of staff at time of employment
Nutrition and dietetic services
57
cerning review to the medical
26. Number and percent of difficulties
by bed size
37
Supervision of staff and related
director
7
of joint motion, upper body, among
44. Number and percent of SNFs that
factors
patients with decubitus ulcers
27
58
2. Number and percent of skilled nurs-
annually verify current status of
Dietetic personnel
58
ing facilities in the national sample
27. Number and percent of difficulties of
licensure or registration of staff by
Documentation
59
survey by bed size
18
joint motion, lower body, among
bed size
37
Menus and nutritional adequacy
59
3. Number and percent of skilled nurs-
patients with decubitus ulcers
27
45. Number and percent of SNFs in
Frequency of meals
60
ing facilities in the national sample
28. Number and percent of fractures or
which there is evidence that staff
Other nutritional care issues
60
survey by type of control
18
dislocations among patients with
utilizes training
37
Sanitation and safety
60
4. Number and percent distribution of
decubitus ulcers
27
46. Percentage of SNFs having agree-
Facilities, space and equipment
61
patients in skilled nursing facilities
29. Transfer status among patients with
ments with outside resources for
Conclusions and implications
61
by age
19
decubitus ulcers
27
services by size of facility
37
viii
ix
Page
Table
Page
Table
Table
Page
Table
Page
47. Number and percent of SNFs in
58. Number and percent of facilities
74. Patients menus planned in writing
81. Patients in skilled nursing facilities
which the consultant apprises the
employing or contracting for spe-
and not in writing related to
having psychosocial data recorded_
63
administrator through written re-
cialized rehabilitative services
49
other characteristics
59
82. Number of patients in facilities with
ports of continuing assessment of
59. Number and percentage of facilities
75. Number and percent of patients
policies affecting continuity of
the service provided.
37
providing rehabilitative personnel
receiving assistance with eating
information, by documentation of
48. Number and percent of SNFs in
specializing in physical therapy,
when indicated
60
psychosocial data
63
which the consultant apprises the
speech therapy and occupational
76. Communication of information con-
83. Number of patients stating they felt
administrator through written re-
therapy by bed size of facility
49
cerning dietetic needs of patients
they received the care they required
ports of his recommendations
38
to the dietetic service
60
by SNF programs and policies
64
49. Number and percent of SNFs in
60. Frequency of physical therapy treat-
49
77. SNFs meeting certain sanitation
84. Staffing patterns for activities pro-
which the consultant apprises the
ments
and safety factors related to food
grams by bed size
64
administrator through written re-
61. Characteristics of the physical ther-
and food service
61
85. Patients having activities data
ports of plans for implementation
apy service provided patients
50
78. Assessment of certain SNF factors
recorded
64
of his recommendations
38
62. Quality indicators related to special-
in food preparation and service in
86. Space and equipment available in
50A. Number and percent of skilled nurs-
ized rehabilitative services pro-
relation to the equipment in use
61
facilities for activities programs
65
ing facilities and range in number
vided in SNFs
50
79. Number of SNFs with full and
of deficiencies
40
63. Space and equipment available to.
part time social work program
Figure
50B. Number and percent of skilled nurs-
provide specialized rehabilitative
staff by bed size
62
1. Flow chart
4
ing facilities in the deficiency range
services in SNFs
50
80. Utilization of social work staff in
2. Regional distribution of 288 facilities
between 0-9
41
64. Number and percent of patients
selected activities
63
surveyed
6
51. Number and percent of skilled nurs-
ing facilities not meeting life safety
receiving drugs by drug category
code requirements by order of
in rank order
52
magnitude
41
65. Information contained on patient's
52. Number and percent of skilled nurs-
individual prescription labels
53
ing facilities meeting life safety
66. Number and percent of facilities by
code requirements by order of
type of information contained on
magnitude
41
the drug profile record
54
53. Review of the total program of care
67. Kinds of pharmaceutical service ac-
by the attending physician during
tivities rendered by pharmacists
a visit at least every 30 days (in the
4 months immediately preceding
to skilled nursing facilities
55
survey) by length of stay
45
68. Hours per week that skilled nursing
54. Review of the total program of
facilities are provided pharmaceu-
care by the attending physician
tical services by a pharmacist(s)
56
during a visit at least every 30
69. Number and percent of facilities
days (in the 4 months immediately
employing a qualified dietetic serv-
preceding survey) by length of stay
ice supervisor either full time or
and by whether the physician saw
part time
58
the patient at the time of each
visit
45
70. Management and supervisory func-
55. Patients receiving specialized reha-
tions performed by qualified die-
bilitative services in skilled nursing
tetic service supervisors in facilities_
58
facilities
48
71. Type of services provided by the
56. Estimated need for specialized re-
dietitian in 5,909 SNFs
58
habilitative services among pati-
72. Dietary characteristics of SNFs with
ents in skilled nursing facilities
48
insufficient dietetic personnel on
57. Patients identified as needing spe-
duty over a 12-hour period
59
cialized rehabilitative services and
the estimated number and percent
73. Dietary characteristics of SNFs with
receiving and not receiving these
sufficient dietetic personnel on duty
services
48
over a 12-hour period
59
xi
CHAPTER 1
Historical Overview of DHEW's Efforts
in Long-Term Care
In 1965, Congress passed Public Law 89-97 and
long-term care. A brief review of the accomplish-
established Medicare and Medicaid under Titles
ments are in the subsequent paragraphs.
XVIII and XIX of the Social Security Act to
Development of uniform standards for skilled
help meet the health care needs of the over 65, and
nursing facilities (SNFs).-In January 1974,
the poor. One of the benefits provided coverage of
uniform Federal regulations governing partici-
care rendered by a certified nursing home. Certifi-
pation of skilled nursing facilities in Titles XVIII
cation was obtained by demonstrating compliance
and XIX were published, and interpretive guide-
with Federal regulations directed toward assuring
lines for professional and consumer groups as
an acceptable quality of care. Since the mid-sixties,
well as instructional guidelines and forms for sur-
the regulations have gone through an evolutionary
veyors were developed. The process by which these
process-from ensuring safety to a greater focus
are developed seeks to assure that standards are
on the need for achieving an optimum quality of
reasonable, yet adhere to sound professional prac-
life and care-keeping in mind the need to provide
tice. The regulations provide a streamlined ef-
the technical assistance to States to support their
ficient mechanism for inspecting and certifying
efforts to upgrade nursing homes. In 1972, the
nursing homes receiving Federal funds and places
Congress approved creation of unified standards
special emphasis on the health and safety of
and regulations governing skilled nursing facili-
patients.
ties under Titles XVIII and XIX.
On October 3, 1974, additional standards were
The Nursing Home Improvement Program, re-
published in final form after having been pub-
sulting from President Nixon's August 1971 mes-
lished as Notice of Proposed Rulemaking on May 1
sage and subsequent administration interest and
for comment. Requirements for medical direction,
directives, has intensified and broadened activities
7-day registered nurse coverage, discharge plan-
already underway and initiated new activities
ning and patients' rights were established. These
where needed. Response to these priorities has
four standards have been long awaited to en-
focused on improving the quality of care and life
hance the quality of care and life that ONHA
through innovation, experimentation, evaluation,
and the Department had made a commitment to
and technical assistance.
improve.
One of the initiatives was to provide a Depart-
In January 1974, the regulations governing In-
mental focal point for standards enforcement and
termediate Care Facilities (ICF) were also pub-
facility improvement, and further development
lished, creating in response to congressional legis-
and coordination of long-term care policy in the
lation, a new level of care to be provided under
Department. These responsibilities were assigned
the Medicaid program.
to the Office of Nursing Home Affairs (ONHA),
Public Health Service. Additional responsibilities
Working with DHEW, the Department of
assigned to this Office have been expanded to in-
Housing and Urban Development established a
clude aging in the Public Health Service and
guaranteed loan program called for by Public Law
Home Health Services. The staff of ONHA co-
93-204. Provisions of the program, published in
ordinates long-term care program aspects of
the FEDERAL REGISTER of August 12, 1974, will as-
agencies throughout the Department. In the same
sist facility administrators to purchase and install
way that ONHA's original responsibilities have
fire safety equipment which would enable them to
expanded, SO have the other initiatives been modi-
meet the Life Safety Code (LSC) requirements of
fied to respond to continuing needs in the area of
the SNF and ICF regulations.
1
The Life Safety Code Survey training sessions
disciplinary teams from other facilities. Materials
CHAPTER 2
were held for State and regional office personnel.
from earlier contracts have been produced for
Approximately 230 State people attended these
distribution.
sessions which were geared to improving interpre-
Research and development and data collection.-
tation and documentation requirements and survey
Through contracts and grants, studies are being
techniques. In addition, a contract has been en-
conducted by the DHEW in the areas of (1) qual-
tered into with an outside consultant for the de-
ity of care; (2) assessment of alternatives to in-
Survey Methodology
velopment of an audiovisual training program
stitutional care; and (3) data collection. ONHA
which can be used by State survey personnel to
coordinates these efforts throughout the Depart-
improve their understanding and application of
ment to avoid duplication.
LSC requirements.
During 1974, the nationwide sample survey of
On June 21, 1974, Under Secretary Frank C.
mum number acceptable if the data collected were
Ombudsman demonstration.-The seven nursing
nursing homes, their residents, and staff, was com-
Carlucci announced the Long-Term Care Facility
to be regarded as nationally representative.
home ombudsman demonstration projects which
pleted by the National Center for Health Statis-
Improvement Campaign, an accelerated project
It is essential that the purpose of the campaign
were initiated following the initiatives were trans-
tics. Data (including cost data) based on a sub-
directed toward upgrading the quality of care pro-
surveys be carefully distinguished from surveys
ferred from the Public Health Service to the Ad-
sample (nearly 300 of the 2,112 homes included in
vided in the Nation's nursing homes. A multi-
conducted for the purpose of certifying homes for
ministration on Aging (AoA) in 1973. An assess-
the survey) has been published. Surveys are
faceted effort, the campaign will ultimately ad-
participation in the Medicare and Medicaid pro-
ment of the experiences of the various models for
planned on a continuing basis for every 2 years.
dress a number of diverse issues relating to long-
grams. The campaign surveys were conducted
resolving grievances of patients in nursing homes
This means that essential trend information as
term care, including development of a computer-
solely as a data collection process with no formal
has been completed. The AoA plans to expand
well as current estimates on this rapidly expand-
ized information system, development of a month-
relation to the certification procedure.
these units as part of its advocacy role for aging.
ing sector of the health care delivery system will
ly cost of care index, and a nationwide uniform
The survey instrument used differed markedly
In fiscal year 1976, AoA plans to assign one full-
be available for planning, providing, and estab-
inspection and rating program for nursing homes.
in format, content, and underlying philosophy
time person to each State to provide leadership in
lishing standards for long-term care.
At that time, the importance of this project was
from previous instruments and particularly from
developing an ombudsman program in that State.
Several other data programs within the Depart-
emphasized, not only because of its immediate im-
those used for certification purposes under Titles
Surveyor training.-On August 7, 1974, Public
ment include long-term care information from the
pact, but even more importantly because of the
XVIII and XIX. The underlying premise of the
Law 93-368 extended for 3 years (until June 30,
Bureau of Health Insurance (SSA), Medical
role it will play in future planning for long-term
Titles XVIII and XIX survey form is that by
1977) the 100 percent Federal funding of salaries
Services Administration (SRS) as well as the Ex-
care as the campaign progresses.
and training of surveyors of long-term care facili-
perimental Health Services Delivery Systems
measuring the capacity of a facility to provide an
ties which was provided for in the original intia-
(HRA). Attention will be given to consolidating
acceptable quality of care, the Federal Govern-
tives. In accordance with recommendations, con-
these data at headquarters and regional offices.
SURVEY PURPOSE AND FORMAT
ment may assume that the facility is in fact pro-
tinued support was needed to ensure that States
Section 222 of P.L. 92-603.-Experiments and
viding care of that quality. In short, the XVIII
could complete inspections required to certify fa-
Demonstration Projects on Reimbursement. The
To appreciate the purpose of the surveys, it is
and XIX forms measure capacity and infer qual-
cilities and assist them to maintain compliance
Secretary was authorized to undertake studies, ex-
helpful to consider them in the context of the
ity. The survey report form used in the campaign
with regulations. Each region has a Health Fa-
periments, or demonstration projects with respect
overall campaign. In order to achieve the cam-
was in some respects more ambitious than its pred-
cility Survey Improvement Program coordinator
to: Various forms of prospective reimbursement
paign's broad goal of upgrading nursing home
ecessors in that its objective was to measure quality
to identify specific need for surveyor training.
of facilities; ambulatory surgical center; inter-
services, it was deemed necessary to assess care-
directly without reliance on surveyor's inferences
Provider training.-Through contracts awarded
mediate and skilled care and homemaker services
fully and objectively the current status of this level
and assumptions.
by the Division of Long-Term Care, National Cen-
(with respect to the extended care benefit under
of care. In short, baseline data were necessary to
Because the Office of Nursing Home Affairs
ter for Health Services Research, HRA, patient
Medicare); elimination or reduction of the 3-day
identify needs, develop programs to meet those
(ONHA) serves as the Departmental and Public
care personnel throughout the country, represent-
prior hospitalization requirement for admission to
needs, and measure the overall success of the initia-
Health Service focal point for Long-Term Care
ing all categories, were provided with opportuni-
a skilled nursing facility; determination of the
tives undertaken. The role of the surveys was to
and nursing home affairs, ONHA staff was asked
ties for short-term training. The total reached by
most appropriate methods of reimbursing for the
collect this baseline data.
to take the leadership role to plan, conduct, and
such opportunities since this initiative was imple-
services of physicians' assistants and nurse prac-
Using a scientific approach for data collection,
coordinate the Long-Term Care Facility Im-
mented is over 100,000. Long-term care coordina-
titioners; provision of day care services to older
steps were taken in accordance with established
provement Campaign's survey research project.
tors have been designated in all DHEW regions
persons eligible under Medicare and Medicaid;
statistical and research principles to eliminate bi-
(The sequential progression of six phases during
and nine regions have identified a "center of excel-
and, possible means of making the services of
ases which might otherwise destroy the integrity
clinical psychologists more generally available
1974 and 1975 are shown on the flow chart-figure
lence" within their jurisdiction, a long-term care
of the surveys. For example, all visits were un-
facility where onsite training can be given to inter-
under Medicare.
1.)
announced to assure that a true profile of the
home's normal operations was obtained; homes to
be surveyed were selected randomly on a regional
RESEARCH PLAN
basis and with no prior knowledge concerning
The initial campaign plan was made with an ad
those facilities ultimately selected. Originally, the
hoc executive committee of representatives from
total figure of 304 visits was selected as the mini-
various segments of the Federal health sector who
3
2
served in an advisory capacity. These representa-
sists of representatives from Michigan State Uni-
jects, such as assessing health care needs in skilled
it was necessary to ensure that all regions of the
tives included health professionals from such com-
versity, Harvard University, Johns Hopkins Uni-
nursing facilities.
country and all sizes of institutions were repre-
ponents as the National Center for Health Statis-
versity, Syracuse University, and others (see ap-
sented in the sample. To achieve this objective, the
tics, National Center for Health Services Re-
pendix B). These key individuals had assisted
search, Bureau of Quality Assurance of the
in the original development of the patient classi-
THE SAMPLE AND HOW IT WAS SELECTED
following procedures were used:
Health Services Administration, Social Security
fication approach and the Patient Classification
1. The U.S. Department of Health, Education,
The nursing home survey was intended to pro-
Administration, Social and Rehabilitation Serv-
for Long-Term Care Users Manual that were
and Welfare (DHEW) 1974 list of all nurs-
ice, Administration on Aging, and Office of Re-
used in this survey.
vide a picture of skilled nursing homes in the
ing homes in the United States participating
gional Operations. Task forces were formed to
Dissemination of findings.-The fourth phase
United States participating in the Medicare/
in both the Medicare and Medicaid programs
obtain professional expertise to select the survey
(see flow chart) was marked by the publication
Medicaid programs and the care being provided to
were divided into the 10 DHEW regions.
format and instruments.
of the Long-Term Care Facility Improvement
benéficiaries in these homes. Survey instruments
(See map of these regions and the number of
homes surveyed.)
Consultation.-Outside as well as Federal con-
Study: Interim Report. After completion of the
and procedures were designed to collect baseline
2. These lists were sent to the regional offices to
sultants were brought into the project at frequent
Introductory Report (phase V), there will be
information on the quality of care and its related
determine which homes were skilled nursing
intervals during the team training phase, when
subsequent monographs (phase VI) that will pre-
costs to guide decision-makers in planning future
homes and which were currently participat-
data were being prepared for analysis, and during
sent in-depth data analyses of drug prescribing
programs in long-term care.
ing in the Medicare/Medicaid programs and
the data analysis stages. One advisory group con-
patterns, nursing care, and other important sub-
Since it was impossible to survey all 7,526 skilled
which were currently in operation.
3. The researchers then took the lists of Medi-
nursing facilities participating in the Medicare/
1974
1975
care/Medicaid certified skilled nursing fa-
Medicaid programs at the time of survey, conduc-
cilities from the 10 regions and divided them
JUNE
JULY
AUG.
SEPT.
OCT.
NOV.
DEC.
JAN.
FEB.
MAR.
APRIL
MAY
JUNE
tion of a sample survey was necessary. In this
into 3 categories based on size:
kind of survey, sampling is the process of choos-
those with less than 50 beds
ing part of a group (the sample) about which
those with 50-99 beds
OBTAIN
PREPARE
we wish to make generalized statements SO that
those with 100 beds and over
TEAM TRAINING
CONSULTATION
DATA FOR ANALYSIS
the selected part will represent the total group-
4. Using these three strata (bed-size categories),
in this case, all 7,526 skilled nursing homes.
three lists of homes were made for each
ANALYZE
A two-stage stratified random sampling design
region. Homes were listed in the following
DATA
START
I
II
III
IV
V
VI
was employed. The initial stage involved the
order: alphabetically by State within the
selection of homes. In the sampling process, homes
region, alphabetically by county within the
were divided into three groups or strata based on
State, and alphabetically by name within the
LTCFIS TASK FORCE MEETINGS
county.
their size. In the second stage, a sample of patients
5. To ensure that certain nursing homes were
DEPLOY
was drawn from the homes in the sample. The
not overburdened with DHEW surveys,
INITIAL
HEADQUARTERS
random selection procedures gave an equal chance
those homes used by the Department's Na-
LTCFIC PLAN
TEAM MEMBERS
LTCFIS ADVISORY & EXECUTIVE MEETINGS
for every skilled nursing home participating in
tional Center for Health Statistics Nursing
the Medicare/Medicaid programs to be selected in
Home Survey conducted in 1973 were re-
the sample. In turn, every Medicare/Medicaid pa-
moved from the lists. Since the National
OBTAIN INPUT AND COMMUNICATE WITH DHEW REGIONAL OFFICES
tient in these homes also had an equal chance of
Center for Health Statistics plans to include
in its 1975 survey facilities with 500 or more
being selected.
beds, homes of this size were eliminated.
The particular sampling process used resulted
There were 32 of these homes at the time of
in the selection of 288 homes. (Figure 2-Map.)
the survey.
KEY:
I
OMB CLEARANCE
From this sample, it is possible to make general-
6. Homes were then selected from each of the
II
DEPLOY AND COORDINATE 15 SURVEY TEAMS TO 10 REGIONS TO GATHER DATA
III
ized statements about the 7,526 skilled nursing
30 lists by using the following random start
COMPLETE DATA GATHERING
IV
PUBLISH INTERIM REPORT
homes. The specific procedures for selecting both
procedures:
V
PUBLISH INTRODUCTORY REPORT
the home and patient samples are described in de-
The first home was randomly selected from
VI
PUBLISH MONOGRAPHS
tail below. In general, the samples were designed
the list. Thus, each nursing home had the
same probability of being selected as any
to make reliable national estimates.
other home.
Using the home selected in the first step
Figure 1
Selection of Nursing Homes
as the starting point every 30th home on
the list was selected if it were on the list
Implementation of LTCFIS Research Plan
Since the study was designed to obtain a na-
whose bed-size category was less than 50;
tional picture of all types of skilled nursing homes
every 25th home was selected if it were on
the list whose bed-size category was be-
participating in the Medicare/Medicaid program,
tween 50-99; and every 10th home was
4
5
588-459
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
The number of residents to be surveyed varied
The relative standard error in table 1 may be
Regional Boundaries and Regional Offices
depending on the size of the home. The number
interpreted as follows: The sample estimated is
REGION I:
BOSTON, MASS. (20)
REGION VI: DALLAS, TEXAS (18)
ranged from all Medicare/Medicaid patients who
that in 5,352 or 81.2 percent of all homes the phar-
II: NEW YORK, N.Y. (26)
VII:
KANSAS CITY, MO. (11)
were available at the time of the survey in homes
macist did not provide written comments to the
III:
PHILADELPHIA, PA. (25)
VIII:
DENVER, COLORADO (16)
IV:
ATLANTA, GEORGIA (29)
IX: SAN FRANCISCO, CALIF. (53)
of 15 residents or less to 1 out of every 35 for homes
medical director. A relative standard error of 0.04
Washington
V:
CHICAGO, ILLINOIS (70)
X: SEATTLE, WASHINGTON (20)
Maine
having up to 500 residents. (See appendix A for
is equivalent to 214 homes or 3.2 percent. Hence,
Montana
the forms and instructions used in selecting the
the chances are about 2 out of 3 that in the total
Seattle
North Dakota
Minnesota
Vt.
sample patients.)
population, the number of homes in which the
Oregon
pharmacist did not provide comments to the medi-
=
Boston
South Dakota
Wisconsin
Mass
cal director lay between 5,352 ± 214 homes, or
RELIABILITY OF THE ESTIMATES
Wyoming
V
New York
equivalently 81.2 + 3.2 percent. Similarly, the
R.I.
California
Idaho
VIII
Pennsylvania
New York
In interpreting the findings from this survey,
chances are 19 out of 20 that the number of homes
Nevada
lowa
Utah
Ohio
Philadelphia
New Jersey
Nebraska
the reader should keep in mind that this was a sam-
in the total population where the pharmacist did
Indiana
Md
VII
Chicago
Del.
ple survey, and that the sample was designed to
not provide written comment is 5,352± (2X214)
IX
Colorado
3
Virginia
III
Missouri
make national estimates. Since all 7,526 skilled
or a range of 4,934-5,770. A comparable range in
Kansas
Illinois
San Francisco
Virginia
nursing homes were not surveyed, it is only possi-
percent of all homes is 74.8-87.6 percent.
Denver
Kansas City
North Carolina
ble to present information or to make the national
As in all sampling surveys, certain difficulties
Kentucky
Arizona
estimates based on the 288 homes in the sample. In
were encountered in the execution of the sampling
New Mexico
Oklahoma
Tennessee
Arkansas
Texas
Georgia S.
Carolina
other words, the 288 homes have to represent all
plan. For example as mentioned previously, 9 of
7,526 homes. The estimates made from a sample
the 16 homes were not surveyed either because they
IV
Mississippi
Atlanta
survey will of course not be quite the same as if a
were closed or were no longer participating in the
complete census had been done. Statisticians refer
Medicare/Medicaid programs when the surveyors
VI
Dallas
Alabama
to the difference between the estimate which is
went into the field. In other cases, Medicare/
Florida
Louisiana
made on the basis of a sample and that which
Medicaid patients were not available for inter-
would be obtained from a complete census as the
views. To overcome these and other difficulties.
"standard error of the estimate". The relative
estimation procedures were introduced into the
standard error of an estimate is obtained through
data during the analysis stage. Essentially, the es-
a mathematical procedure in which the standard
timating procedures used corrected for "nonre-
error of an estimate is divided by the estimate itself
sponse". They included correcting for missing data
Figure 2
and is then expressed as a percent of an estimate.
when (a) Homes in the sampling frame were not
The chances are about 68 out of 100 that an esti-
surveyed; (b) when Medicare/Medicaid patients
Regional Distribution of 288 Facilities Surveyed
mate from the sample would differ from the com-
were not available; (c) when particular forms
plete census by less than the standard error. The
were missing; and (d) when individual question-
chances are about 95 out of 100 that the difference
naire items were incomplete. The technical details
would be less than twice the standard error and
of the estimation procedures are explained in ap-
selected if it were on the list whose bed-size
Selection of Residents
category was 100 beds or more.
about 99 out of 100 that it would be less than 21/2
pendix A along with the formulas employed.
One of the aims of the survey was to determine
times as large. The following table 1 illustrates
These procedures were used to ensure that homes
the status of nursing home residents. Since it was
this estimation procedure and what it means in
selected in the sample in these three bed-size cate-
not feasible to obtain detailed information about
interpreting the data in this report.
METHODS AND PROCEDURES
gories were represented in the same proportion
all of the residents in the homes selected for study,
The Study Team
as they are among all 7,526 skilled nursing homes.
it was necessary to institute procedures for select-
These procedures resulted in the selection of 354
ing a sample of residents. Designers of the study
Table 1.-Number of facilities classified according to whether pharmacist
Fifteen study teams of DHEW employees were
homes. Because of time, staff, and money con-
felt that because of time constraints it would not
provides written comments concerning review to the medical director
used to collect the survey data. Each team was com-
straints the 354 homes were reduced to 304 homes.
be feasible to obtain reliable information on any
Written comments provided to medical director
posed of a physician, nurse, administrator, nutri-
Random selection procedures were again applied
more than 15 patients in a home. The following
tionist, pharmacist, physical therapist, fire safety
to each of 354 homes to eliminate 50 homes. In
procedures were used to obtain the sample patients.
Relative
Count
Percent
standard
engineer, and a social worker. Each of the 10
spite of all of the precautions taken to ensure
When arriving at a home, surveyors obtained a
error
DHEW regions supplied 1 team, the remaining 5
that this sampling would be as accurate as possible,
roster of current residents who were being reim-
Yes
teams were staffed from Public Health Service
it was found when going into the field that 16
bursed through the Medicare/Medicaid programs.
1,239
18.8
0.18
No
5,352
81.2
.04
Headquarters. Fifteen additional health profes-
homes were either no longer participating in the
Random start selection procedures of the same
Total
Medicare/Medicaid program or did not have
type as described in the sixth step of the nursing
6,591
100.0
sionals were also selected from headquarters to
patients that could be included for study. This re-
home sampling procedures were then used to
Unknown
serve as replacements in case of absences of mem-
1,301
duced the sample to 288 homes.
select the sample Medicare/Medicaid residents.
bers of the regular teams.
7
6
Selection of Team Members
certained, 1- to 3-day intensive training programs
determine if patients were properly placed in the
ice in the years 1965-69. During these workshops
Public Health Service Headquarters and the 10
were conducted for the campaign survey. The sur-
facility.
researchers and those delivering and monitoring
DHEW regional offices asked for volunteers from
vey purpose, format, and survey research method-
During the training sessions, extensive instruc-
care attempted to develop a uniform system of
the 8 disciplines outlined above to serve as sur-
ology were made explicit through comprehensive
tion was provided to the surveyors on their own
patient assessment by combining data systems in
lectures and discussions.
veyors. The credentials of the volunteers were pre-
duties and responsibilities during the survey pe-
operation at the time. It became evident, however,
sented to the study directors. The qualifications of
The orientation emphasized that the campaign's
riod. Each discipline was given special instruc-
that the problem was more complex than a mere
potential surveyors were then individually re-
broad goal was to upgrade nursing home services,
tions in order to complete their portion( of the
interdigitation of terminology because of differ-
viewed to determine whether they met special cri-
SO it was deemed necessary to assess carefully and
survey forms. Content of the survey instruments
ences among the systems in scope, structure, type
teria established by the researchers.
objectively the current status and level of nurs-
were discussed item by item to ensure that there
of scale or measurement, and methods of applica-
Priority in selection of team members were given
ing home care. It was conveyed that baseline data
was comparable understanding of all survey items.
tion. It became apparent that a research approach
to candidates having the following qualifications:
were to be obtained to identify needs, develop pro-
In addition, considerable time was spent in the
was necessary. A collaborative effort was then
grams to meet those needs, and measure the over-
training sessions in the discussion of the survey
undertaken by four research groups to develop a
Health status and physical stamina that per-
all success of the initiatives undertaken.
research methodology, including such topics as
patient assessment system, based on their own and
mit a rigorous travel schedule.
Work experience in nursing home standards
It was emphasized that as a data collection tool
survey sampling and survey techniques.
others' experience, that would be useful for a va-
formulation, survey and certification proce-
the survey process must be utilized in a scientifi-
riety of purposes and that could be recommended
dures and standards enforcement.
cally valid manner. For this reason, steps were
Recent clinical or work experience in a health
SURVEY INSTRUMENTS
for general use in the long-term care field. The
taken in accordance with established statistical
four research groups included Case Western Re-
field closely related to or associated with the
and research principles to eliminate biases which
Content of the Instruments
serve University Medical School; Harvard Uni-
nursing home fields of practice.
Personal qualification-demonstrated high
might otherwise destroy the integrity of surveys.
In general, the forms were designed to measure
versity's Center for Community Health and Medi-
standards of performance, and an ability to
All visits were unannounced to obtain a profile of
the cost and quality of care rendered to include
cal Care; Johns Hopkins University, School of
work well with others, an objective attitude,
the home's normal operations. For this reason
the physical, nutritional, rehabilitative, and men-
Hygiene and Public Health, and Syracuse Uni-
and sound judgment.
only, a strictly limited number of people in the
tal health status of the recipients of care.
versity Research Corp. Developmental activities
Special criteria were established for each disci-
Nation knew the identity of a home to be sur-
Four basic instruments were used to collect
of the four groups have included conceptualiza-
pline. For example, the criteria for physicians were
veyed until the day of the visit. Homes to be sur-
data about the home:
tion and construction of the patient assessment
as follows:
veyed were selected randomly on a regional basis
form used in this survey. Prior to use in this sur-
1. Identifying form-included basic character-
Educational Background:
to attain the number acceptable for nationally rep-
istics of the home such as bed size.
vey, the instrument had been field tested for fea-
resentative data.
2. Financial form-used to assess the costs of
sibility, reliability, and usefulness and proved to
Graduation from an accredited medical school.
Residency training in geriatrics, internal med-
It was essential that the purpose of the cam-
providing care.
be a successful instrument.
icine, or family practice preferred.
paign surveys be carefully distinguished from sur-
3. Fire safety form-measures the conformance
Other instruments.-To evaluate the services of
of facilities with established safety and fire
veys conducted for the purpose of certifying
skilled nursing facilities (SNFs), it was neces-
Knowledge and Experience:
standards.
Knowledge of medical audit and utilization
homes for participation in the Medicare and Medi-
4. Facility specific form-consists of the sec-
sary to identify basic measurable elements com-
review.
caid programs. That is, the campaign surveys
tions on management, patient care policies,
mon to all facilities. After considerable deliber-
Recent clinical experience in geriatrics, chronic
nursing, rehabilitation, pharmaceutical, nu-
ation it soon became clear that the requirements
were to be conducted solely as a data collection
illness, or rehabilitation preferred but not
trition and dietetics, and psychosocial fac-
contained in the conditions of participation for
process with no formal relation to the certification
mandatory.
tors.
SNFs in the Medicare and Medicaid programs
procedure under Titles XVIII and XIX.
Two basic forms were used to collect data about
As a further example, nurses were selected on
could serve as a nucleus for developing survey
The central tool of the surveyor was considered
the patient:
the basis of their educational background and ex-
perience, such as:
to be his or her professional training and expe-
1. Patient assessment form.-This instrument
questions since these requirements represent basic
describes the individual patient at the time
standards of service. In this respect only, the sur-
rience, since the questions on the various forms
of the survey. Data are provided about a pa-
vey questions bear resemblance to the survey and
Current license to practice in a State as a regis-
were drawn from the basic tenets of the several
tient's status from several perspectives: his
certification process for SNF's from which it was
tered nurse.
disciplines represented on the teams. In the final
physical function, his impairments, his medi-
divorced. Other questions on generally accepted
Advanced education or experience in adminis-
cal risk status, and his sociodemographic sta-
tration, supervision, geriatrics, or rehabilita-
analysis the surveyor's common sense, courtesy,
service and practice standards were incorporated
tus.
tion.
professional expertise, and initiative were consid-
2. Patient specific form.-This form describes
and an initial set of survey questions were de-
Knowledge and Experience:
ered invaluable contributions.
the care being provided to the patient and
veloped. After undergoing field tests and at least
Emphasis in this health care survey of a
includes: patient care policies, medical care
four different reviews by qualified Federal per-
Experience in nursing service administration,
including diagnosis, nursing care, rehabili-
randomly selected national sample of nursing
sonnel in each field of practice, a final set of ques-
supervision, or ward management, and
tation, pharmaceutical, nutrition and die-
Experience in geriatrics and rehabilitation
tions were developed, approved, and used for the
homes was placed upon assessment of the quality
tetics, and psychosocial aspects of care.
nursing.
survey.
of care (health, nutritional, and psychosocial) in
Orientation and Training of Team Members
relation to costs as they affect the provider, con-
How Survey Instruments Were Developed
SURVEY PROCEDURES
sumer, Federal Government, and the evaluation of
Patient assessment form.-The patient assess-
After the manpower requirements for the na-
safety and environmental factors. A patient classi-
ment form is the outgrowth of a series of work-
Since the survey was intended to provide infor-
tional sample survey of nursing homes were as-
fication assessment tool, for example, was used to
shops sponsored by the U.S. Public Health Serv-
mation about the normal operations of sampled
8
9
homes, the survey team arrived unannounced. The
and Medicaid patients. Using the forms and pro-
CHAPTER 3
administrator on the team usually acted as the
cedures given to him, he randomly selected the
team leader. On arrival at the home, he introduced
sample patients.
himself and asked to speak to the home's adminis-
Individual team members then proceeded to ob-
trator. (If the administrator was not at the home,
tain the information for their portion of the sur-
he asked to speak to the person in charge.) The
purpose of the survey was explained and a letter of
vey instruments. These data were collected by di-
introduction from the Under Secretary of DHEW
rect observation of the operation of the facility,
Summary of Findings and Implications
was presented. In describing the survey, both the
discussions with facility staff, review of records,
team leader and the letter of introduction stressed
etc.
(a) The research nature of the survey; (b) the as-
Upon completion of the data collection over a
surance that the survey was in no way related to
period of 8-16 hours (1-2 days) the team reassem-
The population characteristics of 283,915 pa-
Slightly more than two-thirds (68 percent or 193,-
certification surveys for participation in the Medi-
bled. The facility administrator and the staff were
tients in skilled nursing facilities are changing-
137) needed assistance with their toileting.
asked for their suggestions and recommendations
predominantly still an elderly population but one
Approximately half of all patients were incon-
care/Medicaid program; and (c) the assurance
in which the proportion of residents under 65 years
that all data were confidential and that homes and
for DHEW programs which would meet their
tinent of either urine (54.7 percent) or feces (50.1
of age is 22 percent (62,886). These individuals are
patients in the homes would be identified by num-
needs. These recommendations were recorded. Be-
percent). Over 5 percent had either an indwelling
primarily those who are mentally retarded or de-
ber only.
fore leaving the nursing home, the team leader
urinary catheter or an external device or ostomy
velopmentally disabled. The increased attention
At the conclusion of this introductory session,
checked to determine if all team members had fully
for bladder drainage.
being given to the latter requires study of the
the team leader then obtained the list of Medicare
completed their forms.
The long-term patient with limited mobility is
special needs of these individuals and their appro-
prone to have pressure sores. A relatively low per-
priate placement.
The usual occupations in which the patient is en-
cent (9.2) of patients in this study was found to
gaged or was engaged for the major part of his
have bedsores, which is surprising in view of the
employment were skilled, semiskilled, and un-
large percent of incontinent patients.
skilled work. About 8 percent had been engaged in
As to their orientation and state of awareness,
professional, technical, or managerial activities.
over half of the patients studied had difficulty in
Information on family income of skilled nurs-
their awareness of their situation in respect to
ing facility patients indicates the extent of their
time, place, and self-identification. One out of
limited financial resources. It was found that 67.3
every seven of the patients was not aware of the
percent had less than $3,000 family income or no
environment or was comatose.
income at all.
The majority of patients, i.e., 70.4 percent, had
The survey did not include intermediate care
sight impairments, including 2.6 percent that were
facilities (ICFs) where a larger number of men-
blind and 50.7 percent who wore corrective lenses.
tally retarded and developmentally disabled are
Hearing and speech impairments were found in
found. This year's March 18 deadline requiring the
32.9 and 32 percent, respectively.
survey/certification of the intermediate care fa-
An age differential became evident in the diag-
cilities has highlighted the importance of address-
nostic profile. Two out of 3 of those under 65 had
ing the needs for controlled health and safety
neurological diseases; 1 in 4, mental retardation;
supervision of shelter and residential facilities.
and 1 in 5 had a neurosis or psychosis. For 2 out of
The Department is exploring the need to under-
3 patients 65 and over, the primary diagnoses
take a survey of ICFs.
were cardiovascular and cerebrovascular disease,
senility, and accidents.
Health Care Needs of Patients and Residents
In ascertaining the dental health status of 210,-
The high degree of dependency of patients on
411 patients, it was found that only 8.1 percent
the nursing staff for activities of daily living
had no missing teeth. Edentulousness with den-
raises important questions for consideration. It
tures accounted for 46.8 percent of the patients
was found, for example, that 93.9 percent (263,-
studied. Seven percent had some teeth missing,
551) required assistance with bathing. About 72
but a restoration compensated for the loss. The
percent (202,000) required the services of another
remaining 38.1 percent of the patients required
person when dressing. Those who required as-
teeth replaced, including full dentures, but had
sistance in order to eat amounted to 50.1 percent.
none.
10
11
Nutritional Needs
Physician Services
nursing facilities needed specialized rehabilitative
made to determine the body of knowledge and
The nutritional requirements of the aged are
A determination of physician involvement as
services that they were not receiving, e.g., 47.9 per-
preparation needed by administrators of nursing
the same as for other adults, although they need
cent needed physical therapy, 35 percent needed
homes. There are implications that State nursing
measured by a review of the patient's total program
more proteins and fewer carbohydrates. Also, the
of care during a visit of at least every 30 days was
occupational therapy, and 13 percent needed
home licensure programs are licensing individuals
fact that almost half were edentulous and had
speech therapy. State surveyors need to become
who are ineffective administrators. It is recom-
most difficult to assess. The records for 4 out of 5
dentures and over a third required teeth to be re-
more cognizant of the need for these services and
mended that a review of nursing home administra-
patients did show a physician's signature at least
placed but had no dentures, indicates that food
health personnel, particularly physicians and
tor licensure procedures be undertaken to deter-
every 30 days in 4 months prior to the survey. The
preparation should be selected from basic food
nurses need to be acutely aware of the importance
mine what statutory or regulatory changes are
proportion was higher, i.e., 9 out of 10, for those
groups due to possible chewing difficulty. All too
of ordering and seeing that they are provided. An
needed to assure that only fully qualified individ-
in the facility less than 4 months. About 9 out of
often the edentulous patient is given gruel instead
underlying issue is the slow and inadequate reim-
uals are licensed.
10 patients are seen by their physician during a
of a nutritionally balanced diet.
bursement of rehabilitative services while in
Evaluation of the fiscal management aspect of
visit to the institution, and in 1 in 5 cases, the phys-
About 4 of 10 patient care plans showed perti-
others abuse of the program was apparent.
the survey was directed at finding data to base
ician sees the patient, but does not review the care
national estimates of the cost of care in a skilled
nent information about diet and dietetic problems.
plan. In 3 to 4 percent of patients studied, the
Menus were planned in writing for 89.3 percent of
nursing facility SO that such data could be related
physician reviews the care plan, but does not see
Other Health Professional Involvement
to a cost-of-care index. The lack of uniform cost
the patients in the sample. There were 51,666 pa-
the patient.
tients who refused more than half of the meal
Reference is made frequently to the high turn-
accounting procedures presented the major diffi-
Survey physicians reported patients' records as
over of health personnel, particularly RNs, LPNs,
served them. Only 27 percent (1,530) were offered
culty in obtaining valid and reliable fiscal data.
"incomplete", "mixedup," "not signed". This raises
and aides in nursing homes. Yet what provision is
appropriate substitutes. Approximately 1 out of
Under Public Law 92-603, section 249 such proce-
a question about the validity of using a record re-
made for retirement plans, fringe benefits compa-
5 facilities had a more than 14-hour span between
dures will be mandated by July 1976. It is recom-
view as a source of information on nursing home
rable to hospitals, and opportunities for inservice
mended that research be undertaken to determine
a substantial evening meal and breakfast. There
patients. The over-reliance on the recording of pri-
and continuing education The need for technical
the relationship of the costs of nursing care to the
was no documented evidence in 28 percent of the
mary and secondary diagnoses often did not reflect
facilities that bedtime nourishments were routinely
assistance for all levels of personnel is paramount,
services provided and thus identify the differences
the reason for continued care. Attending phys-
offered to patients to the extent medically possible.
particularly training tools such as self-instruc-
between SNF care and ICF care. Further, cost
icians under-reported many impairments such
tional multi-media training modules.
hypotheses need to be tested concerning the type
as loss of sight, hearing, amputations, etc., as
of control and ownership of nursing homes, the
Pharmaceutical Services
well as senility or chronic brain syndrome. An im-
Administrative and Fiscal Management
size and the major source of cost reimbursement.
Survey pharmacists found that most skilled
portant finding was that one-third of the diagnoses
recorded subsequent to admission may be directly
In evaluating the administrative management
nursing facilities are well on their way toward
linked to the quality of care provided in the nurs-
of skilled nursing facilities the survey team looked
Health and Safety of the Environment
achieving the capacity to render pharmaceutical
services in accordance with accepted professional
ing home, e.g. decubitus ulcers, genito-urinary and
to see how well the management function was
Specifically in this area surveyors looked to see
respiratory infections, and fractures. Laboratory
being performed in relation to the governing
how well SNFs met the requirements of the 1967
practices. Every effort should be made to incorpo-
services were inadequately used by physicians.
body, the nursing home administrator, personnel
Life Safety Code published by the National Fire
rate a drug ordering system in the facility whereby
the pharmacist works directly from a physician's
Over-medication may be attributed to the phys-
management, and outside resources.
Protection Association and a statutory require-
order form. Further, it is important that the at-
ician not discontinuing orders no longer needed.
It was found that the governing body frequent-
ment of Medicare and Medicaid regulations. Each
An important implication of the findings is that
ly does not discharge its obligations in an effec-
facility was evaluated as a whole in addition to
tending physician countersign all verbal orders
quality assessment by physicians requires careful
tive manner. Policies, usually in policy manuals,
reviewing each standard, thus the design features
within a maximum of 48 hours. Research is also
examination of the patients, including laboratory
were often not implemented. Patient care policies
of a facility were taken into account. It was found
needed that would objectively identify the nature,
tests and should not be limited to record review.
were found to lack the input from health care
that few facilities met all Life Safety Code require-
extent, and frequency of clinically significant drug
professionals other than physicians and nurses.
therapy problems in long-term care facilities.
Survey physicians found that some long-stay
ments, that is, 6.1 percent. Sixty-six percent had
There is a need to promote the development of
patients no longer were in need of skilled nursing
There was a lack of coordination between person-
1-9 requirements that were not met. Most im-
care. This should have been identified by periodic
nel management practices and personnel re-
portant, many of these requirements could be met
pharmaceutical service committees in skilled nurs-
ing facilities. The issue of appropriate reimburse-
medical review. There is a dire need for greater
sources. A critical finding was the lack of oppor-
with little or no additional expense, e.g., illumina-
physician involvement and for assessment tools
tunities for career development and continuing
tion of exit signs. One-fourth of the facilities were
ment of the pharmacist needs to be studied.
that confirm that services needed are provided.
education. Outside resources were often not uti-
of fire resistive construction and one-fourth of pro-
This is such an important complex area that the
lized and the findings and recommendations of
tected wood frame construction. The remaining
Office of Nursing Home Affairs is undertaking an
consultants not followed.
Rehabilitative Services
facilities were primarily of protected noncombusti-
indepth analysis of drugs ordered for patients
The fact that governing bodies of a large number
ble construction, protected ordinary construction,
classified as cathartics, analgesics, and antipyre-
These services included physical therapy, oc-
of SNFs do not carry out their duties and responsi-
or ordinary construction.
tics, and tranquilizers. This separate analysis will
cupational therapy, and speech therapy. The sur-
bilities effectively inhibits the delivery of high
State surveyors need to become qualified in fire
be reported in a later monograph.
vey findings showed that many patients in skilled
quality of care. It is recommended that a study be
safety regulations to make valid judgments par-
12
13
ticularly with respect to recommending waivers.
social work, occupational therapy, and therapeu-
and should be redesigned to assess patient care in
3. A complete analysis of the entire fiscal ap-
Nursing home administrators also need this
tic recreation leadership to monitor discharge
long-term care facilities. There must be a shift
proach of reimbursement of facilities for services
information.
planning, transfer arrangements, develop pro-
from the facility's capability to provide services
provided including uniform cost accounting pro-
In addition, regional validation surveys need to
grams in facilities, to identify problems, and de-
to the patients and residents to assessing the serv-
cedures, rate setting, provider/ownership arrange-
be increased to assure that State fire authorities are
velop therapeutic problems. The Department is
ices actually being provided to them.
ments, rentals, and so forth. Well-conceived
accurately assessing compliance with the Life
exploring the need to revise Federal regulations to
The survey findings document that paper com-
experiments by States need to be encouraged.
Safety Code.
emphasize implementation of policies and sound
pliance alone provides insufficient evidence to show
Exploration is also needed of reimbursement
programs, and provide staff for technical assist-
that quality care is being provided to patients in
approaches based on provider's ability to maintain
ance.
a safe environment. A high percent of skilled
patients and residents mobile and behaviorally
Social Services
The necessity for further research concerning
nursing homes showed that the governing bodies
motivated. The Department has several efforts un-
In assessing the importance of psychosocial serv-
psychosocial treatment methodologies, such as
of those institutions did not adopt their own pol-
derway which focus on these problems.
ices to assist in maintaining patient physical, social,
reality-orientation techniques is evidenced by the
icies, rules, and regulations nor did they imple-
4. Alternatives to institutional care such as
and mental health, it was found that SNF patients,
findings.
ment them. Recommendations of utilization re-
home health care and day care must be given the
as a whole, represent patients, whose needs tax
view committees were not acted upon by one out of
highest priority. Steps need to be taken immedi-
facilities for the highest level of staff skill and
five facilities. Further, recommendations not acted
ately to explore ways in which such alternatives
Training
understanding.
upon by governing bodies of facilities included
can be utilized and such services increased. The
Many of these patients suffer from complex
Survey findings identified and reinforced the
those of pharmaceutical committees (42 percent),
Department is supporting several demonstration
physical and emotional problems. The factor of
need for continuing and accelerated training ac-
patient care policies (27 percent), and infection
experiments under section 222 (Public Law 92-
longevity combined with diminution of actual
tivities for all disciplines and levels of provider
control (44 percent).
603) to determine alternative approaches to in-
physical capabilities is often a source of deep frus-
personnel, both on a single-discipline and on a
It is difficult to assess the quality of medical care
stitutional care and costs of services provided un-
tration and patient embarrassment.
multi-discipline basis in order to meet the needs
that patients are receiving on the basis of record
der different combinations of home health care,
Findings indicate that in a number of facilities,
of the elderly. The implicit scope of need was
review alone. The survey documents this finding.
day care, and intermediate care.
efforts were made to provide daily activity at each
found to require the concerted efforts of the Fed-
For example, a patient may have a diagnosis, a
The milestone legislation Public Law 93-641,
patient's appropriate level of functioning irre-
eral Government, States, professional, and pro-
physician visit at least every 30 days, a monthly
"National Health Planning and Resources
spective of physical condition. However, in the
vider organizations, health educators, and con-
review of his care and still show evidences of poor
Development Act of 1974," is being studied very
greater number of facilities, there was very lim-
sumers.
quality medical care. Whether this is due to an
erroneous diagnosis or an overlooked problem, or
carefully by the Department particularly with re-
ited understanding of the importance of psycho-
Each of the study teams in the eight disciplines
ference to alternatives to institutional care.
social services. The goal of enriching the daily en-
concerned with health care delivery noted an ab-
signing of patients' records 6 months in advance
vironment of residents was frequently cited in the
sence of orientation of personnel in rehabilitative
warrants further study.
The survey report provides documentation to
policies but rarely implemented. Recording of the
concepts and psychosocial needs of elderly pa-
The Office of Nursing Home Affairs (ONHA)
show that deterioration of patients' conditions can
patient's social and emotional status, interests,
tients in the facilities they studied. An additional
with the Bureau of Quality Assurance of the
be linked directly to institutionalization and pro-
and adjustments was either incomplete, or if
concern of all disciplines included that of the
Health Services Administration, Social Security
longed bed rest. This was true for 2 out of 5
documented, was rarely readily available for
psychosocial impact on the patient resulting from
Administration, and Social and Rehabilitation
patients under 65 years of age and for 1 out of 3
staff use.
translocation from home or hospital and the sub-
Service is undertaking a complete review of the
patients over 65. Further, one-third of the diag-
Data indicate that most of the facilities sur-
sequent institutionalization in a long-term care
total survey/certification process. The Depart-
noses recorded subsequent to admission can be
veyed were in the process of developing required
facility. The need for increased personnel capabil-
ment of Health, Education, and Welfare, region
linked directly to the quality of care provided in
patient care plans. However, achievement of a
ities for effectively dealing with resultant patient
IV, is now training State surveyors and nursing
the nursing home. Physical and emotional
regular review of patient status, evaluation of
behaviors was also evident.
the kinds of care being given, and documentation
Implications of the findings include the need
home providers to use a patient assessment ap-
rehabilitation or maintaining patients at a given
for research and the subsequent identification of
proach both as a management tool and as an eval-
level is stated as a goal in policies of nursing homes
by way of progress notes in the patient record
was in an initial stage in most facilities. Relative-
multiple sources of public and private funding in
ulation tool. The Department is exploring ways in
but seldom achieved.
ly few facilities had the trained rehabilitative or
order to spread the financial burden of training
which a patient assessment approach can be used
5. Training of health personnel at all levels
social services staff with skills needed to achieve
in the survey/certification process.
must be intensified and continued on a national
equitably. Combined nationwide resources are re-
these goals for the total patient population.
quired from all concerned in order to respond to
2. Nationwide training, credentialing, certifica-
basis. Physicians, nurses, and other health per-
As the importance of the psychosocial dimen-
the multitude of continuing provider training
tion, and licensure of all State surveyors must be
sonnel need to be attracted to long-term care
sions of patient care are recognized, the corres-
achieved as rapidly as possible. A valid and reli-
facilities. Training, career mobility, and other
needs that have been identified.
ponding level and quality of such care in SNFs
able method of survey assessment and quality con-
fringe benefits need to be considered. States and
must be raised. The social and emotional needs of
trol, as an integral part of the survey/certification
providers must assume the major responsibilities
NEEDED ACTION
the patient must receive equal attention with that
process depends on the judgments of the trained
for these efforts.
given to physical and medical aspects.
1. A total review of the survey/certification
surveyors. The Bureau of Quality Assurance
In summary, the findings of the Department's
State and local agencies need to identify ways
process. Present survey items reflect the regula-
working with the Office of Nursing Home Affairs
Long-Term Care Survey have provided a baseline
in which their personnel can receive the necessary
tions which, in turn, are based on a hospital model
is addressing these problems.
for a program for action through a working part-
15
14
nership of the surveyors, the providers, consum-
plementation of a national strategy for long-term
ers, and associations working together with the
care for older Americans, the mentally retarded,
CHAPTER 4
Federal and State governments. Thus this re-
and developmentally disabled who require quality
port provides a basis for the development and im-
care in a safe environment.
Characteristics of
Facilities and Patients
The central focus of the national survey of
to provide but who do require care above the level
skilled nursing facilities was the patient. It is
of room and board.
recognized that the long-term care patients differs
The distribution of homes participating in Medi-
from patients in acute care settings in terms of
care and Medicaid programs follows. ICFs were
their physical, functional, and psychosocial con-
not included in the survey.
ditions and needs. To acquire a thorough knowl-
edge of the requirements for upgrading care in
Skilled nursing facilities
7, 526
long-term facilities basic information on the
Medicare only
(301)
characteristics of the patients served was essen-
Medicaid only
(3,280)
tial. A profile of patients could provide an under-
Both Medicare and Medicaid
(3,945)
standing of the factors affecting the needs and
Intermediate care facilities
9,000
demands for care. It could serve as a basis for
decisions on ways to effect change and improve-
Total
16,526
ments in the delivery of patient care services and a
continuing meaningful Federal role in long-term
Facilities in the Study
care.
The sample survey of skilled nursing facilities
resulted in a national sample for study purposes
Number of Facilities
of 6,591 facilities participating in the Medicare
National estimates, as of July 1974, of the num-
and Medicaid programs, about 87.6 percent of all
ber of nursing homes, defined as facilities which
participating facilities. By bed size, the sample
provide some level of nursing care, participating
homes comprised close to 20 percent with less than
in the Medicare (Title XVIII) and Medicaid
50 beds and approximately 40 percent of homes in
(Title XIX) programs was 16,526 (1). About 7,526
each stratum 50-99 beds and 100 beds or more as
homes or 45 percent were certified as skilled
shown in table 2.
nursing facilities (SNFs) for patients who re-
The stratification of the sample homes by type
quire skilled nursing and rehabilitation services on
of control or ownership is shown in table 3. As
a daily basis to help them achieve their optimal
noted, close to 73 percent of SNFs in the survey
level of functioning. Among the 7,526 SNFs, 3,945
are proprietary homes and 27 percent are under
or 52 percent had multiple certification as Medi-
voluntary nonprofit, government, and religious
care and Medicaid providers. Of 3,581 SNFs cer-
auspices. This stratification reflects the national
tified as single providers, 90 percent were Med-
picture of ownership of nursing homes when all
icaid facilities only.
type of nonprofit homes are grouped together,
More than half of all participating homes, about
In the 1973-74 sample survey of nursing homes of
9,000 or 54 percent are intermediate care facilities
the National Center for Health Statistics, provi-
(ICFs) participating in the Medicaid program
sional data revealed that 73 percent of nursing
They provide health related care and services to
homes in the Nation were operated under proprie-
individuals who do not require the degree of care
tary auspices and 27 percent under nonprofit aus-
16
and treatment that a hospital or SNF is designed
pices (2). The sample size probably does not per-
17
Table 2.-Number and percent of skilled nursing facilities in the national
and Medicaid programs, termination of program
Table 4.-Number and percent distribution of patients in skilled nursing facilities
Table 6.-Number and percent of male patients by race
by age
sample survey by bed size
benefits, disallowance of reimbursement claims, as
Male patients
Bed size
Percent
well as, resident turnover or admissions and dis-
Race(s)
Age group(s)
Number
Percent
Number
Number
Percent
charges preclude the ready availability of mutu-
ally exclusive and definitive data.
283,915
100.0
All races
Total
6,591
100.0
Total
76,845
100.0
In July 1974 there were approximately 30 mil-
4,838
1.7
White
Under 20
66,691
86.8
Less than 50 beds
1,239
18.8
lion beneficiaries enrolled in the Medicare and Med-
20 64
58,048
20.4
Negro/black
7,417
9.6
50 to 99 beds
2,675
40.6
15,139
5.3
Spanish American
100 beds or over
65 to 69
1,899
2.5
2,677
40.6
icaid programs who qualified as potential patients
28,384
10.0
Asian American
120
.2
70 to 74
35,954
12.7
Other
718
.9
in the 7,526 participating skilled nursing facilities.
75 to 79
80 to 84
52,984
18.7
The national sample of Medicare and Medicaid
56,769
20.0
85 to 89
90 and over
31,799
11.2
beneficiaries surveyed in the 6,591 facilities re-
Table 3.-Number and percent of skilled nursing facilities in the national
ported in this survey resulted in a population of
Table 7.-Number and percent of female patients by race
sample survey by type of control
283,914 patients. Information on the demographic
Type of control
Number
Percent
and economic characteristics of these patients and
Sex
Female patients
their educational and employment experience is
Race(s)
Number
Percent
Total
6,591
100.0
presented below.
Women outnumbered men in the skilled nursing
facilities by more than 2 to 1. Only 27.1 percent of
All races
207,067
100.0
Proprietary
4,803
72.9
Voluntary nonprofit
711
10.8
the nursing home patients were male, compared
White
190,136
91.8
Government
465
7.0
DEMOGRAPHIC CHARACTERISTICS
with 72.9 percent female. The predominance of the
Negro/black
12,535
6.1
Religious
612
9.3
female patient is clearly shown within each racial
Spanish American
2,520
1.2
The most outstanding demographic characteris-
Asian American
820
.4
classification as well. (See table 5.)
Other
1,056
.5
tics of the patients surveyed in the 6,591 skilled
nursing facilities described a survey population
mit valid estimates of those homes classified as
which in general is not unlike that of nursing home
Race
nonprofit because of their small number in the
residents as revealed in previous studies (4) They
Slightly less than 10 percent of the patients in-
sample. As a matter of interest, it appears from
present the classic profile of nursing home patients
cluded in the SNF survey represented minority
the white population (5). If the racial distribu-
the crude data that proprietary owners may tend
who are very aged, predominately female, unmar-
tion of SNF patients is related to their distribu-
groups. Included were the black, Spanish Ameri-
can, Asian American, and other racial groups. The
tion in the total population, there is a disparity
to have fewer small homes than nonprofit owners.
ried, and almost exclusively white.
in the utilization rates between the white and non-
The data suggest that about one-third of volun-
largest population of the nonwhite patients were
white races. From a cursory look at the data it
tary nonprofit, government and religious homes in
of the black race, 7 percent. Spanish Americans
Age
appears that the proportions are 0.14 and 0.10
the survey had 50 beds or less while one-sixth of
comprised 1.6 percent and Asian Americans 0.3
percent respectively (6). This does not take into
proprietary homes were under 50 beds.
Today, the primary focus of the skilled nursing
percent. The distribution of male and female pa-
account differences in morbidity, mortality and
facility is still the care of the elderly, although as
tients by race is shown in tables 6 and 7.
longevity of the two groups. These factors have
Number of Patients
a long-term care facility the SNF is a setting for
Previous studies of nursing home residents have
not been compared for this report.
the care of individuals with a wide array of chronic
tended to show a low utilization rate by other than
It has also been noted that the nonwhite popula-
In the 1973-74 National Center for Health Sta-
diseases and disabling conditions irrespective of
tion receive more health-related care outside the
tistics survey of nursing homes, there were 1,098,-
age. It is known that the population with develop-
institution or in the home than the white (7). This
500 residents in the Nation's 16,100 homes (3).
mental disabilities in nursing homes includes the
Table 5.-Number and percent of patients by sex and race
has led to the postulation by some that the in-
Data available at the time of survey indicate that
mentally retarded, persons afflicted with congenital
ability to pay for care and the availability of care
29 percent of all nursing home patients receive
heart disease, chronic renal disease, multiple scle-
Both sexes
Male total
Female total
at home or elsewhere may be factors influencing
total
skilled nursing care financed by Medicaid and 4
rosis, and other related conditions of relatively
Race(s)
Number
Percent
Number
Percent
Number
Percent
the inequality in the utilization of nursing homes
percent receive such care financed by Medicare.
younger patients.
by minorities and their lower proportion in com-
An estimate on this basis would yield a patient
Approximately 78 percent of all patients in
All races
283,912
100.0
76,845
27.1
207,067
73.0
parison to their numbers in the skilled nursing
population of 351,520 beneficiaries in skilled nurs-
SNF's were 65 years of age and over; they totaled
White
facilities.
256,827
90.5
66,691
23.5
190,136
67.0
ing facilities.
221,029. Almost 50 percent were 80 years of age
Negro/black
19,952
7.0
7,417
2.6
12,535
4.4
Spanish American
It is difficult to estimate the number of Medicare
4,419
1.6
1,899
.7
2,520
.9
or older. Patients in the eighth decade of life were
Asian American
940
.3
120
.0
820
.3
Marital Status
and Medicaid beneficiaries who are patients in
Other
the largest proportion of all ages. An additional
1,774
.6
718
.3
1,056
.4
skilled nursing facilities. The reporting system
The marital status of patients clearly depicts
11 percent were 90 years of age and over. For all
and patterns in certification and termination of
patients under age 65, the proportion was 22 per-
1 Uniform procedures were used in computations; there may be a minor difference
the higher survival rate for women in our society.
skilled nursing beds and facilities in the Medicare
together. between the sum total figure and the total obtained when the subtotals are added
Less than one out of every eight patients was
cent and the total number 62,886. (See table 4.)
1
18
19
married at the time of survey. The greatest number
skilled and unskilled services. As shown in table
Table 11.-Current employment status of patients in skilled nursing facilities
Table 13.-Number and percent of male patients by family income
did not have spouses. Most individuals (60.6 per-
cent) were widowed. A few persons had termi-
10, almost one-third of all patients were employed
as farmers, skilled service or clerical workers with
Patients
By male sex
Employment status
Percent
Family income totals
nated their marriages through separation or
number
Number
Percent
an additional one-fifth employed as unskilled la-
divorce. A sizable number (18.7 percent) of in-
borers. Homemakers accounted for slightly more
283,916
100.0
Total
All incomes
78,186
100.0
dividuals had never married (see table 8) and of
than one-fourth of all occupations. Nearly one-
183,190
64.5
these the higher proportion were also women.
seventh of patients had never been employed.
Retired
$15,000 or more
1,437
1.8
Never employed
87,292
30.8
$10,000 to $14,999
254
.3
11,413
4.0
Currently unemployed
$7,000 to $9,999
522
.7
Table 8.-Number and percent of patients by marital status
Currently employed
1,668
.6
Table year of schooling completed by patients in skilled nursing facilities
$5,000 to $6,999
2,009
2.6
353
.1
Sick leave
$3,000 to $4,999
6,141
7.8
Less than $3,000
46,417
59.4
Both sexes total
Male total 1
Female total
Patients
No income
21,406
27.4
Marital status
Years of schooling completed
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Total all groups
283,914
27.1
207,024
72.9
Total
The characteristically associated levels of edu-
Table 14.-Number and percent of female patients by family income
100.0
76,890
283,915
100.0
cational attainment, employment, and family in-
By female sex
Married
37,754
13.3
18,184
6.4
19,570
6.9
Less than 8
Widowed
84,559
171,812
60.6
come is not wholly applicable to SNF patients, be-
Family income totals
26,007
9.2
51.4
8
29.9
Number
Percent
145,804
Separated
62,781
5,567
2.0
2,200
.8
3,367
1 or more years high school
22.1
1.2
37,882
cause of their age; retired, unemployed, or never
Divorced
15,520
5.4
High school diploma
13.3
6,602
2.3
8,918
3.1
36,488
employed status; and the various factors influ-
All incomes
205,731
100.0
Single
53,261
18.7
8.4
10.3
High school (trade) diploma
12.8
23,896
29,365
8,173
One or more college
2.9
10,359
3.6
encing their family and economic situations which
$15,000 or more
588
.3
Baccalaureate degree
11,257
were not studied. However, it appears that patient
$10,000 to $14,999
878
.4
Advanced college degree
4.0
1 Uniform procedures were used in computations; there may be a minor difference
3,499
$7,000 to $9,999
1,232
.6
together. between the sum total figure and the total obtained when the subtotals are added
No schooling
1.2
28,917
and family financial resources are very limited.
$5,000 to $6,999
2,953
1.4
10.2
As presented in table 12, over 68 percent of all
$3,000 to $4,999
8,966
4.4
Less than $3,000
148,532
72.2
family income was less than $3,000 a year. An
No income
42,582
20.7
EDUCATIONAL AND ECONOMIC
CHARACTERISTICS
Table 10.-Usual occupation of patients in skilled nursing facilities
additional 22 percent of families had no income.
This indicates that 90 percent were below poverty
References
The education and employment experiences of
Patients
level.
Occupation
1. U.S. Department of Health, Education and Welfare,
the beneficiary population of skilled nursing fa-
Public Health Service, Office of Nursing Home Af-
cilities participating in the Medicare and Medi-
Number
Percent
fairs. Chart Booklet 1974 Regulations for Skilled
caid programs as well as their level of income pro-
Table 12.-Number and percent of patients by sex and family income
Nursing Facilities and Intermediate Care Facilities.
All
vides insight into the sociological factors affect-
283,915
100.0
November 1974, p. 2.
ing the utilization and the role of these facilities
Clerical, sales, craftsmen, foremen, etc.
91,204
2. U.S. Department of Health, Education, and Welfare,
32.0
Housewives
Both sexes
Male sex
Female sex
78,110
27.5
Public Health Service, National Center for Health
within the health care system.
Unskilled laborers
Family income totals
54,381
19.2
Number
Percent
Statistics. "1973-74 Nursing Home Survey," Monthly
Never employed
37,931
Number
Percent
Number
Percent
13.4
Professional, technical, managerial
Vital Statistics Report, Vol. 23, No. 6, Supplement.
21,493
7.6
Educational Attainment
Members of Armed Forces
796
.3
All incomes
283,917
100.0
78,186
27.6
205,731
72.4
September 5, 1974, p. 2.
3. Ibid., p. 2.
Data on the educational attainment of patients
4. National Center for Health Statistics. Measures of
Very few patients in skilled nursing homes were
$15,000 or more
2,025
.7
1,437
.5
588
.2
may well reflect their age, the social structure at
$10,000 to $14,999
1,132
4
254
.1
878
.3
Chronic Illness Among Residents of Nursing and
in the labor force. While close to 70 percent were
$7,000 to $9,999
1,754
6
522
.2
1,232
.4
Personal Care Homes. June-August 1969, Vital and
the time of their youth, the values placed on edu-
participants at some time, 64 percent were re-
$5,000 to $6,999
4,962
1.7
2,009
.7
2,953
1.0
Health Statistics, U.S. Series 12, No. 24 (HRA)
cation, and their educational opportunities. About
$3,000 to $4,999
15,107
5.4
6,141
2.2
8,966
3.2
74-1709 (Washington: Government Printing Office,
30 percent of all patients had less than 8 years of
tired. The fact that over 95 percent of patients
Less than $3,000
194,949
68.7
46,417
16.4
148,532
52.3
No income
63,988
22.5
21,406
7.5
42,582
15.0
May 1974), pp. 5-8.
schooling. An additional 22.1 percent had com-
were not employed and were not seeking employ-
5. Ibid., pp. 6-7.
ment is shown in table 11.
pleted 8 years. Less than 9 percent of all patients
6. U.S. Department of Commerce, Bureau of the Census.
Statistical Abstract of the United States 1974. 95th
had ever attended college. (See table 9.)
Annual Edition. (Washington, D.C.: U.S. Govern-
Family Income
ment Printing Office, 1974), p. 26.
It is not surprising that proportionately males
Occupation
7. National Center for Health Statistics: Home Care
Information on the family income of patients
tended to have slightly higher levels of family in-
for Persons 55 Years and Over: United States, July
The educational levels of patients are in turn re-
was also sought. Income is the sum of the dollar
come than females. This is particularly so for in-
1966-June 1968. Vital and Health Statistics, Series 10,
flected in their occupational patterns. Few pro-
amounts of money received by all members of the
come in the highest bracket, $15,000 and over.
No. 73. DHEW Pub. No. (HSM) 72-1062. Washington,
fessional workers are represented among skilled
family annually as wages or salary, net self-
However, distribution of income at all levels for
D.C.: U.S. Government Printing Office, July 1972.
nursing home patients. Their usual occupations
employment income, or other income from pen-
both sexes was similar in that the majority had
8. U.S. Department of Health, Education, and Welfare,
Health Resources Administration. Patient Classifica-
(8), defined as the occupation in which the pa-
sions, investments, public welfare, or assistance as
less than $3,000 family income with a substantial
tion for Long-Term Care: Users Manual. DHEW Pub.
tient is engaged or was engaged for the major part
defined for the 1970 census. Family refers to two
number receiving no income at all. (See tables 13
No. (HRA) 74-3107. (Washington, D.C.: U.S. Gov-
of his employment career, were in skilled, semi-
or more people related by blood, marriage, or
and 14.)
ernment Printing Office, December 1973), p. 30.
adoption, living together in the same household.
20
21
588-459 3
CHAPTER 5
Table 16.-Dressing ability of patients
Bathing
About 93.9 percent of all patients or 263,551 re-
Patients
Dressing ability
Number
Percent
quired assistance, either partial (60.2 percent) or
complete assistance (32.7 percent) with their bath.
Total
283,913
100.0
The latter group of 92,702 patients did not partici-
Health Status
pate to any extent as shown in table 15.
Dresses aided by person.
125,605
44.2
Dresses aided by person and device
4,760
1.7
Is dressed
72,206
25.4
Dresses without help
46,044
16.2
Dresses with aid of device
1,034
4
Is not dressed
34,264
12.1
Table 15.-Bathing ability of patients
The Nation's skilled nursing facility (SNF)
nursing home staff a picture of the functional
population of all ages has a variety of pathophys-
status of the patient that enables them to plan a
Patients
iologic conditions and problems commonly de-
Bathing ability
realistic program relative to the patient's needs
Number
Percent
scribed as accidental or developmental disabil-
for care.
Table 17.-Eating ability of patients
ities, chronic illnesses, and diseases of the aging.
283,912
100.0
The easily recognized components of nursing
Total
These conditions are usually associated with some
care in a skilled nursing facility are concerned with
43.6
Patients
123,815
Bathes aided by person
47,034
16.6
Eating ability
type of extent of impairment in the biological, be-
Bathes aided by person and device
Number
Percent
the bathing, dressing, feeding, and toileting of
92,702
32.7
havioral, and physiological capacities and per-
Is bathed
patients. They include assisting patients with
18,871
6.6
Bathes without help
Bathes self with aid of device
1,490
.5
Total
283,913
100.0
formance of individuals that are interrelated and
walking and transferring to wheelchairs or to
Feeds self aided by person.
93,267
32.8
interact with social and psychological changes in-
carry out prescribed special therapies. The admin-
Eats aided by person and device
3,006
1.1
cluding changes in mental health. For the pre-
Is spoon fed.
46,160
16.2
istration of drugs, care of catheters, bladder irriga-
2,533
is
9
dominantly aged population, there are varying
Is fed parenterally
tions and dressings of wounds are nursing func-
degrees of deterioration in all capacities that are
Dressing
Feeds self without help
133,377
47.0
Feeds self aided by device
3,635
1.3
tions. The responsibility of the nursing service to
Unknown
1,935
.7
cumulative. Each patient's condition was assessed
deal with pain and comfort, provide emotional
As measured in this survey, dressing is the com-
as part of the survey to determine his/her needs
and psychological support, identify adverse reac-
plex behavior of putting on, fastening, and taking
for care and the potential demand for services
tions to medications and treatments or altered pa-
off all items of clothing, braces, and artificial limbs
commensurate with these needs.
tient status and patterns of behavior are less
that are worn daily by the patient. Getting and re-
placing these items from closets and drawers is con-
Toileting
obvious. Many other functions and activities that
ACTIVITIES OF DAILY LIVING
contribute to quality care could be described.
sidered part of dressing. Approximately 72 per-
Toileting is the act of getting to and from the
In the absence of other in-house health profes-
cent of patients or more than 202,000 required the
toilet room for bowel and bladder functions, trans-
A readily available and objective method to de-
services of another individual when dressing.
sionals, the management, provision and continuity
ferring on and off the toilet, cleansing self after
termine the patient's requirements for basic care
About 17 percent dressed themselves unaided by
elimination and, arranging clothes. Slightly more
and dependency on the nursing home staff is to
of total care in skilled nursing facilities becomes
primarily the responsibility of the nursing service.
another. The remaining patients, about 12 percent,
than two-thirds (68 percent) of all patients, a
assess the varying degrees of ability he/she has in
The components of care may be assessed, directed,
were not dressed. These relationships are shown in
total of 193,137 needed assistance with their toi-
coping with the activities of daily living (ADL).
and supervised by professionals other than nurses.
table 16.
leting. The toilet room was not used by 82,968
Evaluation of the patient's usual performance in
bathing, dressing, eating, toileting, and mobility,
Their execution is most often delegated to the nurs-
patients (29.2 percent). (See table 18.)
as well as the patient's bladder and bowel func-
ing service, and care is carried out by the least
Eating
The four measures of self-function in patient's
tion; orientation as to time, place, and persons;
prepared members of the health team, the aides. A
activities of daily living, bathing, dressing, eat-
Eating concerns the process of getting food
communication of needs; and behavior are included
heavy load of responsibility for patient care co-
from a plate or receptacle into the mouth without
in this report. These activities serve as measures of
ordination and management is borne by the nurs-
regard to social niceties. The process requires co-
ing service administrator.
Table 18.-Toileting ability of patients
the patient's biological and psychosocial function-
ordination, tactile sense, and manipulative skill
ing in terms of his/her capacity to function alone
The varied and multiple functions and responsi-
in handling utensils. Patients were almost evenly
Patients
or require assistance of another person, mechani-
bilities assumed and carried out by the nursing
divided between those who required assistance of
Toileting ability
Number
Percent
cal aids or devices.
service in SNFs is reflected in the reports on each
some kind in order to eat (50.1 percent) and those
Viewed in their totality, these activities give the
who were able to eat unaided (48.3 percent).
Total
283,915
100.0
of the other services. The dimensions of nursing
care will be described in a separate monograph. A
About 2,500 patient were fed parenterally (0.9
73,061
25.7
Uses toilet without help
1 Katz, S., and others, "Studies of Illness in the Aged,
Uses toilet aided by device
17,717
6.3
The Index of ADL: A Standardized Measure of Biological
few aspects are highlighted in this report since
percent) and the eating ability of the remaining
Uses toilet aided by person.
73,155
25.8
and Psychosocial Function". Journal of American Medical
they are well defined areas of nursing responsi-
few was unknown (0.7 percent) as shown in table
Uses toilet aided by person and device
37,014
13.0
82,968
29.2
Does not use toilet room
Association. 185 914, 1963.
bility.
17.
22
23
ing, and toileting reveals that at least half of all
ble 19). The remaining patients, however, had
dependent in both functions. When patients had
personality characteristics. In appropriate behav-
patients are dependent upon the skilled nursing
bladder control difficulties. The majority (54.7
surgical openings of devices, they most often did
ior on this basis is described as passive, disruptive,
home staff for assistance in carrying out one or
percent) were incontinent of urine at least occa-
not care for themselves. This fact raises the ques-
and other acts detrimental to life, comfort and
more activity. Patients, as a whole, were least
sionally. About 5.7 percent of patients had either
tion of patients' potential for rehabilitation, an-
property. Patient behavior was assessed from staff
able to function independently and required as-
an indwelling catheter, an external device or an
other responsibility of the nursing home staff.
reports, recordings, and observation of patients'
sistance in bathing followed by dressing, toileting,
ostomy to compensate for their biological bladder
actions of this nature.
and eating. A small proportion of patients were
dysfunction.
Orientation and Behavior
For 58.4 percent of patients behavior was suit-
self-functioning by virtue of the use of special
About half of all patients had difficulty with
able to the environment although 41.1 percent of
aids. The performance of bathing, dressing, eat-
bowel sphincter control at least occasionally. Less
The effects of developmental disabilities, of
patients exhibited behavioral problems. Patients
ing, and toileting require complex organized
than 1 percent had had surgical intervention to
chronic illness, and aging on mental functions are
manifesting inappropriate behavior for the most
neurological and locomotor responses. Dependence
correct previous pathological conditions (table
complex, difficult to measure, and have wide vari-
part equally divided between those who were pas-
of patients in more than one activity or a combi-
20).
ation among individuals. The awareness of an in-
sive, those disruptive and those with other detri-
nation of activities is usual and suggested by the
The status of patients' bladder and bowel func-
dividual within his environment can range from
mental behavior as shown in table 22.
data. These relationships will be explored and
tions poses another area of considerable depend-
oriented to disoriented. Oriented means the pa-
It appears from the profile of the orientation
described in a future report.
ence on the nursing home staff for assistance and
tient is aware of who he is, where he is and what
and behavior patterns of patients in the skilled
care. More patients had full control of bowel func-
time, day, month, or year it is. Disoriented means
nursing facilities that a sizeable proportion pre-
tion than bladder. Half may be dependent at some
the patient is unaware of time, place, and his iden-
sent major management problems both in terms
Mobility
time for care in one functional area. The data in-
tity. Disorientation may be in one of more spheres
of providing a safe environment and in rendering
The mobility status of patients involving walk-
dicate that at least 10 percent of patients may be
as time only or time and place and the patient may
care. The inappropriate behavior and disorienta-
have alternating periods of awareness-unaware-
ing, wheeling, stair climbing, or functional ability
tion which ranged from 41.1 to 54.2 percent of pa-
ness or intermittent disorientation. As a practical
to move about physically has not been analyzed
tients requires nursing expertise of the highest
matter clinical intuition and impressions are tradi-
for this report. The number of chairfast and bed-
Table 19.-Bladder function of patients
order. What has been termed nursing psychiatry
fast patients and the transferring of patients be-
tionally used as a basis of screening for mental
is believed by some to probably constitute the
Patients
functions and impairment. Answers were sought
tween the bed, chair, and wheelchair is being ex-
most important vehicle of patient management in
Bladder function
Number
Percent
to simple questions about orientation of the
amined. It is interesting to note that 13.2 percent
care of the long-term care patient. Bathing, dress-
skilled nursing facility patient for time, place, and
of patients or 37,437 were fully ambulatory and
ing, and feeding of the disoriented patient can
Total
283,914
100.0
person spheres.
able to leave the facility and walk outdoors at
challenge all the conventional techniques and skill
No problem
112,492
39.6
The answers to these simple questions indicated
known to nurses. It may be just as difficult to elicit
will. The reasons for institutionalization of these
Incontinent of urine
155,392
54.7
that over half of all patients had some degree
a response and stimulate participation in care
patients is immediately questioned. While alter-
External device
912
.3
of difficulty in their awareness of the existing situ-
from the passive patient so that he will utilize his
natives to skilled nursing home care are suggested,
ation with reference to time, place and identity of
(a) Self-care
full potential for carrying out his activities of
they need to be ruled out by analysis of these pa-
46
0
(b) Not self-care
866
.3
self. One-seventh of patients had no awareness of
daily living.
tients' care plans and examination of the services
their environment at any time or were comatose.
being received.
Indwelling catheter
14,701
5.2
(See table 21.)
(a) Self-care
755
.3
Another concern in long-term care is the be-
Communication of Needs
(b) Not self-care
13,946
4.9
Bladder and Bowel Function
havioral capacities of patients and whether their
Another consideration in the care of the long-
Ostomy
417
.2
patterns of behavior are appropriate to the nurs-
term patient is the ability to make known by any
The physiologic process of elimination from the
(a) Self-care
45
0
ing home environment as distinguished from their
means his needs for physical, mental, and social
bladder and bowel is referred to as continence. In-
(b) Not self-care
372
.2
continence is the involuntary loss of urine and/
Table 21.-Patient's orientation as to time, place, and person-spheres
Table 22.-Patients classified according to appropriate behavior
or feces. The process of elimination may take place
through an external opening resulting from a sur-
Table 20.-Bowel function of patients
Patients
Patients
gical procedure (ostomy) such as a colostomy or
Orientation state(s)
Behavior classified
Number
Percent
a device such as a catheter may be used in the
Number
Percent
Patients
process. The function was assessed in terms of con-
Bowel function
Number
Percent
Total
trol without regard to influencing factors as con-
283,914
100.0
Total
283,914
100.0
Oriented
stipation and medications. In cases where patients
Total
283,913
100.0
165,847
58.4
Disoriented
130,130
45.8
1. Appropriate
153,784
54.2
had surgical openings or external or internal de-
2. Inappropriate
116,578
41.1
No problem
139,467
49.1
vices were used, need for assistance with care was
Incontinent of feces
142,188
50.1
(a) Some spheres, some time
(60,544)
(21.3)
(a) Wanders; passive
(38,627)
(13.6)
Ostomy
2,258
.8
(b) Some spheres, all the time
(33,508)
(11.8)
(b) Aggressive; disruptive
(42,006)
(14.8)
determined.
(c) All spheres, some time
(d) All sphres, all the time
(15,915)
(5.6)
(c) Inappropriate-other
(35,945)
(12.7)
Approximately 40 percent of patients manifest-
(a) Self-care
367
.1
(e) Comatose
(41,292)
(14.5)
(b) Not self-care
1,891
.7
(2,525)
(1.0)
3. Comatose.
1,489
0.5
ed no problem with bladder sphincter control (ta-
24
25
comfort. In its broadest sense, communication can
Considering their diagnoses, functional status,
Approximately 7 of every 10 patients (18,271 of
Table 29 -Transfer status among patients with decubitus ulcers
be regarded as a system of significant symbols
and dependency, a relatively low number of pa-
26,812) with a decubitus ulcer also had an associ-
ated difficulty with joint motion of the upper body,
Method of transfer
Number
Percent
which permit ordered human interaction. If a pa-
tients in skilled nursing facilities had bedsores,
tient can communicate he can transmit his needs
26,037 or 9.2 percent, and of these the majority had
e.g., shoulder, elbow, wrist, etc. Limited movement
Total
26,498
100.0
effectively through the use of language and thus
but one site. This fact speaks well for the nursing
was most frequently cited (59.6 percent). (See
table 26.)
Transfer without any help
2,036
7.7
his needs can be understood. This patient has an
services. (See table 24.)
Transfer with help of device
388
1.5
advantage over the patient who must communicate
It is well to remember that every patient who is
Approximately 85 out of every 100 patients (22,-
Transfer with aid of person.
9,651
36.3
nonverbally by substituting gestures, pointing or
882 of 26,773) with a decubitus ulcer also had an
Is transferred
9,322
35.2
bedridden for an extended period of time, is a
Transferred with device and person
2,457
9.3
using written means for spoken and understood
possible candidate for a decubitus ulcer or pressure
associated difficulty with joint motion of the lower
Bedfast
2,643
10.0
words.
sore. Because elderly patients are more prone to
body, e.g., hip, knee, ankle, etc. Limited movement
Most patients (74.5 percent) in the survey com-
skin breakdown due to decline in circulation and
was most frequently cited (45.7 percent). (See
municated verbally and an additional 6.9 percent
a tendency toward dry skin, extra care of the skin
table 27.)
Approximately 3 out of every 10 patients with
Diagnoses of patients with decubitus ulcers.-
communicated on a nonverbal level. However, in
and preventive measures are indicated. These in-
Approximately 15 percent (3,931) of all patients
respect to the attention that is necessary for the
clude protection of the patient against pressure
an ulcer (8,093 of 26,614) also had a fracture or
with decubitus ulcers (26,765) were diagnosed as
patient with whom contact relationships and re-
and the maintenance of proper body alignment.
dislocation. The majority of fractures or 70.3 per-
sponse must be established, a sizeable number 52,-
cent of them (5,690) were fractures of the hip.
being diabetic. The presence of anemia was found
Patients with certain diseases and/or conditions
in 6.3 percent (1,677) of patients with decubitus
745 patients or 18.6 percent did not communicate
require particular attention and these patients in-
(See table 28.)
ulcers. Alcoholism and drug were rarely present
verbally or nonverbally. (See table 23.)
clude those with: Diabetes, arteriosclerosis, pa-
Fewer than 10 percent of all patients with de-
The lack of ability of patients to communicate
tients with neurologic damage, e.g., paraplegia and
cubitus ulcers (2,424 of 26,498) were self sufficient
among these patients. The data show alcoholism
for 454 or 1.7 percent of 26,613 patients and drug
illustrates yet another dimension of long-term
those deprived of sensory feedback, e.g., the blind.
in their ability to transfer without the assistance of
abuse in 217 or 0.8 percent of 26,746 patients.
care. Additional information on patients' speak-
Patients with limited movement, e.g., wheelchair
another person. (See table 29.)
Decubitus ulcer sites.-It has been established
ing ability is described in the following section.
patients as well as those who are bedfast, should
that prolonged concentration of body weight on a
be observed most carefully.
Table 26.-Number and percent of difficulties of joint motion, upper body,
small area of soft tissue over a bony prominence,
It is significant to note that 75.6 percent of all
among patients with decubitus ulcers
CONDITION OF THE SKIN
e.g., the heel is the leading cause of decubitus ul-
patients with decubitus ulcers (20,086 of 26,554)
cer formation. Table 30 gives the number and dis-
The long-term care patient with limitations on
did not walk. And of equal interest is the fact
Difficulties, joint motion upper body
Number
Percent
tribution of the various sites of decubitus ulcers
mobility is particularly susceptible to decubitus
that only 1,113 of the remaining 6,468 patients did
ulcers or bedsores. Prevention as well as thera-
Total
18,271
100.0
among the patient population. It will be noted that
walk without any assistance. The assistance of
the sacrum, hip, heel, and spine were the four most
peutic measures are nursing functions. The basic
other persons or devices or both were needed by
Limited movement
10,884
59.6
Immobility
1,180
6.5
prevalent sites of decubitus ulcers. A larger pro-
causes of bedsores are a blocking of blood flow to
the 5,355 other patients. (See table 25.)
Instability
757
4.1
portion of patients having ulcers in these sites as
the affected area and lack of normal movement. A
Combinations (of above)
5,450
29.8
compared to other parts of the body did not walk,
combination of external etiological factors of
Table 24.-Number and percent of decubitus ulcers among patient population
transfer out of bed or use the wheelchair.
pressure, temperature, and moisture plus multiple
and site frequency among those patients with decubitus ulcers
Treatment and care of decubitus ulcers.-Pre-
internal debilitating and nutritional associated
Table 27.-Number and percent of difficulties of joint motion lower body
vention of the decubitus ulcers is most important.
factors influence the formation of ulcers. Pres-
Patient population
Number
Percent
among patients with decubitus ulcers
Care is often difficult, painful for the patient and
sure, however, is considered the fundamental cau-
sative agent. The obvious external causative fac-
Total, all patients
100.0
Difficulties, joint motion lower body
Number
Percent
283,907
Table 30.-Distribution, number and percent of decubitus ulcer sites among
tors are one that nurses can conceivably control.
Ulcer-free patients
257,870
90.8
Total
22,882
100.0
patients who do not walk, who are not transferred, and who are not wheeled
The prevention and care of bedsores requires
Patients with decubitus ulcers
26,037
9.2
technical skill and attention to the causative fac-
Limited movement
10,456
45.7
One site only
Various mobility/immobility attributes
(16,770)
(5.9)
Immobility
2,026
8.9
tors and the application of the full talents of
Two sites
(4,709)
(1.7)
Instability
883
3.8
Various sites of
Does not walk
Is not transferred
Is not wheeled
Three or more si tes
nurses.
(4,558)
(1.6)
Combinations (of above)
9,517
41.6
decubitus ulcers
Number
Per-
Number
Per-
Number
Per-
cent
cent
cent
Table 25.-Walking status of patients with decubitus ulcers
All Sites.
29,726
100.0
5,080
100.0
11,737
100.0
Table 23.-Patients' ability to comunicate needs
Table 28 Number and percent of fractures or dislocations among patients
Patients
with decubitus ulcers
Degrees of walking ability
Sacrum coccyx
11,008
37.0
1,210
23.8
3,714
31.6
Number
Percent
Shoulder blade
1,366
4.6
325
6.3
433
3.7
Patients
Communication state(s)
Elbow
780
2.6
207
4.1
301
2.6
Fractures or dislocations
Number
Percent
Number
Percent
Heel
3,572
12.0
544
10.7
1,364
11.6
Total, all
26,554
100.0
Foot (other heel)
2,946
10.0
593
11.7
1,364
11.6
Total
Total
8,093
100. 0
Knee
889
3.0
184
3.6
1,008
8.6
283,913
100.0
Does not walk
20,086
75.6
Hip
5,808
19.5
1,457
28.7
215
1.8
Walks with help/person
2,451
9.2
Hip fracture, right or left
5,543
68.5
859
2.9
184
3.6
2,871
24.5
Verbally
Spine (upper)
211,491
74.5
Nonverbally
Walks with help person/device
1,693
6.4
Hip fracture, right and left
147
1.8
Ribs (chest)
479
1.6
0
0
252
2.2
19,677
6.9
Walks with help/device
Does not communicate
1,211
4.6
Fracture or dislocation, not hip
2,403
29.7
Other
2,019
6.8
376
7.4
215
1.8
52,745
18.6
Walks without help
1,113
4.2
27
26
challenges the skill of the medical and nursing
pose of classification of patients, impairments in
staff. Decubitus ulcers can present complications
understandable. Among the defects are articula-
care services. In long-term care, diagnosis alone
that require additional nursing care to prevent fur-
sight range from "no impairment" to being "le-
tory defects, stuttering, voice problems, conditions
is not meaningful. The patient's functional status
ther ulceration and damage to the skin and under-
gally blind." The majority of skilled nursing fa-
associated with impaired hearing, organic dis-
and limitations must be related to his clinical
lying tissue. One sign of progressing deteriora-
cility patients (70.4 percent of 200,005) were as-
orders and retarded speech development. For the
status. The chronically ill present great variability
sessed as having sight impairment. Of these 2.6
tion of ulcers is the presence of exudate-serous
purpose of classifying patients, speech impair-
in stages and severity of illness. In addition, the
fluid or pus. Table 31 shows the number of pa-
percent (7,441) were legally blind; 50.7 percent
ments ranged from "no impairment" to "does not
aged characteristically have more than one chronic
tients that had exudative ulcers and the frequency
(149,682) wore corrective lenses/glasses; and 15.1
speak." Some terms used in the classification are
condition, disease, or disability. Patient care re-
of treatment given to these patients. For 56.4 per-
percent (42,882) were not users of eyeglasses. (See
defined for clarification. Aphasia is a defect or loss
quirements must be measured in terms of the ag-
table 32.)
cent of patients with draining ulcers, treatment
of the power of expression by speech. Dysarthric
gregate of physical, functional, and psychosocial
was given twice a day or more often.
Hearing.-Hearing is the act, faculty, or proc-
means imperfect articulation in speech.
needs at given points in time.
The data of decubitus ulcers present a classic
ess of perceiving sound through the ear. For the
Each of the speech impairments, stuttering,
The physician traditionally refers to the needs
picture of one aspect of nursing care in the skilled
purpose of classification of patients, impairment
nursing facility. It emphasizes the particular at-
ranges from "no impairment" to "does not hear."
dysarthria, aphasia, jargon, and no speech were
of patients in terms of diagnostic categories. The
identified with no single defect occurring in more
diagnoses of the patients in the survey are pre-
tention that the long-term patient demands. Pa-
Hearing was assessed in terms of the patient's re-
than 8.8 percent of patients. Normal speech was
sented below. They illustrate the multivaried med-
tients must be examined frequently and observed
sponse to normally audible and shouting voice
most frequent for 68 percent of patients. (See
ical conditions that must be considered in plan-
for any abnormal signs or changes in their physi-
sound waves. To understand the findings, it should
be explained that for the aging, hearing changes
table 34.)
ning long-term care. Further correlations between
cal status and functioning. The techniques of care
include a gradual loss of high frequency sounds
Among the patients surveyed, visual impair-
patients' functional status and diagnoses could ex-
embrace all of the nursing judgment and skill re-
quired for the short-term patient. In addition, it
and distortion of environmental sounds, for exam-
ments occurred with greatest frequency or 70.4
pand on definitive care requirements.
percent followed by hearing and speech impair-
The review of records both on admission and
must incorporate a fuller measure of prevention,
ple traffic in the street or dripping faucets. Loss
of high frequency sound impairs speech discrimi-
ments which were of almost equal frequency, hear-
subsequent to admission made possible identifica-
health maintenance, and restorative care in terms
nation. Shouting which is a high frequency sound
ing in 32.9 percent of patients and speech in 32
tion of the traditional medical descriptors of
of particular disease states, disabilities, and func-
percent.
patients:
tional status, and patient care needs.
is distorted. The person with a high frequency loss
needs to be addressed clearly and slowly in a lower
1. The primary diagnoses judged to be the rea-
pitched voice, rather than by shouting. Hearing
PATIENT DIAGNOSES
son for admission to the facility (table 35).
IMPAIRMENTS IN SENSORY PERCEPTION
aids which amplify sound do not help the person
2. The aggregate of diagnoses identified on ad-
with high frequency sound loss.
Diagnosis is a common basis for defining pa-
mission to the facility (table 36).
Characteristically, long-term care patients have
tients' needs for care and in organizing patient
3. The diagnoses identified subsequent to ad-
No impairment in hearing was found for 67.1
mission (table 37).
many impairments. Those impairments related to
percent of patients (190,407). At the other ex-
sensory perception may be: congenital, associated
In these three tables there are significant differ-
treme, a relatively small number of patients did
Table 33.-Classification of patients according to hearing acuity
with developmental disabilities, the sequelae of
ences demonstrated in comparison of age groups
disease or accidents, or constitute deterioration in
not hear, 1.2 percent or 3,364 patients. The largest
Patients
(i.e., those under 65 and those 65 and over) and of
function due to the aging process. The sensory
number of patients with impairments responded
Hearing state(s)
Number
admission and postadmission diagnoses.
to a loud voice, not shouting. These 60,286 patients
Percent
perception of the patients in the skilled nursing
In table 35 it is clear that the primary diagnoses
facilities was assessed by descriptors without ref-
were 21.2 percent of total patients in the survey
100.0
for nearly two-thirds of those under 65 years of
and 64.5 percent of those with hearing impair-
All
283,913
erence to their etiology. The descriptors constitute
age is pathology of the nervous system, i.e., neuro-
a scale of severity of impairment without judg-
ments. Very few patients identified as having
No impairment
190,407
67.1
Impairment one or both ears
89,212
31.4
hearing losses wore hearing aids, 4.6 percent of
logical disease, mental retardation, neuroses and
(a) Hears loud voice no shouting
(60,286)
(21.2)
ment about the contribution of the impairment to
the overall disability of the patient.
12,907 patients. (See table 33.)
(b) Hears normal and loud voice with hearing aid.
(9,543)
(3.4)
psychoses, stroke, and chronic brain disease. On
(c) Hears only shouting no hearing aid
(16,019)
(5.6)
the other hand, for the same proportion of patients
Sight.-Sight is the act, faculty, or process of
Speech.-Numerous defects and disorders pro-
(d) Hears only shouting with hearing aid
(3,364)
(1.2)
perceiving objects through the eye. For the pur-
duce speech that is indistinet, unpleasant or not
over the age of 65, the diagnoses judged to be the
Does not hear
4,294
1.5
primary reason for institutionalization are heart
disease, chronic brain disease (including senility),
Table 32.-Classification of patients according to visual perception
stroke, fractures and generalized arteriosclerosis
Table 31 -Number and percent of patients with exudative ulcers and the fre-
Table 34.-Classification of patients according to speaking ability
quency of treatment of the ulcers
and hyptertension. As would be expected, those
Patients
Visual state(s)
Patients
under 65 enter the nursing home for develop-
Patients
Number
Percent
Speaking state(s)
Frequency of treatment
Number
Percent
mental disabilities and their sequelae; those 65 and
Number
Percent
over for the disorders and accidents common to the
All
283,912
100.0
All
283,913
100.0
Total
aging process.
8,061
100.0
No impairment
83,907
29.6
Once day or less
Impairment one eye (with glasses)
Normal speech.
192,957
68.0
Table 36 provides a broader perspective of the
2,764
34.4
3,787
1.3
Twice day
Impairment both eyes (with glasses)
Stuttering (not d/sarthria)
7,423
2.6
145,895
51.4
diagnostic profile of patients admitted to nursing
3,083
38.2
Dysarthria (with intelligible speech)
25,002
8.8
More than twice day
Impairment one eye (no glasses)
1,470
18.2
3,010
1.1
Aphasic (conveys thoughts)
9,485
3.3
homes since it shows all diagnoses recorded on
None
744
Impairment both eyes (no glasses)
39,872
9.2
14.0
Speaks (makes no sense)
24,317
8.6
Legally blind
7,441
2.6
admission. Again, an age differential is clearly
Does not speak
24,729
8.7
evident. Of those under 65, two out of five have an
28
29
Table 35.-Primary diagnoses recorded on admission by diagnostic group and by age
65 and over (7.3 percent) than in those under 65
findings relating to medical needs for care and
Under 65
(5.2 percent). Postadmission diagnoses of dis-
services as indicated by diagnoses:
All ages
65 and over
Diagnoses
Number
Percent
Number
eases that are more related to the aging process
Percent
1. The primary diagnoses on admission for two
Number
Percent
than to institutionalization occurred more fre-
out of three patients under 65 years of age
Total
283,300
100.0
100.0
232,900
quently in the 65 and over. One in four diagnoses
were pathology of the nervous system, pri-
50,400
100.0
44,300
in this age group was for diseases of the eye and
marily developmental disabilities and their
Heart disease
15.6
Chronic brain disease
2,500
5.0
41,900
18.0
Stroke
3,700
7.3
35,500
15.2
ear, musculoskeletal or cardiovascular systems. In
sequelae.
39,200
13.8
2. For two out of three patients 65 and over, the
30,300
10.7
Fractures
3,900
7.7
26,400
11.3
24,800
those under 65, only one in six diagnoses was for
8.8
Neurological disease
1,700
3.4
primary diagnoses were of cardiovascular
23,100
9.9
19,000
6.7
Generalized arteriosclerosis and hypertension
9,600
19.0
9,500
4.1
these conditions.
and cerebrovascular disease, senility, and
17,300
6.1
Neuroses and psychoses
1,300
2.6
16,000
6.9
15,200
5.4
These differing characteristics are summarized
accidents.
Diabetes
5,700
11.3
9,500
4.1
14,300
3.4
12,600
in table 38, which shows the comparative rank
3. For those under 65, the diagnoses recorded
5.0
Diseases of musculoskeletal system
1,700
5.4
13,400
4.7
Mental retardation
2,000
4.0
11,300
4.9
order of both primary and all diagnoses made on
postadmission are those infectious diseases
9,300
3.3
Neoplasms
9,000
17.9
400
.2
or disorders generally related to institution-
8,400
3.0
Diseases of respiratory system.
1,800
3.6
6,600
2.8
admission and of diagnoses made postadmission
alization and prolonged bed rest in two out
6,600
2.3
Diseases of digestive system
800
1.6
5,700
2.4
6,500
2.3
for these two age groups.
of five cases. In those 65 and over, this pro-
Diseases of genito-urinary system
600
1.1
6,000
2.6
3,700
1.3
Diseases of eye and ear
500
1.0
3,200
1.3
In summary, the following were the significant
portion was one in three.
3,300
1.2
Other
600
1.1
2,700
1.2
27,700
9.8
5,000
10.0
22,700
9.7
Table 37.-Most prevalent diagnostic groups (recorded postadmission) by age
Table 36.-All diagnoses recorded on admission by diagnostic group and by age
Age Group
All ages
All Ages
Cumulative
Under 65
65 and Over
Under 65
Diagnoses
65 and over
Diagnoses
Total
Number
Percent
(percent)
Number 2
Percent
Number
Percent
Number
Percent1
Number
Percent 2
Number
Percent
Diseases of genito-urinary system
11,500
11.8
11.8
1,700
7.4
9,700
13.1
Heart disease
108,200
Chronic brain disease
38.1
7,800
15.2
100,400
431
Decubitus ulcers and other skin conditions
9,500
9.8
21.6
2,600
11.3
6,900
9.3
83,000
29.2
Generalized arteriosclerosis and hypertension
6,900
13.5
76,100
9,500
9.8
31.4
1,600
6.9
7,900
10.6
32.7
Diseases of eye and ear
64,800
22.8
Diseases of musculoskeletal system
6,800
13.3
57,900
24.9
Diseases of musculoskeletal system
7,200
7.4
38.8
900
3.9
6,300
8.5
55,800
46.1
2,700
11.7
4,300
5.8
Stroke
19.7
6,100
11.9
49,700
21.4
Diseases of respiratory system
7,100
7.3
51,300
Fractures
18.1
6,900
13.5
44,400
7,100
7.3
53.4
1,100
4.8
6,000
8.1
19.1
Heart disease
46,200
16.3
Neurological disease
4,400
8.6
41,800
6,700
6.9
60.3
1,200
5.2
5,400
7.3
18.0
Fractures
Diabetes
43,800
15.4
21,500
42.0
22,300
9.6
Diseases of digestive system
6,600
6.8
67.1
2,000
8.7
4,600
6.2
40,700
14.3
Neuroses and psychoses
6,100
11.9
34,600
14.9
34,100
12.0
Diseases of digestive system
10,500
20.5
23,600
10.1
30,700
10.8
Diseases of genito-urinary system
4,000
7.8
26,700
11.5
29,600
10.3
Diseases of eye and ear
5,500
10.7
24,100
10.4
1 Total postadmission diagnoses equals 97,400.
28,400
10.0
Diseases of respiratory system
5,900
11.5
22,500
9.7
2 Total postadmission diagnoses among the under 65-age group equals 23,100.
21,400
7.5
Neoplasms
3,400
6.6
18,000
7.7
3 Total postadmission diagnoses among 65 and over age group equals 74,300.
15,800
Mental retardation
5.6
3,300
6.4
12,500
5.4
Note-Not all patients had a postadmission diagnosis and there were multiple diagnoses for some patients.
Other
14,900
5.2
13,700
26.8
1,200
(4)
52,700
18.6
11,600
22.7
41,100
17.7
1 Percentages are based on a total of 283,900 patients.
Table 38.-Rank order of most common diagnostic groups by time of recording and age group
2 Percentages are based on a total of 51,200 patients.
3 Percentages are based on a total of 232, patients.
4 Less than 0.1 percent.
Primary diagnoses on admission
All diagnoses on admission
All diagnoses postadmission
Rank order
5 Includes major surgery, endocrine disease (other than diabetes mellitus), anemias, nutritional disease, and decubitus ulcers and other skin disorders.
Under 65
65 and over
Under 65
65 and over
Under 65
65 and over
Note.-Percentages add up to more than 100 because of multiple diagnoses recorded on admission for same patients.
1
Neurological disease
Heart disease
Neurological disease
Heart disease
Diseases of respiratory
Diseases of genito-
system.
urinary system.
identified neurological disease, one in four is men-
2
Mental retardation
Chronic brain disease.
Mental retardation
Chronic brain disease.
Decubitus ulcers and
Diseases of eye and ear.
patterns for the two age groups. See table 37. For
other skin diseases.
tally retarded, and one in five has a neurosis or
3
those under 65, nearly two out of five of the diag-
Neuroses and psychoses
Stroke
Neuroses and psychoses
General arteriosclerosis
Diseases of digestive
Decubitus ulcers and
and hypertension.
system.
other skin diseases.
psychosis. For those 65 and over, over two in five
noses recorded are diseases of the respiratory, gas-
4.
Stroke
Fractures
Heart disease
Diseases of musculo-
Diseases of genito-
Diseases of musculo-
have heart disease; nearly one in three have
skeletal system.
urinary system.
skeletal system.
trointestinal, or genito-urinary systems or decubi-
5
Stroke
Diseases of eye and ear.
Heart disease.
chronic brain disease; one in four have generalized
Chronic brain disease
General arteriosclerosis
Chronic brain disease
tus ulcers, in other words, mainly infectious dis-
and hypertension.
arteriosclerosis or hypertension; and one in five
6,
Heart disease
Diabetes
Stroke
Fractures
Fractures
Fractures
eases or disorders generally related to institution-
7
Diseases of musculo-
Diseases of musculo-
General arteriosclerosis
Diabetes
Heart disease.
Diseases of digestive
have stroke or a disease of musculoskeletal system,
alization and prolonged bed rest. For those over
skeletal system.
skeletal system.
and hypertension.
system.
i.e., arthritis.
8
Neoplasms
Neuroses and psychoses.
Diseases of musculo-
Diseases of digestive
Diseases of musculo-
Diseases of respiratory
65, of the diagnoses recorded subsequent to ad-
skeletal system.
system.
skeletal system.
system.
Finally, the diseases or disorders diagnosed
mission, one in three was for these conditions.
9
Diabetes
Neurological disease
Diabetes
Diseases of genito-
following admission also demonstrate differing
urinary system.
Fractures occurred slightly more frequently in the
10
Fractures
Neoplasms
Diseases of eye and ear
Neuroses and psychoses.
30
31
DENTITION
Findings.-Among the 210,411 patients repre-
CHAPTER 6
That good dental health is an essential compo-
sented in the report, only 8.1 percent had no miss-
nent of good general health is by now a truism.
ing teeth. (See table 39.) An additional 7 percent
What needs to be emphasized, however, is that
had some missing teeth, but a restoration compen-
while maintaining a sound dentition preserves the
sated for the loss. Edentulousness with dentures
masticatory function and all that implies with
accounted for an additional 46.8 percent of the
respect to nutrition, it also adds immeasurably to
patients. The remaining 38.1 percent of the pa-
one's appearance, ability to speak, and sense of
tients required tooth replacements, including full
The Patient Care Setting
well-being.
dentures, but had none.
Despite this, the universality of dental disease
Though some prostheses had been provided for
and its generally nonfatal character tends to foster
53.8 percent of the patients, the extent to which
complacency concerning its prevention and treat-
these needed repair or replacement-a not uncom-
The physical environment, administration, and
the governing body must perform such duties as
ment. Yet dental diseases are not self-healing;
mon service requirement-was not determined.
fiscal management of all health care institutions
(2):
most are irreversible and become more severe with-
Similarly, neither the extent to which patients
including skilled nursing facilities (SNF) are the
a. Adoption of bylaws, patient care policies, ad-
out treatment. It is in this context that the dental
with teeth required extractions because of dental
basic support for all services offered. The size of
ministrative policies and rules and regulations
health problems of the long-term patient must be
caries or periodontal disease nor the need for oral
the facility, its configuration, administrative, and
which govern and direct the operation of the
weighed.
hygiene services, a particularly common need
fiscal policies and how they are implemented de-
facility. These policies and rules and regula-
Survey methods.-There were no dentists on the
among the ill and aged, was documented. Thus,
termine the extent of services offered, the resources
tions must be reviewed and revised as neces-
survey teams nor were patients routinely examined
employed in rendering services, their quality, and
sary;
these data undoubtedly underestimate the preva-
b. appointment of a competent, licensed admin-
to determine dental health status. Instead, team
lence and severity of dental problems among the
the efficacy of services (1).
istrator with full responsibility for operating
physicians attempted to determine whether pa-
surveyed population and, therefore, any conclu-
This section of the report will describe the health
the nursing home in accordance with policies
tients selected in the survey had significant unmet
sions drawn from them with respect to dental
and safety environment of SNFs and management
established by the board;
dental health problems. This was done by review
service needs should take this into account.
and fiscal practices based on data available at the
c. conducting meetings periodically and for spe-
cific purposes to take care of ongoing policy
of medical records and by interviewing facility
time of survey.
personnel. Additional information was obtained
Table 39.-Patients status of dentition
and operational matters of the nursing home.
Governing body members must attend these
when the physicians saw and talked with the
meetings. Minutes of the meetings must be
patients.
Patient
ADMINISTRATIVE AND FISCAL MANAGEMENT
Dentition status
kept as they are legal records of decisions
Notwithstanding the limitations of this proce-
Number
Percent
made. Such decisions must be transmitted to
The major concern in evaluating the adminis-
those having direct operational responsi-
dure for determining the dental health status of
Total
trative management of SNFs in the survey was
bility; and
the patients-particularly the lack of attention to
210,411
100.0
how well the management function was being per-
d. provision of assurance that the nursing home
soft tissue problems which are prevalent among
No teeth missing
16,958
8.1
Some missing
formed. The issues are divided into discussion of
is operated in compliance with applicable
adults and impact significantly with respect to
53,310
25.4
Federal, State, and local laws.
(a) Compensated
The governing body, the nursing home adminis-
treatment needs-it did provide a gross measure
14,593
7.0
(b) Not compensated
of tooth loss among the surveyed population. It-
38,717
18.4
trator, personnel management, and outside
If a facility does not have an identifiable govern-
Edentulous
resources.
ing body or if the governing body does not func-
also indicated the extent to which this loss had
140,143
66.5
tion effectively, many of the activities carried out
been compensated for by restorations and pros-
(a) With plates
98,761
46.8
thetic appliances.
(b) Without plates
in the facility diminish, especially the quality of
41,382
19.7
The Governing Body
patient care. In 96.9 percent (6,389) of the facili-
Federal regulations require that every nursing
ties a governing body or a designated person func-
home must have an identifiable authority having
tioning in the same capacity with full legal
full legal and moral responsibility for all aspects
authority and responsibility for the operation of
of facility operations. This authority might be
the facility was identified. Although most homes
called the "governing body," "board of directors,"
have a governing body, the frequency of meetings
"board of trustees," "owners," or other appropriate
prescribed by the adopted bylaws was not complied
designation. The individual or group, regardless
with in 16 percent (1,057) of the facilities.
of the formal name, has responsibilities and duties
The minutes of the governing body should show
with which it is charged and of which it cannot
actions taken in formally adopting bylaws and
be relieved by delegation. The degree to which
policies, including patient care policies, subsequent
these responsibilities and duties are conscientiously
revisions made, action taken on recommendations
fulfilled, have a direct relationship to the effective-
made by various facility committees that require
ness of the facility's performance. Representing
governing body consideration, and the appoint-
minimum standards and as a basis for comparison,
ment of the administrator. In 50.4 percent (3,320)
32
33
of the facilities, the recorded minutes of the gov-
The administrator evaluates and implements
Table 40.-Number and percent of SNFs which have adopted rules and
Patient Care Policies
erning body meetings were considered complete
recommendations from the facility's committees,
regulations pertaining to the health care of patients
and/or adequate. The larger the home the greater
In order to meet all needs of the patients, the
and maintains liaison with the governing body,
the likelihood of finding the minutes complete. The
Health care rules and
medical staff, and other professional and supervi-
patient care policies of the facility should be de-
Bed size
Facilities
Total
regulations
difference between the small and large facility in
veloped with the advice of representatives of all
sory staff (4). A qualified alternate employee to
Yes
No
having adequate minutes is 20 percent. In other
health care disciplines. In at least 98 percent of
serve as administrator should be designated in
facilities the minutes did not reflect the details
writing. The administrator usually establishes the
Total
Number
6,591
6,142
449
facilities with written patient care policies, nurses
93.2
6.8
of the matters discussed and did not provide ade-
Percent
100.0
and physicians participated in their development.
overall atmosphere of the home. Interest in pa-
quate information on the decisions made. Fre-
tients receiving quality care will also be reflected
49
Number
1,242
1,167
75
This same high degree of participation by other
quently the content of the minutes reflected cor-
Percent
100.0
94.0
6.0
by the staff. The opposite will usually prevail if
health professionals, however, was not found. For
50 99
Number
2,682
2,453
228
porate financial matters to the exclusion of those
the administrator has other interests.
Percent
100.0
91.5
8.5
instance, participation by pharmacists occurred
Number
2,668
2,522
146
matters directly affecting the quality of patient
in 64.1 percent (4,226) by dietitians in 54.9 per-
It was found in the survey that 29.2 percent
100 and over
Percent
100.0
94.5
5.5
care.
(1,926) of the administrators had not been SO des-
cent (3,617) and by a physical or occupational
Apparently in many nursing homes, either the
therapist in 43 percent (2,836) of the facilities.
ignated in writing by the governing body. In 96.7
governing body did not hold meetings in accord-
Of major importance are the services included in
percent (6,372) of the facilities, however, there
a facility's patient care policies. Nearly all facili-
ance with the frequency stated in its own bylaws
were administrators, whether designated in writ-
Table 41.-Number and percent of SNFs in which the administrator enforces
rules and regulations pertaining to the level of health care provided
ties have policies covering admission of patients
or did not record the substance of such meetings.
ing or not who were responsible for the overall
and nursing services. A number of facilities did
This inattention to its bylaws and to operational
management of the facility.
Enforced health care
matters indicates that frequently, governing
Bed size
Facilities
Total
rules and regulations
not have policies in the following areas: Dental
Administrative policies were in writing in 93.8
Yes
No
services, 917 facilities or 13.9 percent; restorative
bodies do not fully meet their obligations and re-
percent (6,179) of the facilities. In 19.5 percent
services, 898 facilities or 13.6 percent; categories of
sponsibilities. Additionally, the governing bodies
(1,284) of these facilities, however, these policies
Total
Number
6,591
5,294
1,297
patients accepted, 1,007 facilities or 15.3 percent;
of a large number of facilities, apparently did not
had not been adopted by the governing body and
Percent
100.0
80.3
19.7
categories of patients not accepted, 1,290 facilities
understand the necessity for keeping minutes that
in 29.1 percent (1,915) of facilities, the policies
1 49
Number
1,245
988
257
or 19.6 percent; and for social services, 1,077 facili-
were complete enough to reflect the details of
had not been implemented. Further, 19.5 percent
Percent
100.0
79.4
20.6
ties or 16.3 percent. It is apparent that most facili-
50 99
Number
2,689
2,161
528
matters discussed at meetings and decisions made.
(1,284) of the facilities failed to revise these poli-
Percent
100.0
80.3
19.7
ties have patient care policies, administrative poli-
100 and over
Number
2,657
2,145
512
cies to meet changing requirements.
cies, and rules and regulations pertaining to the
Percent
100.0
80.7
19.3
Nursing Home Administrator
Findings related to administrative policies in-
health care of patients. A disturbing aspect of the
dicated that similar conditions would exist rela-
findings, however, is the tendency towards "paper
The administrator is fully responsible for the
tive to the adoption and implementation of rules
compliance" as evidenced by the high percentage
day-to-day operation of the nursing home and is
Table 42.-Number and percent of SNFs in which the governing body has
of facilities in which the governing body did not
and regulations for the health care of patients.
accountable to the governing body alone. Ap-
adopted rules and regulations for the general operation of the facility
adopt their own policies and rules and regulations,
This was found to be the case. In 93.2 percent
pointed by the governing body, the administrator
or if adopted, policies were not fully implemented
(6,142) of the facilities, rules and regulations per-
Rules and regulations
is delegated in writing the responsibility for
Bed size
Facilities
Total
by the administrator.
taining to the health care of patients were estab-
Yes
No
operating the home in accordance with policies,
The facility establishes committees as necessary
lished, but in 19.7 percent (1,297) of the facilities,
rules, regulations, and operating procedures
Total
Number
6,591
5,303
1,287
to develop policies and procedures dealing with
the administrator did not enforce these rules and
Percent
100.0
80.5
19.5
utilization review, pharmaceutical services, patient
adopted by the governing body (3).
regulations; and in 19.5 percent (1,287) of the fa-
49
The governing body should appoint an ad-
Number
1,239
1,127
111
care, infection control and other services of areas
cilities, there was no documentation that the gov-
Percent
100.0
91.0
9.0
deemed appropriate. Committees meet on a regular
ministrator who is currently licensed by the State
50 99
Number
2,675
1,968
707
erning body had adopted the rules and regulations
Percent
100.0
73.6
26.4
basis to review, discuss, and revise policies as nec-
and qualified by education and experience to effec-
for the health care of patients. In 95.1 percent
100 and over
Number
2,677
2,208
470
essary. Minutes of meetings are recorded and con-
tively manage the facility. The administrator is
Percent
100.0
82.5
17.5
(6,267) of the facilities, patient care policies are in
tain recommendations which are submitted to the
normally charged with defining the objectives of
writing but in 22.3 percent (1,471) of the facilities
administrator for appropriate action (5).
the facility and transmitting them to the profes-
policies have not been adopted by the governing
Action to implement recommendations of facil-
sional staff and other employees SO that they know
body and in 39.3 percent (2,593) of the facilities,
a person in writing. In order to maintain continu-
ity committees is important in order for the facility
what is expected of them. The administrator has
the policies have not been implemented. (Tables
ity of management of the facility during the ab-
to maintain the delivery of high quality care. It
responsibility for effectively coordinating staff
40, 41, and 42.)
sence of the appointed administrator, another
is the duty and responsibility of the administrator
efforts to assure the delivery of high quality pa-
In many facilities, when the administrator is
qualified employee should be authorized to assume
to consider and act on recommendations submitted
tient care. Employment of an adequate number of
absent, it appears there may be uncertainty as to
the duties of the administrator. The appointment
by committees. He must, of course, refer to the gov-
qualified personnel by the facility and mainte-
who has the authority to act in that capacity. It
should be in writing to ensure that the authority
erning body for consideration, those recommenda-
nance of appropriate personnel records for each
was found that in 34.5 percent (2,274) of the fa-
of the administrator has been properly delegated
tions requiring major policy decisions. It appears
employee are fundamental.
cilities the administrator had not designated such
to a specific person.
that administrators in many facilities do not re-
34
35
spond to the recommendations of the facility's
ity, and the requirements of State licensing regu-
Table 43.-Number and percent of SNFs that verify the licensure and
Table 45.-Number and percent of SNFs in which there is evidence that
registration of staff at time of employment by bed size
staff utilizes training
committees. Recommendations of the utilization
lations and Federal qualifications standards (11).
review committee were not acted upon by the ad-
The survey found that nearly all facilities main-
Verify licensure and
Utilize training
Bed size
Facilities
Total
registration
Facilities
Total
ministrator in 18.7 percent (1,229) of the facili-
tain a personnel record for each of its employees.
Yes
No
Yes
No
ties. The pharmaceutical committee recommenda-
The content of the record did not, however, pro-
tions were not acted upon in 42.2 percent (2,782)
vide evidence that management was as selective as
Number
6,591
4,856
1,735
Total
Number
6,591
5,492
1,098
Percent
100.0
73.7
26.3
of facilities, the patient care policy committee rec-
it should have been as to whom they hired, espe-
Percent
100.0
83.3
16.7
ommendations in 27.1 percent (1,787) of facilities,
cially in respect to the employees' health and qual-
49
Number
1,245
952
293
and the infection control committee recommenda-
ifications. While 96.2 percent (6,341) of the facili-
Percent
100.0
76.4
23.6
tions in 44.3 percent (2,922) of the facilities.
ties required an application for employment, 35.3
50 99
Number
2,689
2,197
492
Table 46.-Percentage of SNFs having agreements with outside resources
for services by size of facility
Percent
100.0
81.7
18.3
percent (2,324) did not maintain evidence of a
100 and over
Number
2,657
2,344
313
Percent
100.0
88.2
11.8
Bed size
preemployment health examination; 26.2 percent
Personnel Management
Services
All
1-49
50-99
100 and over
(1,724) did not provide a position description;
Nursing home management has the responsibil-
32.2 percent (2,123) did not have a current health
Table 44.-Number and percent of SNFs that annually verify current status
of licensure or registration of staff by bed size
Physical therapy.
51.0
29.3
52.8
59.4
ity for providing the best possible care to all pa-
record; and 23.5 percent (1,548) did not include
Speech therapy
32.9
14.6
33.7
40.7
tients and to employ a staff trained and qualified
the employees' current license or registration num-
Occupational therapy
22.7
11.8
20.6
30.0
Verify licensure or
Pharmacy.
79.1
57.8
85.5
82.4
to perform their duties. (6). Clearly, the quality
ber in their personnel record. Omission of these
Bed size
Facilities
Total
registration
Dietary
68.9
53.0
68.6
76.8
of health care in a facility can be no better than the
important items and data from employee person-
Yes
No
Social service
38.9
21.3
37.4
48.4
Medical records
63.4
38.0
67.3
71.4
quality of personnel the facility employs (7).
nel records raises a major question as to the ad-
Other
61.7
48.3
60.9
68.6
The process for employment of qualified per-
ministrators' real concern for employing staff
Total
Number
6,591
5,288
1,303
Percent
100.0
80.2
19.8
sonnel begins with the application. This important
having appropriate qualifications and providing
tool should provide basic information about the
high quality service.
49
Number
1,242
837
405
Percent
100.0
67.4
32.6
administrator containing recommendations, plans
background, skills, education, license or registra-
As for professional personnel requiring a li-
50 99
Number
2,683
2,192
491
Percent
100.0
81.7
18.3
for their implementation and continuing assess-
tion number, working experience, and other related
cense, it was found that one-sixth of the facilities
100 and over
Number
2,666
2,259
407
ment of the services provided. These reports are
essential information (8). The facility should ver-
did not verify the license or registration number
Percent
100.0
84.7
15.3
used by the administrator to followup on recom-
ify the information contained in the application
of the applicant at the time of employment, and
mendations made and to evaluate the performance
form and, above all, the license or registration
one of five facilities did not recheck annually, or
of the services for which consultation was pro-
number of the prospective employee to be sure it is
biannually, as appropriate, to verify the current
no evidence in over one-fourth of the facilities to
vided. It is through these reports, as well as other
valid and current (9). Additionally, verification of
status of the license. In both instances, the smaller
indicate that the staff applied what was learned
contacts, that communication between the consult-
required licenses of current employees must be
facilities had the highest percentage of negative
(table 45).
ant and administrator is maintained and serv-
made at time of each renewal.
responses. (Tables 43 and 44.)
ices improved.
A preemployment health examination for pro-
The administrator should take an active part
Use of Outside Resources for Consultative Services
Review of consultants' activities indicates that
spective employees is necessary to determine if they
in the development of the staff through well
such reports are either not made or are incomplete.
are of sufficient good health to discharge their
planned and constructed inservice educational ac-
If the facility does not employ a qualified per-
The data indicate that in 42.5 percent (2,802) of
duties, are free from communicable diseases, and
tivities directly related to the work performed by
son(s) to render a specific required or offered
the facilities, the reports do not apprise the ad-
are physically and mentally fit for the position. A
the staff in performing their duties (12).
service, the facility must contract with an outside
ministrator of a continuing assessment of the serv-
personnel record should be maintained for each
Nearly one-fifth (1,313) of the facilities did not
resource, a person or agency that renders direct
ices provided. In 38.4 percent (2,534) of the facil-
employee. These records deserve careful attention
conduct an ongoing staff development program.
service to patients, or acts as a consultant. The
ities, the reports do not include recommendations
as they should contain the application, references,
As for subject matter, 21.9 percent (1,379) of the
services most frequently furnished in this manner
of the consultants, and in 45.4 percent (2,994) of
performance evaluations, status of health, position
facilities did not provide an orientation program;
are physical, occupational, and speech therapies;
the facilities, these reports do not contain plans
employed in, insurance, salary, inservice education,
skills training was not carried on in 22 percent
consultation for dietary, social, and pharmaceu-
for implementing recommendations if any were
and similar information which provides a profile
(1,452) of the facilities; staff was not provided an
tical services and medical records administration.
made (tables 47, 48, and 49).
of the individual (10).
opportunity to participate in an ongoing education
Data indicate that there was a wide variation
In order to maintain an adequate staff to meet
program in 37.1 percent (2,445) of the facilities;
in homes having written agreements with outside
the needs of the facility, the administrator must
and of major importance, the supervisory staff was
resources to provide services not otherwise avail-
Table 47.-Number and percent of SNFs in which the consultant apprises
the administrator through written reports of continuing assessment of the
anticipate the staffing needs. The factors to be
not provided with leadership/supervisory training
able in the facility. In almost all cases, the larger
service provided
considered include the diversity of tasks to be per-
in nearly two-thirds (4,015) of the facilities.
the facility the more likelihood there was of find-
formed, the need for replacements due to turnover,
Not only were specific types of inservice educa-
ing such an agreement (table 46).
Reports of services provided
Facilities
Total
the requirements for certain levels and kind of
Once an agreement is negotiated, there must be
Yes
No
tional programs often absent, 20.2 percent (1,334)
staff performance, the services offered to patients,
of the facilities did not maintain staff develop-
evidence that the services of the consultant are
Number
6,591
3,789
2,802
the various types of specific functions performed
ment records containing the names of attendees
provided. When acting as a consultant, the out-
Percent
100.0
57.5
42.5
by the facility, the number of patients in the facil-
and the subject matter covered. Also, there was
side resource must furnish regular reports to the
FORD
37
36
588-459 O
LIBRARY
Table 48.-Number and percent of SNFs in which the consultant apprises
it is quite possible that many are not fully aware
FISCAL MANAGEMENT
3. Future surveys taking 1 and 2 into con-
the administrator through written reports of his recommendations
sideration should be conducted to obtain
of their responsibilities. Clearly, these individuals
The goals of the financial information aspect of
data for a cost-of-care index.
need direction in how they can best perform their
the survey were: (1) To obtain data upon which
4. More research should be done on the relation-
Reports of recommendations
Facilities
Total
duties and responsibilities more effectively and
to base national estimates of the cost of care in a
ship of the costs of nursing home care to the
Yes
No
ensure that the nursing home they operate will
quality of services provided SO that the differ-
skilled nursing facility (SNF) certified under the
ences between SNF care and ICF care can be
Number
6,591
4,057
2,534
provide care of high quality.
Medicare program, the Medicaid program, or
determined.
Percent
100.0
61.6
38.4
Additionally, it would be helpful to develop and
both; (2) to test the applicability of this survey
5. Future surveys should be undertaken to esti-
issue concrete examples, applicable to each type of
method for setting up a monthly cost-of-care index
mate the cost of improving each facility so
facility sponsorship, of the kinds of matters prop-
that it meets the standards of the Medicare
on a national and regional basis; and (3) to ex-
Table 49.-Number and percent of SNFs in which the consultant apprises
erly requiring governing body action, as well as
and Medicaid programs for which it is
the administrator through written reports of plans for implementation of his
plore the possibility of identifying relationships
certified.
recommendations
model minutes and mechanism and procedures for
between the cost data reported and data re-
transmitting their decisions to the administrator
ported on facilities, administrators, and patient
Rigorous cost hypotheses concerning the type
Reports of plans for recom-
and staff of the facility. This could be similar to
characteristics.
of control and ownership of nursing homes, the
Facility
Total
mendations
the kinds of assistance, such as seminars and man-
Unfortunately, the cost data obtained were not
size, the major source of cost reimbursement and
Yes
No
uals, provided by and through the American Hos-
other factors that influence the financial variables
of the caliber sufficient to allow these goals to be
pital Association to hospital trustees.
Number
6,591
fulfilled. The fact that survey visits were unan-
need to be tested. Application here of the statisti-
3,597
2,994
Percent
100.0
54.6
45.4
2. The nursing home administrator is not con-
cal method of regression analysis may be useful
nounced aided the objectivity of the data collected
sistently "managing" to contribute to care of high
SO that the researcher can examine the influence
for the other assessment measures, but the unavail-
quality. Patients in these facilities are probably
of each important factor on a dependent variable.
ability of the cost data at the time of the visit led
Summary of Findings*
not receiving the quality of services to which they
Particular attention could be given to the influence
are entitled.
to sizable nonresponses for many financial infor-
on total expense per patient per day of (1) Dif-
The governing body frequently does not dis-
3. As indicated, a large number of facilities do
mation survey items. The cost data were often not
ferent proportions of Medicare and Medicaid
charge its obligations in a consistently effec-
not have written agreements with outside re-
on hand in the facility but retained in an ac-
patients (or beds) to total patients (or beds) in an
tive manner.
The administrator's overall direction for the
sources for the provision of health care services
countant's office or in the corporate headquarters
institution; (2) the type of control of the skilled
of a nursing home chain. Because the Office of
nursing facility; and (3) the payroll expenses,
operation of the facility is not always con-
and consultation. The data do not indicate the
sonant with his professional status and re-
proportion of these facilities which in fact fur-
Nursing Home Affairs promised the SNFs that
especially employee wages. For example, a regres-
sponsibilities.
nished needed health services to their patients and
their identity would be held in strict confidence,
sion analysis of the differences between private
Policies of the facility are in most instances
obtained consultation despite the absence of agree-
it was not possible to follow up on the non-
pay patients' charges and the Medicare or Medi-
documented but often not implemented.
Patient care policies often lack input from
ments. The failure of the facility, however, to
responses.
caid patients' costs might be fruitful.
health care professionals other than physi-
formalize the responsibilities of those practitioners
Another problem was the use of many different
cians and nurses.
and consultants by written agreements leads to a
accounting systems. Under these circumstances,
HEALTH AND SAFETY OF THE ENVIRONMENT
Personnel management practices do not ap-
lack of clarity in defining their role and responsi-
the surveyors assessing cost factors were instructed
pear to contribute to personnel resources that
bility in providing services. Furthermore, because
Both Congress and the Department recognize
enhance the quality of patient care rendered.
to record data from Medicare on State Medicaid
of uncertainty, the full scope of services required
the need for providing a nursing home environ-
Management does not consistently provide the
Cost Reports whenever possible and to use the
opportunity for or encourage staff to develop
by many patients may not be provided. Ultimately,
ment which adequately protects patients against
facility's financial statements only when the pro-
new skills and update existing ones.
the lack of written agreements adversely affects
health and fire hazards. The requirements man-
Outside resources are often not utilized, and
gram cost reports were not available.
facility performance and the quality of care pro-
dated by Congress in the Medicare and Medicaid
when they are, management frequently fails
Although data analyses could not be made as
vided and facilities should be consistent in obtain-
law are those contained in the institutional occu-
to act upon their findings and recommenda-
anticipated, inferences and implications can be
pancy section of the 1967 Life Safety Code. The
tions.
ing agreements with outside resources.
4. There are clear implications that State nurs-
drawn from the very fact that obtaining financial
code is a publication of the National Fire Protec-
information was SO difficult:
ing home licensure programs are licensing individ-
tion Association and its requirements are intended
Conclusions and Implications
uals who are ineffective administrators. A review
1. The unannounced survey method is inappro-
to provide a reasonable degree of safety against
1. There is considerable evidence that the gov-
of nursing home administrator licensure proce-
priate for obtaining cost data as data were
not only fire but also its by-products, i.e., smoke,
erning bodies of a large number of facilities do
dures should be explored to determine what statu-
not readily available and the confidentiality
heat, and toxic fumes.
requirement precluded following up on non-
The Life Safety Code requirements generally
not properly carry out their duties and responsi-
tory or regulatory changes are needed to ensure
responsive financial information data sources.
bilities in an effective manner, thus inhibiting the
2. Efforts should be made toward achieving a
address the following areas: Fire and smoke con-
that only fully qualified and capable individuals
delivery of high quality care. The education, back-
are licensed as nursing home administrators.
national uniform system of accounts for
tainment, safe and orderly evacuation of patients,
Further, consideration should be given to require
nursing homes. Nursing home accounting
and limiting the potential fuel for fire. In all cases,
grounds, interests, and motives of members of gov-
the suspension or revocation of the license of an
systems do not appear to be able to maintain
these requirements must be met. However, what
erning bodies of nursing facilities are varied and
monthly statements because of accruals.
administrator whose facility is found to have a
specific individual requirements a facility must
There appears to be a need for a continuing
* Federal regulations are used as a minimum standard
pattern of serious deficiencies in successive certifi-
panel to assist in developing a uniform
meet to be in compliance with these general ob-
and as a basis for comparison.
cation surveys.
system.
jectives are in great part determined by the facili-
39
38
ty's construction type. In other words, buildings
ments that were not met. It is to be noted that a
Table 50B.-Number and percent of skilled nursing facilities in the deficiency
Table 52.-Number and percent of skilled nursing facilities meeting Life Safety
that have a lesser resistance to fire will have more
substantial majority of facilities 4,813 (73 per-
range between 0-9
Code requirements by order of magnitude
stringent requirements than those that have a
cent) had fewer than 10 requirements that were
not met. The distribution of deficiencies among
Deficiency range 0-9
Number of
Percent of
Survey
Facilities
greater resistance to fire. Therefore, it is essential
facilities
facilities
code
Requirement
that a building be evaluated as a whole rather than
No.
Number
Percent
these facilities (0-9 deficiencies) is shown in table
evaluating one requirement at a time. Addition-
50B. It is to be noted that 293 facilities (6 percent)
Total, 0-9
4,813 1
100.0
4-5
Proper windows in patient rooms
6,418
97.4
ally, the code recognizes that while the ideal is to be
had no deficiencies with an additional 476 others
293
6.1
4-6
Proper doors in fire and smoke partitions
6,408
97.2
0
sought, it is more often than not unattainable. Ac-
or (9.9 percent) with but a single deficiency. There
476
9.9
4-2
Door width
6,378
96.8
1
550
11.4
4-1
Travel distance to exits
6,362
96.5
cordingly, it provides for exemptions to code re-
were certain requirements that were more fre-
2
411
8.6
3-8
Horizontal exits
6,360
96.5
3.
quirements where the State fire authority can
521
10.8
6-6
Absence of space heaters
6,339
96.2
quently found to be "not met" than others. (See
4.
631
13.1
3-1
Stairs and smokeproof towers meet required classification
6,248
94.8
document that correction of a deficiency would not
table 51.) Many of the requirements shown in
5.
647
13.5
3-10
Room egress
6,201
94.1
6.
enhance patient safety and would cause undue
table 51 can be met with little or no additional
7.
628
13.0
3-6
Accessibility to exits
6,142
93.2
92.6
255
5.3
5-4
Automatic emergency lighting
6,104
hardship on the provider. For example, the code
expense. Examples include: Illumination of exit
8.
399
8.3
5-11
Manually operated fire alarm system
6,096
92.5
9
requires that patient room doors be not less than
6-2
Portable fire extinguishers
6,086
92.3
signs, weekly testing of fire alarm systems, posting
6-8
Fire protection plan is in effect and available
6,062
92.0
40 inches in width. If the doors in question are 35
of smoking regulations, electrical monitoring of
6-3
Proper maintenance of fire extinguishers
6,050
91.8
The total 4,813 is correct for the 0-9 group of facilities. A difference of 2 (4,811
inches in width the fire authority could waive the
3-7
Capacity of exits
6,033
91.5
sprinkler control valves, and the posting of evac-
rather than 4,813) will be found when the subgroup totals are added together due to
4-3
Proper locks on patient room doors
5,985
90.8
requirement.
uation plans. These are indicated in table 52.
having the subgroup totals calculated separately.
3-9
Corridors are of required width
5,841
88.6
In any event, the requirements must be consid-
5-3
Proper emergency lighting
5,836
88.5
The data also revealed that there were eight
5-5
Interior finish of walls and ceilings meet required classifi-
ered together with the design features of a facility,
construction types among the 6,591 facilities. The
Table 51.-Number and percent of skilled nursing facilities not meeting Life
cation
5,815
88.2
including furniture arrangements, in order to
Safety Code requirements by order of magnitude
6-13
Noncombustible wastebaskets
5,801
88.0
number by type in descending order of frequency
6-11
Furnishings and decorations do not obstruct exits
5,747
87.2
make a decision as to whether or not a particular
is as follows:
3-5
Proper number and type of exits
5,552
84.2
facility provides adequate protection against fire
Survey
Facilities
5-1
Proper illumination of exit and directional signs
5,551
84.2
code
Requirement
Type
Number
Percent
no.
Number
Percent
6-10
Fire drills
5,546
84.1
hazards. For this reason, it is not possible to judge
All types
6, 591
100. 0
whether a facility provides adequate safeguards
Fire resistive
740
26. 4
4-8
Proper illumination of exit signs
3,433
52.1
against fire hazards solely on the basis of the num-
Protected wood frame
1,668
25. 3
6-1
Weekly testing of fire alarm system
3,210
48.7
ber of requirements not met.
Protected noncombustible
6-14
Adoption, implementation, and posting of smoking regu-
2. Nursing home administrators need to be
866
13. 1
lations
2,454
37.2
knowledgeable about fire safety requirements;
The recently revised Fire Safety Survey Report
Protected ordinary
634
9.6
6-4
Fire protection of hazardous areas
2,161
32.8
Ordinary
619
9.4
5-10
Electrical monitoring of main sprinkler control valve
2,058
31.2
and
Form developed by the Federal Government and
Mixed types
568
8.6
6-12
Flame retardant draperies and curtains
1,940
29.4
3. The Office of Long Term Care Standards En-
presently used by State surveyors to inspect long-
6-5
Maintenance of air conditioning and ventilating equip-
forcement in the DHEW regional offices need
Wood frame
320
9
ment.
1,925
29.2
term care facilities was selected as one of the Long-
to increase regional validation surveys to
Noncombustible
176
2.7
2-10
Doors to hazardous areas are not to be held open auto-
Term Care Facility Improvement Campaign in-
matically
1,759
26.7
assure that State fire authorities are accu-
Among the eight construction types, over one-
5-8
Maintenance, testing, and inspection of automatic sprin-
rately assessing Life Safety Code compliance.
struments with minor modifications. The objective
kler system
1,663
25.2
of this part of the survey was to ascertain the
fourth (26.4 percent) were of fire-resistive con-
2-1
Compliance with construction requirement.
1,491
22.6
struction. This is the type of construction which is
5-7
Automatic sprinkler protection
1,451
22.0
number and type of fire safety requirements that
2-2
Proper separation of corridor walls from sleeping rooms
1,445
21.9
References
were met or not met. There was no investigation
most resistive to fire and it does not require an
5-9
Electrical interconnection of sprinkler system with fire
1. U.S. Department of Health, Education, and Welfare.
as to whether the State fire authority had excused
automatic sprinkler system. Protected wood frame
alarm system
1,402
21.3
4-7
Proper notice on stairwell doors
1,280
19.4
Public Health Service. Nursing Homes Environmen-
the provider from meeting the requirement, nor
construction, on the other hand, is more susceptible
6-9
Evacuation plan is posted in prominent locations
1,275
19.3
tal Health Factors. PHS Pub. No. 1009 (Washington,
2-3
Proper door to patient rooms and treatment room
1,264
19.2
whether the provider had plans to, or was in the
to fire and the Life Safety Code requires that fa-
7-1
Nonflammable medical gas systems
1,067
16.2
D.C.: U.S. Government Printing Office, February
process of meeting the requirements. Conse-
cilities of this type of construction have automatic
1967), p. iii.
2. General Services Administration. Office of the Fed-
quently, no conclusions are drawn concerning the
sprinkler systems. The Life Safety Code contains
eral Register. Code of Federal Regulations, Title 20,
number of facilities that are or are not in compli-
definitions for the various construction types (13).
Conclusions and Implications
Employee's Benefits, Chapter III Social Security Ad-
ance with code requirements. The data obtained
ministration, Department of Health, Education, and
were analyzed to determine program implications.
In deciding whether or not an individual facility
Welfare 405.1120 Conditions of Participation Gov-
The Fire Safety Survey Report Form consists
Table 50A.-Number and percent of skilled nursing facilities and range in
complies with the Life Safety Code requirements,
erning Body and Management, Washington, D.C.: U.S.
number of deficiencies
Government Printing Office, Apr. 1, 1974, p. 521.
of 61 requirements against which a facility is
State surveyors must exercise a great deal of pro-
3. Springer, Eric W., et al. "The Administrator." Nurs-
surveyed, not less than once annually, by the State
Number of deficiencies
Number of
Percent of
fessional judgment. The number, type, and the
ing Home Law Manual. (Pittsburgh Aspen Systems
fire authority. The analysis of the fire safety data
facilities
facilities
interrelation of deficiencies are considered. Thus a
Corporation, 1972), p. 12.
when projected to the total number of long-term
Total, to 36
6,591
100.0
judgment must be made on a case-by-case basis.
4. Ibid, pp. 1-22.
care facilities indicated that few facilities actually
Data obtained in the study indicate that:
5. U.S. Department of Health, Education, and Welfare,
0 9.
met all of the Life Safety Code requirements.
4,813
73.0
Bureau of Quality Assurance, Interpretive Guidelines
10 19
1,341
20.3
Table 50A shows the breakdown for the 6,591 fa-
20 29
388
5.9
1. State surveyors need to be better qualified to
and Survey Procedures for the Application of the Con-
30 36
49
.8
assess fire safety requirements that are not
ditions of Participation for Skilled Nursing Facilities.
cilities (100 percent) that have 0 to 36 require-
met;
Nov. 6, 1974, pp. 86 and 100.
40
41
CHAPTER 7
6. Mathieu, Robert P. Hospital and Nursing Home Man-
Nursing Home. (Boston: Caliners Publishing Co., Inc.,
agement. (Philadelphia: W. B. Saunders Co., 1971),
1972), p. 20.
p. 5.
10. McQuillan, Florence L., op. cit., p. 70.
7. McQuillan, Florence L. Fundamentals of Nursing
11. Rogers, op. cit., p. 17.
Home Administration. (Philadelphia W. B. Saun-
12. McQuillan, Florence L., op. cit., p. 70.
ders Co., 1974), p. 77.
13. National Fire Protection Association. Code for Safety
8. U.S. Department of Health, Education, and Welfare,
to Life from Fire in Buildings and Structures. NFPA
Bureau of Quality Assurance, op. cit., p. 4.
No. 101-1967. Boston: National Fire Protection As-
Patient Care Services
9. Rogers, Wesley, Wiley. General Administration in the
sociation, 1967. 209 pp.
For the long-term care patient, the goals of care
The discussion of each service generally includes
are to manage disease states; correct, restore, or
a description of measurement criteria, discussion
maintain biological functions; and support the
of findings in the specific area of inquiry, con-
psychosocial needs that arise as a consequence of
clusions reached, and implications of the findings.
chronic illness, the aging process or institutionali-
Priorities for action are detailed in the introduc-
zation. The components of care are monitoring
tory chapter on summary findings, implications,
and maintaining vital functions, curative care,
and recommendations.
rehabilitation, prevention, and guidance in psy-
chosocial problems. The services through which
care is provided strive to assist the patient to
PHYSICIAN SERVICES
become maximally independent in functioning, in
The medical care and management of the long-
carrying out their own programs of required
term care patient presents a particular challenge
therapy and in attaining or maintaining their
to the physician. The pathology and symptomatol-
optimal level of health and well-being.
ogy presented by the chronically ill and aged and
Providing patient care in terms of the individ-
ual's physical, functional and psychosocial needs
their unique response to prescribed treatment de-
mand keen discernment and an individualized
requires an overall assessment of the patient's
condition and the needs for care and the develop-
medical care plan. Perhaps no other group re-
ment of a patient care plan by the total profes-
quires a higher level of performance of the art
sional staff specifying the services to be given and
and application of the science of medicine.
the goals to be accomplished. Evaluating the re-
Traditionally, nursing homes have not had a
sults of care and the patient's response is equally
full-time house staff and daily medical supervision
as important for obtaining indications of the ade-
by the private attending physicians is often absent.
quacy of care given and additional requirements.
The attending physician has primary professional
In the survey, services provided in skilled nursing
and legal responsibility for the medical assessment
facilities to the beneficiaries of the Medicare and
and management of his patients in skilled nurs-
Medicaid programs were examined as they related
ing facilities. This includes establishing a diag-
to the service requirements of these patients.
nosis, prescribing treatments, diet, medications,
The survey did not include an inventory of num-
and rehabilitative therapies and providing su-
bers and kinds of personnel employed by the
pervision and followup of those patients under
skilled nursing facilities. Some data and informa-
his care.
tion are included relative to staffing patterns for
It was recognized from the beginning that the
specialized services and arrangements for con-
data gathered about physician care, although
sultative and supervisory services. The 1973-74
allowing significant statements about the type and
Nursing Home Survey conducted by the National
timing of health care delivery, would not be suf-
Center for Health Statistics contains data on the
ficient to evaluate the "quality" of physician serv-
number and type of full-time equivalent employees
ices in the settings surveyed. It is quite difficult to
providing care (1). Nursing staff are categorized
assess the quality of medical care that patients are
by level of education and training and other per-
receiving on the basis of a questionnaire survey.
sonnel are classified by professional and nonpro-
This problem resides in the nature of the medical
fessional status.
care process. A patient may have a diagnosis, a
43
42
record that shows a physician visits at least every
example, a discharge summary was received from
month, a review of this care every 30 days, etc.,
the transferring institution in nearly 75 percent
alternate schedule may be justified by the phy-
the early months (up to 4 months) of institution-
and still receive poor quality medical care.
of the cases; and in nearly 90 percent of these
sician up to every 60 days. In the immediate 4
alization where a schedule of visits every 30 days
Whether this is due to an erroneous diagnosis or
cases, this discharge summary was received in
months preceding the survey, the attending phy-
is applied in 9 out of 10 patients. Three out of four
an overlooked problem, or signing patients' rec-
advance of, or at the time of, admission. In addi-
sician had carried out visits every 30 days for
longer-stay patients had their program of care
ords 6 months in advance needs further study.
tion, for two-thirds of the patients where the dis-
nearly 4 out of 5 patients. Table 53 shows that the
reviewed by their physician every 30 days.
Thus, an assessment of the quality of care de-
charge summary was not received or was judged
length of stay in the institution affects only slight-
Table 54 shows a composite answer to the ques-
livered is related to the state of the art of evaluat-
by the surveyor to be inadequate, additional in-
ly the proportion of patients whose physicians
tion of whether a physician visited the institution
ing quality of care, the nature of the survey, and
formation had been received within 48 hours of
review and revise their plan of care except for
to review the care plan and at the same time ac-
information provided. Reliance only on a patient's
admission. One in seven patients had no discharge
records provides only a partial picture of the pa-
summary, or additional information; or it was
tient's condition and services provided.
impossible to determine that basic information
Table 53.-Review of the total program of care by the attending physician during a visit at least every 30 days (in the 4 months immediately preceding survey) by
While other team members were usually able to
length of stay
had been submitted to the nursing home in time
discuss their specialty areas with the appropriate
to allow for appropriate immediate care follow-
Program of care reviewed
facility representative, physicians or medical di-
ing admission. Notations by the survey physicians
Total
Yes
No
rectors were seldom available to team physicians.
indicated that in many instances the information
Length of stay
Therefore, team physicians relied on the follow-
Number
Percent
Number
Percent
Number
Percent
was supplied later than 48 hours as required by
ing: (1) The facility's written policies and pro-
regulations and a few days to a few weeks elapsed
Total
283,400
100.0
221,700
78.2
61,700
21.8
cedures; (2) the medical records of the selected
before the admitting nursing home had informa-
patients; and (3) interviews with pertinent per-
100.0
41,200
90.4
4,400
9.6
tion as to medical findings, diagnoses, or immedi-
Less than mo
45,600
4 to 12 mo
46,200
100.0
34,400
74.5
11,800
25.5
sons from the facility staff. The medical record
ate orders for many patients.
1 to yr
74,400
100.0
58,600
78.8
15,800
21.2
perusal was limited to the current chart, except
More than 3 yr
61,500
100.0
45,000
73.2
16,500
26.8
On the other hand, in terms of patients trans-
Unspecified
55,700
100.0
42,500
76.3
13,200
23.7
where review of old records was necessary to de-
ferred from the community, the physician ex-
termine admission information for long-stay pa-
amined 56 percent of them within 48 hours yet
tients. Selected patients were seen or examined as
he provided medical findings for only 31 percent
deemed necessary. Many items such as discharge
of the patients, diagnoses for 41 percent, and im-
summaries, supplemental information on admis-
Table 54.-Review of the total program of care by the attending physician during a visit at least every 30 days (in the 4 months immediately preceding survey) by
mediate orders for almost 42 percent. These per-
length of stay and by whether the physician saw the patient at the time of each visit
sion, progress notes, or records of histories taken
centages also reflect that in nearly 50 percent of
and physical examinations done were not in the
the records, information of this nature was im-
Program of care reviewed
record at all, or if recorded, were inadequate, late,
Physician saw
possible to determine. Of greatest concern was the
Length of stay
patient
Total
Yes
No
incomplete, or unsigned by the physician. The
fact that many patients' charts on admission re-
Number
Percent
Number
Percent
Number
Percent
patient who had been in the nursing home for
vealed no evidence that the patient had the bene-
Grand total
Total
283,306
100.0
221,646
78.2
61,660
21.8
years was apt only to have very recent records, and
fit of a physician's examination or medical assess-
initial old records were not available for review.
ment. For those transferred from the community,
Yes
259,126
91.5
212,863
75.1
46,263
16.4
No
24,180
8.5
8,783
3.1
15,397
5.4
30.9 percent fell into this category. For those
Less than mo
Total
45,543
100.0
41,172
90.4
4,371
9.6
Admission Data
transferred from another institution, the percent-
age who had neither a discharge summary nor ad-
Yes
42,856
94.1
40,397
88.7
2,459
5.4
Information on medical findings, diagnoses,
No
2,687
5.9
775
1.7
1,912
4.2
functional status, and response to previous treat-
ditional information provided within 48 hours of
admission was about half of that, or 16.7 percent.
12 mo
Total
46,131
100.0
34,356
74.5
11,775
25.5
ment and care, as well as orders to initiate care are
Yes
43,350
94.0
33,394
72.4
9,956
21.6
essential for appropriate immediate care of pa-
No
2,781
6.0
962
2.1
1,819
3.9
tients following admission. Efforts were made by
Continuing Care
Total
74,366
100.0
58,624
78.8
15,742
21.2
the physicians on the survey teams to determine
Continuing physician care following admission
Yes.
69,485
93.4
56,510
76.0
12,975
17.4
the availability of such information supplied by
was another concern of the survey physicians. As
No
4,881
6.6
2,114
2.8
2,767
3.8
the attending physician on patients admitted from
a minimum standard and basis of comparison, the
Over yr
Total
61,525
100.0
44,998
73.1
16,527
26.9
the community. Discharge summaries and orders
Federal regulations require that the attending
Yes
54,835
89.1
42,499
69.0
12,336
20.1
received from transferring facilities were also
physician carry out a review of the patient's total
No
6,690
10.9
2,499
4.1
4,191
6.8
sought by team physicians.
program of care during a visit at least once every
Unspecified
Total
55,741
100.0
42,496
76.3
13,245
23.7
Comparison of patients in terms of the transfer
location reveals some interesting differences. For
30 days. After the first 90 days, for the patient
Yes
48,600
87.2
40,063
71.9
8,537
15.3
requiring skilled nursing, not rehabilitation, an
No
7,141
12.8
2,433
4.4
4,708
8.4
44
45
from the community, where the appropriate diag-
tion of the patients, including laboratory tests
tually saw the patient. It also shows only a slight
stable at three out of four for those institution-
nostic work-up had not been done.
where needed. It was recognized, however, that
diminution of the percentage of patients actually
alized longer.
5. One diagnostic category, senility or chronic
this would be both costly and time consuming,
seen by the physician as the length of stay in-
5. About 9 out of 10 patients were actually
brain syndrome, may be underrecorded on admis-
would require the use of physicians active in clini-
creases from 94.1 percent for those in the institu-
seen by their physician during a visit to the insti-
sion because of the fear the attending physician
cal practice and licensed in the States where the
tion less than 4 months, to 89.1 percent for those
tution and in one in five cases, the physician saw
has of "labeling" a patient and subsequently risk-
nursing homes were to be surveyed, not to mention
there over 3 years. A more definite trend down-
the patient but did not review the care plan. In
ing his classification as "custodial." Further, since
the added and almost impossible burden of ob-
ward from 88.7 percent to 69 percent can be seen
only 3 to 4 percent of patients, the physi-
the attending physician may see the patient only
taining patient consent and attending physician
as the length of stay increases when both questions
cian reviewed the care plan but did not actually
briefly and intermittently, and seldom does a com-
approval on an "unannounced" visit.
are applied, i.e., review of the care plan and pa-
see the patient.
plete physical examination to determine patient
11. The future role and involvement of the med-
tient seen by physician. It also appears that after
status, he may not recognize the development of
ical director should be vital in programs of cor-
the first 4 months of institutionalization, the phy-
Conclusions and Implications
this condition subsequent to admission.
rection of the observed areas of poor quality-
sician sees the patient but does not review the
6. One-third of the diagnoses recorded subse-
poor medical records, inadequate laboratory test-
care plan in about one out of five cases, whereas
1. One needs to question the validity of using a
quent to admission may be directly linked to the
ing, failure to see and/or examine the patient, in-
the reverse of this, where the care plan is reviewed
record review as a source of information on nurs-
quality of care provided in the nursing home, e.g.,
appropriate or overmedication, etc. The medical
but the patient is not seen occurs in only 3 to 4
ing home patients. Physicians reported records as
decubitus ulcers, genito-urinary and respiratory
director (required by January 1, 1976 unless
percent of cases depending on the length of stay.
"incomplete", "mixed up", "not signed". For long-
infections, and fractures. Others, such as arthritis,
waiver is given to the nursing home) would review
Again of greatest concern are the patients who
stay patients, the only record available was of re-
may be the result of immobilization but also might
the policies of the nursing home and revise them
have the advantage of neither of these physician
cent origin, the rest of the record was stored else-
represent an acute flare-up of a longstanding con-
as needed. Acting as liaison between the adminis-
services. This percentage is about the same for all
where.
dition. Some diagnoses, such as blindness, deaf-
trator and attending physicians, he would work
patients about 4 percent except for those in the
2. The reliance of the survey on the recording of
ness, probably represent worsening conditions, un-
toward the improvement of quality of medical
institution over 3 years where it is nearly 7 per-
primary and secondary diagnoses on admission is
reported on admission and be discovered during the
care for all patients. It is expected that the medi-
cent.
influenced by several factors. Examples of these
course of care. Finally, it should be noted that ac-
cal director in most nursing homes would be part
are:
cidental injury is not totally or even well repre-
time, but it was possible for our survey physicians
Summary of Findings
a. For reimbursement purposes (Medicare) pri-
sented by recorded diagnoses of fractures and dis-
in less than 2 days to uncover conditions, mostly by
mary diagnosis must be tied in with reason
locations. Many injuries were of minor character
record review and discussion without staff, that, if
The following summary of findings presents the
for hospitalization, whether or not it is the
and never recorded, and when recorded in prog-
remedied, would greatly improve the quality of
major indicators of the extent of physician in-
reason for nursing home care.
ress notes, were not presented as diagnoses and
care rendered in the institution.
volvement and medical care in skilled nursing
b. Many physicians did not identify primary
thus were not recorded in the survey.
12. Review of the records, and observation, re-
facilities:
and secondary diagnoses as such, merely list-
1. A discharge summary was received for three
ing several diagnoses, of equal importance,
7. Generally, it was evident that laboratory
vealed that some of the patients, usually long-stay,
which may actually be the situation.
services were inadequately used, either in terms of
were no longer in need of skilled nursing care. In
out of four patients admitted from an institution,
c. Whichever diagnoses were identified on ad-
reaching an accurate diagnosis, or in monitoring
other words, they were not eligible for continuing
of which two-thirds were received in advance of
mission may not be the reason for continued
the care given.
reimbursement under Medicaid. Periodic medical
or at least at the time of admission.
care.
8. In terms of overmedication, it appears that
review should have identified such patients no
2. For two out of three patients whose discharge
3. There was underreporting of many impair-
in some instances it is due to failure on the part
longer needing skilled nursing care and if cus-
summaries were not received or were inadequate,
ments such as amputations, loss of sight, or of
of the physician to discontinue orders no longer
todial beds were not available in the facility, ap-
additional information was received by the institu-
hearing, etc., for several reasons:
needed. In other cases, however, there was no
propriate referral to and placement in other com-
tion within 48 hours after admission. Of the total,
clinical evidence of the need for potentially
munity resources should have been carried out.
for one patient in seven, evidence of any discharge
a. The diagnosis (etiology) was listed rather
summary or additional information could not be
than sequelae, e.g., glaucoma-but not im-
dangerous drugs.
13. Although for four out of five patients, the
found in the record.
paired vision.
9. Because the attending physician often failed
attending physician had made monthly visits to
b. The impairment was longstanding and al-
to do a physical examination, or provide medical
the facility, these often were reported to be per-
3. In terms of patients transferred from out
though appearing in the record of physicians'
findings and orders for the patient on admission
functory and did not include a careful assessment
of institutional settings, over one-half were not
examinations, was not identified as a diag-
directly from the community, one might ask if the
of the patient's medical care needs. Some patients
examined by the attending physician within 48
nosis, or condition on admission, e.g., ampu-
tation of leg following gangrene.
3-day prior hospitalization required to qualify for
never saw the physician at all, particularly long-
hours of admission, only 3 in 10 had recorded
c. Impairments were not recognized because of
Medicare extended care benefits is in addition an
stay patients. Thus, in too many cases, the attend-
medical findings, and 4 in 10 immediate physi-
lack of accurate testing on admission or dur-
opportunity to provide a complete work-up neces-
ing physician spent less and less time on those who
cian's orders for care.
ing the course of care, e.g., no vision and hear-
sary for adequate continuing care.
might indeed have needed his services more.
4. In the immediate 4 months preceding the sur-
ing tests were conducted to determine if im-
10. In terms of the survey itself, the physicians
14. It was unfortunate that a dentist could not
vey, the records showed that attending physicians
pairment was present.
were quick to point out that assessment of quality
have been a member of the team, but as in several
had made visits every 30 days to review the plan
4. Other diagnoses were not recorded by the at-
of care through record review alone was inade-
areas, physical therapists covered occupational
of care for four out of five patients. This propor-
tending physician at the time of admission, pos-
quate. This suggests that quality assessment by
therapy, social workers covered recreational activ-
tion was higher-9 out of 10-for those in the
sibly because he was unaware of the condition.
physicians would require more careful examina-
ities, the physician had to cover this part of the
facility less than 4 months, but remained fairly
This is most apparent in those transferred directly
47
46
assessment. Even though only a gross estimate of
Specialized Rehabilitative Services
need was possible, dental health seemed to be the
may have more than one specialized rehabilitative
Frequency of Treatments
The majority of patients in SNFs receiving
service need. In relation to need, physical therapy
largest problem existing among the younger pa-
tients, i.e., those primarily with developmental
specialized rehabilitative services were receiving
was more often provided than the other two ther-
Data on the frequency with which patients re-
disabilities who had been transferred from an-
physical therapy; 40,949 patients or about 14 per-
apies. Almost 90 percent of patients in need of
ceived physical therapy was available for 37,368
other institution to the nursing home. Since the
cent of the patient population. Less than 4 percent
occupational therapy and an equal proportion in
of the 40,949 patients receiving this service. Esti-
other institution was most frequently a State fa-
received occupational therapy and about 1 percent
need of speech therapy were not receiving the
mated frequencies of treatment reveal that 55.8
cility for the mentally retarded, one can hypothe-
received speech therapy (table 55).
service. About 70 percent of patients needing
percent of these patients receiving physical ther-
size that dental care was poor or nonexistent in
The therapist surveyors judgment of the need
physical therapy were not receiving it.
apy received these services at least once a day. An
that institution.
for physical therapy, occupational therapy, and
additional 29 percent received these treatments two
speech therapy was based on a review of the pa-
or three times each week. The remaining patients
Utilization of Specialized Rehabilitative Services
tient's diagnosis, observed functional status, medi-
either received them on a weekly or less frequent
REHABILITATIVE SERVICES
cal records, and discussion with staff, patients and
Nursing homes were utilizing physical thera-
basis (6.7 percent) or the frequency of their treat-
other survey team members. The following esti-
pists more frequently than other rehabilitative
ment was not determined or not available (8.1 per-
A large number of long-term care patients have
mates of need were made: Among the total patient
specialists. It was estimated that 72.2 percent of
cent) (table 60). Estimates regarding the fre-
been disabled by chronic illness or injury and re-
population of 283,912, 47.9 percent needed physi-
skilled nursing facilities in the nation employed
quency of speech therapy and occupational therapy
quire specialized rehabilitative services and long
cal therapy, 35 percent needed occupational ther-
or contracted with physical therapists to provide
could not be determined from the available data.
periods of care and supervision. The objectives of
apy, and 13 percent needed speech therapy. (See
services. Approximately 40 percent of SNFs pro-
such services include restoring patients to their
table 56.)
vided the services of speech therapists and about
highest possible levels of physical, psychological,
A patient's estimated need for specialized reha-
32 percent had arrangements to provide occupa-
Table 60.-Frequency of physical therapy treatments
and social functions; to prevent deformities; to
bilitative services is compared with the estimated
tional therapy (table 58).
retard the rate of deterioration in progressively
number receiving each of these services, that is,
Patients
Frequency of treatment(s)
degenerating conditions; and to teach patients to
physical therapy, occupational therapy and speech
Number
Percent
Table 58.-Number and percent of SNFs employing or contracting for
function effectively and independently within
therapy in table 57. It is to be noted that a patient
specialized rehabilitative services
their limitations. Such services include tests,
Total
37,368
100.0
Facilities
measurements and various therapeutic modalities
Table 55.-Patients receiving specialized rehabilitative services in skilled
(1) Atleast once a day.
20,864
55.8
nursing facilities
Specialized rehabilitative services
Number
Percent
(2) Two or three times week
10,980
29.4
and procedures directed at improving such func-
(3) Once week or less
2,509
6.7
tions as eating, toileting, dressing, sitting, turning,
Patients
(4) Frequency not available or not determined
3,015
8.1
Specialized rehabilitative services
Total
6,591
100.0
standing, walking, wheeling, transferring, and the
Number
Percent
Physical therapy
4,757
72.2
use of prosthetic devices. They are also concerned
Occupational therapy
2,640
40.1
Total
283,913
100.0
Speech therapy
2,094
31.8
with verbal and nonverbal communication, the re-
Characteristics of the Services
direction of interests, and motivating, encourag-
Physical therapy.
40,949
14.4
Occupational therapy
10,818
3.8
It is important in providing rehabilitative serv-
ing, and keeping patients physically, mentally and
Speech therapy
3,988
1.4
Skilled nursing facilities of 100 beds or more on
ices that the plan for therapy be written and be
socially active. The three principal rehabilitative
the average were more likely to provide physical
coordinated with the patient's total plan of care.
services considered in this survey were physical,
Table 56.-Estimated need for specialized rehabilitative services among patients
therapy, speech therapy, and/or occupational ther-
Information on patients' plans of care were avail-
in skilled nursing facilities (SNFs)
occupational, and speech therapy.
apy. These services were somewhat less likely to be
able for 39,360 of the 40,949 patients receiving
This portion of the survey was accomplished by
Total patients
Estimated need
available in homes having between 50 and 90 beds
physical therapy. For slightly more than half of
Specialized rehabilitative services
qualified physical therapists who evaluated the
Number
Percent
Number
Percent
and least likely to be available in facilities with
these patients receiving physical therapy services
physical, occupational, and speech therapy serv-
fewer than 50 beds (table 59).
(55.8 percent), written plans of care were coordi-
Physical therapy.
283,912
100.0
133,438
47.0
ices provided by the facilities, in collaboration
Occupational therapy
283,912
100.0
99,369
35.0
with the other members of the multidiscipline sur-
Speech therapy
283,912
100.0
36,908
13.0
vey team. The therapists assessed patient's needs
Table 59.-Number and percent of SNFs providing rehabilitative personnel specializing in physical therapy, speech therapy, and occupational therapy by
for service, and examined the organizational struc-
Table 57.-Patients identified as needing specialized rehabilitative services
bed size of facility
and the estimated number and percent receiving and not receiving these
ture, physical facilities, coordination of services,
services
and other conditions under which the services were
Facilities providing services
Total
Specialized
Estimated need
Receiving service
Not receiving
Bed size strata
rendered. They also reviewed factors related to
Physical therapy
Speech therapy
Occupational therapy
rehabilitative
service
services
Number
Percent
Number
Percent
Number
Percent
Number
Percent
quality of services, and completed selected sections
Number
Percent
Number
Percent
Number
Percent
of the patient assessment portion of the survey.
All strata
Physical therapy
133,438
100.0
40,949
30.7
92,489
69.3
6,591
100.0
4,757
100.0
2,640
100.0
2,094
100.0
This report contains the significant findings of
Occupational therapy
99,369
100.0
10,818
10.9
88,551
89.1
0 49 beds
1,239
18.8
694
14.6
362
13.7
289
13.8
the rehabilitative services aspects of this survey
Speech therapy
36,908
100.0
3,988
10.8
32,920
89.2
50 99 beds
2,675
40.6
1,949
41.0
860
32.6
679
32.4
100 or more beds
effort.
2,677
40.6
2,114
44.4
1,418
53.7
1,126
53.8
1 Note a patient may have more than one specialized rehabilitative service need.
48
49
ten policies for preventive maintenance is as fol-
nated with the patients' total plan of care. The
At least 8 of every 10 providers of specialized
necessary, to assist facilities to meet them. This
lows: Physical therapy-3,737 facilities or 56.7
nursing staff participated in the rehabilitative pro-
rehabilitative services met the Medicare/Medicaid
implies: (a) A need for better trained surveyors;
grams of about 58 percent of the patients receiving
Qualification Requirements. About half of the
percent; occupational therapy-2,039 facilities or
(b) an increased utilization of specialized rehab-
30.9 percent; and speech therapy-1,566 facilities
physical therapy services. These figures suggest
facilities had written organizational plans for
ilitative personnel to survey skilled nursing fa-
or 23.8 percent.
that coordinating the patient's specialized reha-
achieving objectives of the various specialized re-
cilities; and (c) provision for consultation to the
bilitative service plan of care with the total plan
habilitative services. Except for speech therapy at
Without preventive maintenance policies, de-
facilities and to other disciplines who are required
of care may influence whether the nursing service
least half of all facilities had written service pro-
terioration of this equipment is more likely to go
to survey specialized rehabilitation services.
unobserved, subjecting patients and staff to un-
participates in the patient's rehabilitative program
cedures. (See table 62.)
3. It is urgent that attention be given to
necessary hazards.
(table 61). This type of data unfortunately was
the financial reimbursement aspects of these serv-
not available for either occupational therapy or
ices. Slow and inadequate reimbursement appears
Space and Equipment
speech therapy.
Summary of Findings
to affect the delivery of appropriate services in
The most desirable arrangement is to have the
many instances while in other situations fiscal
Table 61.-Characteristics of the physical therapy service provided patients
facility provide a specific space with sufficient
The survey substantiates that there are many
abuse of the program appears to be occurring.
patients in skilled nursing facilities who need
Patients
equipment for patients needing specialized reha-
specialized rehabilitative services that are not re-
Characteristics of service
Total
Frequency of finding
bilitative services. These provisions are often lack-
PHARMACEUTICAL SERVICES
ceiving them.
number
Number
Percent
ing. Accommodations for physical therapy were
The survey further substantiates that there is a
Pharmaceutical services are an essential and
found most often. (See table 63.) Sixty-five per-
significant lack of other critical elements in the
Treatments according to written plan
39,360
26,397
cent of SNFs had a specific space for physical
integral component of the total spectrum of serv-
67.1
Therapy plan identifies objectives
39,360
23,335
59.3
specialized rehabilitation services of facilities:
therapy services while a slightly smaller propor-
ices provided to patients in skilled nursing facili-
Plan identifies procedures and modalities
39,360
27,379
69.6
1. Many facilities are not observing the prin-
Written plan coordinated with total plan of
tion, 57 percent, had sufficient equipment.
ties. Of the various therapies (physical, occupa-
ciples of electrical safety, particularly with
care
39,360
21,975
55.8
Surveyors looked at equipment to determine
tional, speech, etc.), chemotherapy has become a
Nursing staff participates in rehabilitation
occupational therapy and speech therapy
program
39,360
22,702
whether: (1) Equipment used for therapy was
principal element in the restoration of the pa-
57.7
equipment.
safe and structurally sound; (2) accepted electri-
tient to optimal physiological and psychological
2. Preventive maintenance policies and proced-
cal safety principles were met; and (3) preven-
ure for rehabilitative equipment are absent in
body function.
Only a small number of patients, 45,009 or about
tive maintenance was being carried out.
many facilities.
The delivery of quality chemotherapeutic or
16 percent of patients in skilled nursing facilities
The continued safety of the specialized reha-
3. Many rehabilitative plans of care do not in-
pharmaceutical services in the institutional setting
clude treatment objectives.
bilitation services equipment is of concern because
requires the combined talents of three professions:
had baseline data from initial rehabilitation tests
4. There is a lack of documentation of baseline
and measurements recorded in their medical rec-
many of the facilities providing services did not
Medicine, pharmacy, and nursing. The goal that
data from initial rehabilitative tests and
ords when such tests were applicable. About 11
have written policies for preventive maintenance
measurements in patients' medical records.
these three disciplines strive to attain is to assure
percent of patients (or 31,553) had joint motion
for their specialized rehabilitation equipment. The
5. Many specialized rehabilitation plans of care
that the right drug is prescribed for the patient's
are not being coordinated with patient's total
condition; that the prescribed drug is administered
measurements and/or strength tests and measure-
number and proportion of facilities lacking writ-
plans of care.
to the right patient, in the right dose and dosage in-
ments recorded when such tests were applicable.
6. Frequently, nursing personnel do not par-
Table 63.-Space and equipment available to provide specialized rehabilitative
terval; that the drug achieves its desired effect;
The surveyors were asked to determine whether
services in SNFs
ticipate in patient's rehabilitative programs.
and that it does SO without resulting in signifi-
selected factors related to the quality of services
cant adverse effects.
were being met. These indicators were: (1) Person
Facilities
Conclusions and Implications
providing specialized rehabilitative service met the
Sufficient Equipment
The attainment of this goal is dependent on a
Rehabilitative services
Specific Space
Medicare/Medicaid Qualification Requirements;
Number
Percent
Number
Percent
1. Since January 17, 1974, Federal regulations
number of functions, each of which have many
(2) the organization plans for achieving the objec-
for Medicare and Medicaid patients require that
facets. These functions may be classified as fol-
Physical therapy
4,284
65.0
3,758
57.0
Occupational therapy
1,826
27.7
1,343
20.4
participating facilities not admit nor retain
lows:
tives of the service were written; and (3) written
service procedures for the discipline were available.
Speech therapy
889
13.5
713
10.8
patients in need of specialized rehabilitative serv-
1. Drug prescribing;
ices unless they are provided, either directly or
2. Drug ordering (from the pharmacy by nurs-
under arrangements with outside resources. Fed-
ing personnel):
Table 62.-Quality indicators related to specialized rehabilitative services provided in SNFs
eral and State agencies responsible for surveying
3. Drug dispensing;
and certifying skilled nursing facilities need to
4. Drug distributing;
Facilities meeting factors related to services
take appropriate action to make certain that sur-
5. Drug administering and recording;
Selected factors
Physical Therapy
Occupational Therapy
Speech Therapy
6. Drug monitoring;
veyors carefully assess facilities: admission poli-
7. Drug storing and inventorying;
Number
Percent
Number
Percent
Number
Percent
cies, the services they provide, and their patients'
8. Supervising pharmaceutical services;
needs to assure that facilities comply with this
9. Coordinating pharmaceutical services; and
Discipline met medicare qualification requirements.
4,311
91.3
1,739
83.0
2,340
89.1
regulation.
10. Drug counseling.
Written organizational plans for achieving objectives of service
2,776
58.8
1,154
55.1
1,336
50.9
Written service procedures
2,573
54.5
1,086
51.9
1,085
41.3
2. The need exists for surveyors to become more
The principal facets of each of these functions will
cognizant of the reasons for these requirements
be examined in an effort to determine to what ex-
in specialized rehabilitative services, and when
tent the attainment of the above goal is being
50
51
achieved in skilled nursing facilities in this coun-
shown since some drugs can be classified in more
required for the correct administration of medica-
the pharmacist has access to the original physi-
try. It should be noted that these functions are a
than a single category. For example, an analgesic
tion. The patient's individual prescription label
cian's order and the degree to which orders are
measure of the capacity of a facility to attain the
with codeine may also be classified as a controlled
contained each of the following items of informa-
transmitted verbally. In turn, the location of the
stated goal. The actual attainment of that goal is
substance. The detailed discussion of drugs will
tion in close to 99 percent of the time: patient's
pharmacy may affect the amount of time the phar-
dependent upon the diligence and professionalism
be in a forthcoming monograph.
name, prescribing physician's name, name of drug,
macist has available and spends in the SNF for
with which each professional carries out his or her
strength of drug and the prescription number.
patient counseling, staff development, drug regi-
responsibility.
Eighty-eight percent of the time the labels con-
men review and policy development for SNF
Drug Ordering
tained the date dispensed and dispensing instruc-
pharmaceutical services.
This aspect of the drug distribution system is of
tions. Accessory and/or cautionary statements ap-
The primary source of drug supply for SNFs is
Drug Prescribing
particular importance in that a significant num-
peared on 72 percent of the labels and the quantity
the community pharmacy. Currently, almost 89
Although determining whether the right drug
ber of medication errors are created at this point.
dispensed was a surprisingly high 63 percent. On
percent of the facilities are being served profes-
is prescribed for the patient's condition is a critical
It is believed by pharmacists that the interpreta-
the average, 87 percent of the labels included all
sionally by community pharmacists. The remain-
element in providing quality pharmaceutical serv-
tion and transposition of drug orders afford the
of the information listed below (table 65).
ing 11 percent are being supplied by hospital
ices, this survey did not attempt to assess this par-
greatest opportunity for medication errors. The
The imperative nature of the information con-
pharmacies and pharmacy units located within the
ticular function of the service. Since peer review is
most accepted manner of eliminating or reducing
tained on a prescription label cannot be argued.
SNFs.
a more appropriate mechanism, the survey did,
errors at this point is through the use of a physi-
Any diminution in label information results in the
While the survey finding for the numbers of
however, measure physicians' prescribing pat-
cian's order form that provides the pharmacist the
patients being placed at greater risk with respect
community pharmacies were of a significant na-
terns by therapeutic categories. The categories
original physician's order or a direct copy thereof
to medication errors.
ture, the data for the other sources were not indi-
from which drugs are most frequently prescribed
as his working document. The survey attempted
Pharmacists traditionally take great pride in the
vidually significant.
are shown in table 64.
to determine the degree to which drugs were or-
completeness of their labels. The findings of this
There are a number of speculations that can
dered in this manner. The data reveal that the
survey substantiate this attitude. The survey did
be made from this data, but no definitive conclu-
pharmacist receives the original or direct copy of
not attempt to define the professional interpreta-
Administering and Recording
sions can be made from these gross statistics. An-
the physician's order form 24.2 percent of the time.
tion of labeling ascribed to by each pharmacist;
The administration of drugs is another poten-
alysis of the individual drugs prescribed in each
Verbal orders present a particular problem rel-
nor were State pharmacy laws and regulations
tial major source of medication errors in the skilled
of these categories by individual patient will re-
ative to drug ordering in that the person receiving
taken into consideration. In many instances, State
nursing facility. Medication errors have been re-
veal more interesting information from which
the verbal order may misinterpret it. With the
laws do not require the pharmacist to include on
ported in the literature to occur at a rate of from
more definitive conclusions about drug prescribing
myriad of drugs that are pronounced similarly,
the label all of the items included in the survey.
15 to 50 percent (2) (3).
may be made. This analysis may alter the figures
the opportunity for error is increased when orders
A medication error is said to occur when a medi-
are given verbally. With this realization, the orig-
Drug Distributing
cation is administered to the wrong patient, the
Table 64.-Number and percent of patients receiving drugs by drug category in
inal Medicare regulations required that the attend-
wrong drug or dosage strength is administered,
rank order
ing physician countersign these orders within 48
For the skilled nursing facility, the physician's
the wrong dosage form is administered or medica-
Patients
hours. The survey data show that physicians coun-
orders can be filled and drugs distributed from a
tions are administered at the wrong time. Proper
Drug category
Number
Percent
Rank
tersign verbal orders within 48 hours 71.5 percent
community pharmacy, from a pharmacy in a hos-
drug administration is essential to protect the
of the time and that nurses receive and sign these
pital of which the SNF is a part or from a phar-
health and safety of the patient. Prompt and ac-
Cathartics
1,839
53.3
1
verbal orders 96 percent of the time.
macy within the SNF itself. The location of the
curate recording of the administration of drugs is
Analgesics and antipyretics
1,645
47.7
2
Tranquilizers
1,549
44.8
3
Although a significant number of pharmacists
source of supply of drugs can influence the effec-
an essential element of drug administration. The
Other
1,258
36.4
4
are dispensing from the original or direct copy of
tiveness of pharmaceutical services. The proximity
survey attempted to identify who administers
Diuretics
1,169
33.8
5
Vitamins
1,149
33.3
6
the physician's orders and a significant number of
or remoteness of the pharmacy and pharmacist to
medication and the degree to which proper re-
Sedatives and hypnotics
1,147
33.2
7
physicians are countersigning verbal orders within
the SNF largely determines the degree to which
Cardiac drugs
1,000
28.9
8
cording takes place.
Skin and mucous membranes
613
17.7
9
48 hours, the possibility of medication errors oc-
Except in a small percentage of the facilities
Antiinfectives
559
16.9
10
curring through the drug ordering process remains
Antacids and absorbents
489
14.2
11
Table 65.-Information contained on patient's individual prescription labels
surveyed, registered or licensed practical nurses
Antihistamine
479
13.8
12
great.
administer drugs to patients and to a great extent
Hypotensives
428
12.4
13
Eye, ear, nose, and throat
408
11.8
14
Prescription label
drugs are recorded as having been administered.
Information
Spasmolytics
394
11.4
15
Dispensing of Medications
Number
Percent
The data show that licensed nursing personnel
Insulin and antidiabetic agents
384
11.1
16
Controlled substances (Schedule II)
372
10.7
17
administer the medications 92.5 percent of the
Electrolyte replacements
345
9.9
18
The physician's order sheet is the legal document
Name of patient.
6,367
96.6
time while unlicensed personnel administer drugs
Vasodilating agents
298
8.6
19
for dispensing drugs. The medication sheet, med-
Date dispensed
5,804
88.1
Antidepressants
289
8.4
20
Prescribing physician's name
7.4
ication card, Kardex, and prescription label are
6,213
94.3
7.5 percent of the time in the SNF. The nurse
Anticonvulsants
257
21
Name of drug.
6,418
97.4
makes a written record of each dose administered
Estrogens/androgens
121
3.5
22
controls in the correct administration of medica-
Strength of drug
6,330
96.0
Thryroid replacements and antithyroid agents
87
2.5
23
Quantity dispensed
4,133
62.7
to a patient 93.3 percent of the time. Written
Adrenals
77
2.2
24
tions. The prescription label is the single most
Dispensing instructions
5,793
87.9
records included the documentation of nonpre-
Anticoagulants
37
1.0
25
important documentation in the process of admin-
Accessory or cautionary statement
4,754
72.1
Prescription number
6,091
92.4
scription medication administered 91.4 percent of
istering drugs. It should contain all information
the time. Past experiences in the certification proc-
1 Category reference: American Society of Hospital Pharmacists Formulary Service.
52
588-459
53
ess raises the question of the validity of the data
but are experiencing some problems in developing
that shows that only a small number of unlicensed
appropriate methodologies and effective reporting
Comprehensive Drug Abuse Prevention and Con-
Supervising Pharmaceutical Services
personnel are administering drugs. On January
relationships. Patient drug profiles are often used
trol Act of 1970. Another important aspect in the
13, 1975, the Department, through its Office of
to assist pharmacists in monitoring the drug ther-
storing of drugs is the assurance that the integrity
The activities of the pharmacist in the long-term
Nursing Home Affairs, issued a policy statement
apy. These patient drug profile records were re-
of thermolabile and photosensitive drugs is main-
care facility can be categorized into three func-
to assure that unlicensed personnel who admin-
ported to be maintained by about 65 percent of
tained, and that drugs are stored in an orderly
tions: (1) Dispensing or supplying drugs to the
ister drugs receive training in drug administra-
the pharmacists. Eighty-six percent of the drug
fashion thereby precluding confusion and error
facility; (2) monitoring the patients' drug
tion.
profile records were located at places other than
in preparing drugs for administration. In view
therapy; and (3) supervising the overall phar-
the SNF, presumably in pharmacies. The patient
of the enormous dollar volume of drugs and the
maceutical service. Although these functions are
A significant number of facilities do not govern
drug profile records often do not contain informa-
presence of significant amounts of controlled sub-
often carried out by the same individual, it is not
the administration of drugs with a stop order
policy. The administration of drugs not specifi-
tion (i.e., drug sensitivities, chronic diseases)
stances in the nursing homes, it becomes necessary
uncommon to find two or more pharmacists pro-
cally limited as to the time and number of doses
which would help the pharmacist in monitoring
to constantly maintain the security of these prod-
viding services, each with some degree of spe-
should be controlled by established written stop
drug therapy. Information contained on the
ucts (4). The legal aspects of controlled drugs,
cialization. For example, each of the pharmacists
order policies. The data showed that an automatic
SNFs' drug profile records is shown in table 66.
mandate complete records of receipt and disposi-
in a pharmacy may dispense drugs to the SNF; a
stop order policy was in effect at 77.2 percent of
About 68 percent of the pharmacists reported
tions. Proper drug storage and inventory increases
single individual may review the drug regimen;
the SNFs. Of those SNFs with a stop order policy,
that they reviewed the drug regimen at least
the efficiency of the pharmaceutical service and
while yet another may provide overall supervision
54.1 percent had the approval of the Pharmaceu-
monthly. Forty-six percent of those reviewing the
aids in reducing medication errors.
of the pharmaceutical service. Supervision is a key
drug regimen, reported that they provide written
In 31 percent of the facilities there is a separate
element since all of the various activities related
tical Services Committee. A major effort is needed
for the implementation of automatic stop order
comments concerning the review to the registered
drug storage room. This room is separate and dis-
to drug use, distribution, and control must be
nurse; 45 percent to the administrator; 27 percent
tinct from the drug medication room usually
properly coordinated for effective pharmaceutical
policies or other control methods when drugs are
to the attending physician; and 19 percent to the
found in conjunction with the nurses station
services.
not specifically limited as to time or number of
doses.
medical director. Only 21 percent of the pharma-
wherein medications are "set up," "measured,"
While the survey did not assess the extent of the
cists reported that they participated in the devel-
or "poured" prior to administration.
pharmacists' activities in each functional area,
opment of patient medication therapy plans. If
Survey data revealed that over 86 percent of all
some data were obtained which helped to evaluate
Drug Monitoring
the drug regimen review is to be effective in im-
facilities utilize the individual patient prescrip-
the extent of the pharmacists' activities in moni-
proving overall drug therapy in long-term care
tion system, while the remaining 14 percent is
toring the patients' drug therapy and in supervis-
The appropriate use of pharmaceuticals in long-
facilities, the methods and procedures used will
made up of floor stock systems and variations of
ing the pharmaceutical services. Although most
term care facilities has been a matter of concern
need to be improved.
the unit dose system.
for a number of years. The original Medicare
of this data are discussed elsewhere in the report,
There appears to be a certain laxness in inven-
a brief summary of the kinds of pharmaceutical
regulations required that the physician and nurse
torying controlled drugs in skilled nursing facili-
review orders for the patient at least monthly to
service activities that SNFs are rendered by phar-
Storage and Inventorying
ties, particularly in maintaining records for veri-
macists follows in table 67.
determine whether or not the drug therapy of the
patient was appropriate for the diagnoses and
The security of medications at all points of its
fication of receipt and disposition of controlled
In view of the many activities which were re-
substances as required by the condition's of par-
whether or not adverse drug reactions and drug
movements from manufacture to the patient must
ported as being performed by the pharmacists,
interreactions were occurring. It became common
be assured. In the institutional setting it is impor-
ticipation for SNFs. The fact that 21 percent of
the small number of hours spent in providing
tant that the drug storage be secure to prevent
facilities do not maintain proper disposition rec-
pharmacy services, questions about the overall ef-
practice for the physician's orders to be consoli-
dated or "recapped" into a single sheet of the
unauthorized use and that periodic inventories of
ords of controlled drugs, indicates weakness in
fectiveness of pharmacy supervision and of the
drugs are performed to determine if unauthorized
this area. Separate records are maintained for
physician's order form and for the physician and
pharmaceutical services can be raised. If the phar-
use is occurring. This is of particular importance
controlled drugs in 79 percent of the facilities
nurse to review the orders at monthly intervals.
macist is expected to provide more services than
On February 19, 1974, new regulations for skilled
with respect to drugs listed as being subject to the
surveyed. Over 95 percent of these controlled
he can do in the time he spends in the facility,
drug records contained each of the following items
nursing facilities became effective which required
the overall quality of pharmaceutical services is
Table 66.-Number and percent of SNFs by type of information contained
of information: Patient's name, name of drug,
the pharmacist to review the drug regimen of each
apt to be diminished. The amount of time per week
on the drug profile record
strength of drug, date administered and balance
patient in the SNF at least monthly and to report
remaining. The time and dose administered were
any irregularities to the medical director and ad-
Facilities
Information
present 91 percent and 93 percent respectively.
Table 67.-Kinds of pharmaceutical service activities rendered by
ministrator. The national survey of nursing homes
Number
Percent
On the other hand, there seems to be a misuse
pharmacists to skilled nursing facilities
attempted to identify problems in drug therapy
6,131
93.0
and to obtain data on the new role of the pharma-
Name of patient
of professional nursing time in inventorying con-
Facilities
2,579
39.1
trolled drugs at each shift change. The inordinate
Pharmaceutical service activities
Age
cist in monitoring the drug regimen of SNF
4,254
64.5
Number
Percent
Drug sensitivities
2,091
31.7
Chronic diseases
amount of time devoted to controlled drug counts
patients.
5,834
88.5
Date prescription filled
The pharmacist's role, his proficiency and com-
Prescription number
5,397
81.9
by nursing personnel at shift change may deprive
Prepare a written report for the Pharmaceutical Service
Committee
Name of drug
6,115
92.8
4,867
73.9
the patients of many hours of professional nurs-
3,041
46.1
Maintain a drug profile
4,298
65.2
munication patterns in monitoring the drug ther-
Directions
Date to be refilled
2,037
31.5
ing service. Eighty percent of the facilities utilize
Review the drug regimen of patients at least monthly
4,496
68.2
apy of SNF patients are still being developed.
5,868
89.0
Conduct inservice training sessions with personnel
4,482
68.0
Name of prescriber
the services of two nurses to inventory controlled
Responsible for medications throughout the SNF
5,337
81.0
Pharmacists are willing to review drug regimens
drugs at each shift change.
Periodically check drugs and biologicals for deterioration
5,791
87.9
54
55
maceutical services in skilled nursing facilities.
4. There is a need to promote the development
that a pharmacist provides pharmaceutical serv-
Drug Counseling
But this coordinative mechanism must be nurtured
of pharmaceutical service committees in skilled
ices in skilled nursing facilities was determined
Another important function in the provision of
and supported by its professional disciplines in the
nursing facilities to a greater extent and more im-
by the survey as follows in table 68.
quality pharmaceutical service is that of drug
years ahead in order for it to fully realize its po-
portantly, to encourage and assist them to actually
counseling. This entails the provision of drug in-
tential for improving patient care.
achieve their coordinative task. Emphasis should
Coordinating Pharmaceutical Services
formation to patients and to the nursing staff. The
The supervision of pharmaceutical services like-
be placed by State agency surveyors on the im-
principle activity within drug counseling has to
wise holds considerable promise for effecting an
plementation of the requirement for establishing
An extremely critical element in the provisions
do with staff development. The current regula-
efficient and high quality service, but the data
a pharmaceutical services committee and in deter-
of quality pharmaceutical services in the skilled
tions contain a standard on staff development that
show that this element of the service must also be
mining that the pharmaceutical services committee
nursing facility, and one that has in the past had
requires that an ongoing educational program for
improved in order for the pharmacist to assist
is actively discharging its responsibilities. Tech-
little attention, is the coordination of the activities
the development and improvement of the skills
medical and nursing personnel in enhancing the
nical assistance should be provided in order
of pharmacy, nursing and medical personnel. Be-
of all the facility's personnel be planned and con-
quality of care rendered to skilled nursing facility
to aid these committees in performing their
cause each of these disciplines performs an essen-
ducted. This requirement includes inservice train-
patients.
responsibilities.
tial role in the provisions of this service, it is im-
ing the pharmacist could develop for nursing serv-
5. The amount of time the pharmacist spends in
perative that each is aware of the others' activities
ice and other appropriate personnel with respect
and how their respective activities are combined
Conclusions and Implications
the SNF may be due to the inability of the phar-
to drug ordering, storage, distribution, adminis-
macist to receive adequate reimbursement for his
into an efficient and effective whole. Achievement
tration, and monitoring.
1. Assiduous attention to strict drug ordering
services. The issue of appropriate reimbursement
of this coordination may be accomplished in many
The survey sought information on the phar-
procedures is required to prevent errors in drug
should be studied and some steps taken to correct
ways. Inservice training is one mechanism. In-
macist's involvement in inservice training sessions.
ordering. Wherever feasible, the pharmacist
the inequities in reimbursement, if it is proved
formal discussions between these disciplines is
A significant number of pharmacists from the
should be working from the original physician's
to be the problem.
another. The formal mechanism for accomplishing
community pharmacy sector, 63.6 percent, con-
order or a direct copy thereof. Intensive efforts
this coordination is through the development and
ducted inservice training programs; of the phar-
should be made to incorporate a drug ordering
NUTRITION AND DIETETIC SERVICES
operation of a pharmaceutical services committee
macists from a pharmacy within the facility, 66.9
system in the SNF whereby the pharmacist works
whose task it is to oversee the entire service and to
percent conducted training; and of the hospital
from a physician's order form. Also, increased ef-
The basic nutritional requirements for the aged
develop and implement comprehensive policy for
pharmacists serving SNFs, 82.4 percent conducted
forts should be made to assure that the attending
are essentially the same as for other adults. How-
it.
training sessions.
physician countersigns all verbal orders within a
ever, the need for calories is not as great as activ-
The requirement for a pharmaceutical services
maximum of 48 hours. A study might be designed
ity is decreased and the basal metabolic rate is
committee for skilled nursing facilities is rela-
and conducted to determine the effectiveness of
lower. Generally, nutritional needs of the elderly
tively new (February 19, 1974). The survey data
Summary of Findings
various mechanisms, their availability, cost, and
can be met by following the basic four food plan
reveal that within 9 months in 69.4 percent of
Considering all the functions and levels of per-
the degree to which they reduce error rates.
each day. The groups are milk and milk products,
facilities, (4,575 out of a universe of 6,591) a phar-
formance that constitute quality pharmaceutical
2. The State surveyors need to be encouraged
meat and fish, breads and cereals, and fruits and
maceutical services committee had been estab-
services that have been examined in this report, it
to utilize more fully the information contained in
vegetables. If the diet is adequate, vitamin and
lished. These committees are still in the process of
is fair to conclude that most skilled nursing facil-
the SNF interpretative guidelines on pharmaceu-
mineral supplements are seldom necessary.
development and have yet to fully implement their
ities are well on their way toward achieving the
tical services and to further the greater implemen-
To prevent inadequate fluid intake, many older
charge of coordinating and overseeing phar-
capacity to render pharmaceutical services in ac-
tation of standards for these services. Providers
persons need to be reminded to drink sufficient
maceutical services. Of the 4,575 facilities which
cordance with accepted professional practices.
of long-term care need to be aware of the impor-
fluids. One of the biggest dietary problems is to
had established pharmaceutical services commit-
The review of the patients' drug regimen by
tance of controlled substances and the storing and
assure sufficient roughage to maintain natural
tees, the data show that 80 percent were meeting
the pharmacist holds great promise for improving
inventorying of drugs. State agency pharmacy
regular elimination.
at least quarterly, that 72.2 percent were docu-
the monitoring of the patients' chemotherapy, but
consultants should work more closely with com-
Food preparation methods should allow for
menting their activities, findings, and recommenda-
this challenge will require diligent applications of
munity pharmacists to spread this information.
slower digestive processes and poorer chewing
tions, and that 66.5 percent were receiving the
the pharmacist's knowledge, and the cooperation
Studies might be conducted to determine the
ability. The presence and fit of dentures may affect
pharmacists' written report to guide their activ-
of and coordination with the nursing and medical
amount of time spent by nursing personnel in
the choice of foods.
ities and recommendations.
profession in order for this review to benefit the
counting controlled drugs at each shift change
A substantial proportion of individuals 60 years
patient. To assist pharmacists in this task, the De-
and, surveillance should be increased to assure that
of age and older consume less food than needed to
partment has already sponsored a successful train-
only trained personnel administer medication.
meet nutrient standards for their age, sex, and
Table 68.-Hours per week that skilled nursing facilities are provided
ing program now nearing its completion which
3. A research program should be undertaken to
weight-especially calcium, vitamins A and C
pharmaceutical services by a pharmacist(s)
identify objectively the nature, extent, and fre-
will enhance their skills in reviewing drug regi-
(5).
Facilities
mens and in interacting with nursing and medical
quency of clinically significant drug therapy prob-
The long-term care patient's care plan, there-
Hours per week services provided
Number
Percent
lems in long-term care facilities SO that the
fore, must include nutrition goals to meet identified
personnel in this regard.
pharmacist would be better equipped to know
Less than 5 hr.
4,362
The development and effective operation of a
needs. To carry out therapeutic diets prescribed
66.2
5 10 hr
1,201
18.2
where to concentrate his time in reviewing drug
10 to 20 hr
729
pharmaceutical services committee also hold con-
by the physician, a hygienic dietetic serv-
11.1
regimens.
More than 20 hr
299
4.5
siderable promise for the improvement of phar-
ice, managed by a qualified dietetic service super-
57
56
visor(s) with an adequate number of supportive
facility varied widely from less than one-half
Documentation
day per month to full time, i.e., 35 or more hours
scribed diets were found on 77.5 percent of pa-
staff is required. Proper equipment, ample stor-
tients' records.
age and space for food preparation and service,
per week. Some States require at least weekly
Approximately 4 out of 10 patient care plans
are necessary for efficient work and personnel
visits with the number of hours per week based
showed pertinent information about diet, goals,
upon the size of the facility.
and action steps to resolve dietetic problems. How-
Menus and Nutritional Adequacy
satisfaction.
Good food in pleasant surroundings in the com-
Information provided by the nutritionist team
ever, there was infrequent evidence of interven-
pany of others, adds to the enjoyment of eating.
member indicated that the quality of dietetic serv-
tion by the dietitian to help resolve dietetic prob-
Menus were planned in writing for 89.3 percent
Modification of established eating habits may be
lems of individual patients. For example, malnu-
of the patients in the sample. There was a positive
ice provided by the facility was directly related to
necessary to maintain or improve the nutritional
the amount of time spent by the dietition. It is
trition exacerbates and delays healing of decubitus
correlation between the patient's menu being
status of some patients. Since food habits are
ulcers. Nevertheless, only 5.5 percent (1,449) of
planned in writing and the nutritional adequacy
not surprising, considering the limited amount of
of his or her meals; also, between the written
established early in life, assisting a patient to
time many dietitians provide, that they are more
the patients with decubitus ulcers had dietary
menu and the accuracy in preparing and serving
change long-standing eating patterns can be ac-
likely to provide assistance with policy develop-
progress notes or problem statements written by
the meal as ordered (table 74).
complished only by exercising great tact and skill.
ment and inservice education for dietetic service
the dietitian contained in their medical records.
A current therapeutic diet manual approved by
A proper climate for eating makes any indicated
employees than to provide the more time consum-
In only 7.6 percent of the medical records belong-
the dietitian available to attending physicians,
change in eating habits more likely.
ing responsibilities of continuing liaison with
ing to patients on therapeutic diets were there
nursing and dietetic personnel was not available
medical and nursing staffs and counseling of pa-
entries made by the facility's dietitian to indicate
in only 23 percent of the facilities (1,530). There
tients. Data on 89.6 percent (5,909) of the facil-
Supervision of Staff and Related Factors
the patients response. Progress notes or problem
were 51,666 patients who refused more than half
ities in table 71 illustrate the type of service pro-
statements indicating individual response to pre-
of the meal served to them. Only 27 percent of
Approximately 4 of every 10 facilities surveyed
vided by the dietitian.
had a full time qualified dietetic service super-
Table 71.-Type of services provided by the dietitian in 5,909 SNFs
visor (table 69).
Table 72.-Dietary characteristics of SNFs with insufficient dietetic personnel on duty over a 12-hr period
Facilities
Characteristics noted
Characteristics not noted
Table 69.-Number and percent of facilities employing a full-time qualified
Services identified
Number
Percent
Dietary characteristics
Number of
facilities
Number
dietetic service supervisor
Percent
Number
Percent
Total all
5,909
100.0
Percent
Span between evening meal and breakfast 14 hr or less
1,909
1,240
65.0
669
35.0
Full-time qualified dietetic service supervisor
Number
Foods prepared by methods that conserve flavor and appearance
1,909
1,242
65.1
667
34.9
Continuing liaison with medical and nursing staffs
3,182
53.9
Foods served in a form to meet individual needs
1,909
1,486
77.8
423
22.2
3,306
55.9
6,591
100.0
Patient counseling
Bedtime nourishments routinely offered to all patients (not contraindicated).
1,909
1,017
53.3
892
46.7
Total all
Assistance in development of dietetic policies
4,352
73.7
Assistance with inservice education
4,877
82.5
Employed
2,644
40.1
3,947
59.9
Not employed
Table 73.-Dietary characteristics of SNFs with sufficient dietetic personnel on duty over a 12-hr period
Dietetic Personnel
Characteristics noted
Characteristics not noted
Appropriate management and supervisory
Dietary characteristics
Number of
The survey findings indicated that 28.96 percent
facilities
Number
Percent
Number
Percent
functions were performed more frequently in
facilities with a full time qualified dietetic service
of facilities had insufficient dietetic personnel on
duty over a 12-hour period. There was a significant
Span between evening meal and breakfast 14 hr or less
4,682
3,940
84.2
742
15.8
supervisor than in facilities without such a full
Foods prepared by methods that conserve flavor and appearance
4,682
4,152
88.7
530
11.3
relationship between sufficient dietetic personnel
Foods served in a form to meet individual needs
4,682
4,177
89.2
505
10.8
time qualified supervisor. These relationships are
and proper spacing of meals; preparation of food
Bedtime nourishments routinely offered to all patients (not contraindicated).
4,682
3,694
78.9
988
21.1
shown in table 70.
Ninety percent of skilled nursing facilities
by methods to conserve nutritive value, flavor, and
(SNFs) received some consultation or supervision
appearance; food service in a form to meet indi-
Table 74.-Patients menus planned in writing and not in writing related to other characteristics
of their dietetic service from a qualified dietitian.
vidual needs and the routine offering of bedtime
The amount of time spent by the dietitian in the
nourishments. (Tables 72 and 73.)
Patient menus
Food planning, other characteristics
Total patients
In writing
Not in writing
Table 70.-Management and supervisory functions performed by dietetic service supervisors
Number
Percent
Number
Percent
Number
Percent
Total facilities
In facilities employing full
In facilities not employing a
time qualified supervisor
full time qualified supervisor
Meal plans
283,911
100.0
253,485
89.3
30,426
10.7
Management and supervisory functions
Number
Percent
Meals as planned
283,911
100.0
253,874
100.0
30,037
100.0
Number
Percent
Number
Percent
Nutritionally adequate
100.0
259,030
91.2
243,699
96.0
15,331
51.1
6,591
100.0
2,644
100.0
3,947
Nutritionally inadequate
24,881
8.8
10,175
4.0
14,706
48.9
Total all
81.6
2,470
93.4
2,908
73.7
5,378
Meals prepared and served
283,911
100.0
253,485
90.2
30,426
100.0
Orientation, work assignments, food handling, techniques, personnel
65.4
2,290
86.6
2,019
51.2
Menu planning, recommending supplies for purchase, record maintenance
4,309
3,584
54.4
1,898
71.8
1,686
42.7
As ordered
240,578
84.7
228,743
9.8
11,835
38.9
Participation in regularly scheduled conferences
Not as ordered.
43,333
15.3
24,742
57.1
18,591
61.1
58
59
them or 14,035 were offered appropriate substi-
Frequently, patients are admitted to skilled
Facilities, Space and Equipment
this time, such problems frequently are over-
tutes. One can surmise, therefore, that it is the ex-
nursing facilities from hospitals. In the interest of
There were positive correlations between proper
looked by the skilled nursing facility's staff.
ception rather than the rule for providers to make
continuity of care, pertinent information for im-
dietetic preparation equipment and the following:
A range of acceptable labor time per meal
this offer.
mediate care of the patient should be transmitted
Foods served at proper temperatures; the practice
served for all supportive dietetic personnel.
by the hospital to the skilled nursing facility. Just
of food preparation methods that conserve nutri-
This would help providers and surveyors to
over half of the patients (54 percent) who had been
Frequency of Meals
tive value, flavor, and appearance; and sanitary
assess whether there are sufficient supportive
transferred to their facilities from hospitals had
conditions in food storage, preparation, distribu-
personnel scheduled over a period of 12 or
At least three meals or their equivalent should
any transfer information containing pertinent diet
tion, and service (table 78). There was a finding of
more hours each day to carry out the func-
be served daily with not more than a 14-hour span
information.
inadequate work space in dietetic areas in one out
tions of the dietetic service properly.
between a substantial evening meal and breakfast.
Nursing service personnel should be aware of the
of every four facilities.
Utilization of information.-Dietetic personnel
Patients experience discomfort resulting from an
nutritional needs and observe the food and fluid
need to utilize data from routine weighing of pa-
overlong span between the last substantial meal of
intake of patients. There must be an established
procedure to inform the dietetic service of diet
Conclusions and Implications
tients and other available measures as a part of a
one day and breakfast of the next day.
system for regular assessment of food intake and
Approximately one out of five facilities had an
orders and patient's dietetic problems. In the sur-
Standards enforcement.-Enforcement of com-
nutritional health; monitor returned food from
overlong span between these two meals (i.e., more
vey, however, reports from nursing service were
pliance with existing Federal regulations would
patients and offering replacements that constitute
than 14 hours). There was no documented evidence
received by the dietetic service for only 56.2 percent
result in significant improvement in the dietetic
"similar nutritive value"; and assure that all
in 28.5 percent of the facilities (1,880 of 6,591)
of those patients having dietetic problems (table
services in SNFs. The Department is exploring the
menus, especially those for special diets, are plan-
that bedtime nourishments were routinely offered
76).
need for the following changes in Federal regu-
ned in advance and records kept of the menus
to patients to the extent medically possible. Bed-
lations:
actually served. Also needed are more effective
time nourishments also help elderly patients, who
have variable appetites at mealtime, to prevent
Sanitation and Safety
A range of the minimum number of hours per
transfer agreements to improve continuity of care
week for the dietitian to spend in the facility
through the flow of pertinent information about
hunger sensations in the night (tables 72 and 73).
The survey indicated that 94.2 percent of facili-
based on bed capacity or the number of pa-
the patient's dietetic problems and needs.
ties disposed of waste properly and 84.3 percent
tients in the facility. This would help ensure
Studies or special projects.-Reports of studies
Other Nutritional Care Issues
had written reports of sanitation inspections by
sufficient time for dietitians to aid full-time
and projects published in journals or other media
State or local authorities on file. In somewhat fewer
Data show that 19,224 patients or 18.8 percent
staff members in identifying and resolving
available to nursing home personnel can have a
of 102,436 patients needing help in eating were not
facilities, i.e., 76.7 percent dietetic employees were
nutrition problems of individual patients. At
beneficial influence on the nutritional care of pa-
given prompt assistance upon receipt of their trays.
practicing hygenic food handling techniques. In
The number of patients needing self-help eating
almost three out of four facilities or 75.5 percent,
devices was 32,609. Surveyors found such devices
surveyors answered yes to the question "Is food
Table 77.-SNFs meeting certain sanitation and safety factors related to food and food service
in use by only 21, 485 or 65.9 percent of these pa-
stored, prepared, distributed, and served under
Total
Meeting
Not meeting
Sanitary and safety factors
tients (table 75).
sanitary conditions (Table 77.)
Number
Percent
Number
Percent
Number
Percent
Table 75.-Number and percent of patients receiving assistance with eating when indicated
Total, all
6,591
100.0
82.6
17.4
Proper waste disposal
6,591
100.0
6,208
94.2
383
5.8
Patients requiring assistance
Filed written inspection reports-State or local
6,591
100.0
5,554
84.3
1,037
15.7
Employee hygienic food handling
6,591
100.0
76.7
1,537
Type of assistance required
Total
Receiving assistance
Not receiving assistance
5,054
23.3
Sanitary conditions regarding food storage, preparation, service, etc.
6,591
100.0
4,973
75.5
1,618
24.5
Number
Percent
Number
Percent
Number
Percent
Total, all
135,045
100.0
104,697
77.5
30,348
22.5
102,436
100.0
83,212
81.2
19,224
18.8
Table 78.-Assessment of certain SNF factors in food preparation and service in relation to the equipment in use
Assistance in eating needed
Self-help eating devices indicated
32,609
100.0
21,485
65.9
11,124
34.1
Total
Proper equipment present
Proper equipment not present
Food preparation and service
Number
Percent
Number
Percent
Number
Percent
Table 76.-Communication of information concerning dietetic needs of patients to the dietetic service
Total, all
6,591
100.0
5,706
86.6
885
13.4
Foods served:
Patient information
Proper temperature
5,417
100.0
4,549
84.0
868
16.0
Kind of patient information
Total
Communicated
Not communicated
Not at proper temperature
1,174
100.0
521
44.4
653
55.6
Number
Percent
Number
Percent
Number
Percent
Preparation methods:
Conserve value, food, etc
5,386
100.0
4,560
84.7
826
15.3
Do not conserve value, etc
1,205
100.0
517
42.9
688
57.1
Total, all
360,178
100.0
197,720
54.9
162,458
45.1
Sanitary conditions, food storage, service, etc.:
Present
4,973
100.0
4,215
84.8
758
15.2
Transfer information contained pertinent dietetic inputs
217,993
100.0
117,817
54.0
100,176
46.0
Not present
1,618
100.0
836
51.7
782
48.3
Nursing service reports patient's problems to dietetic service
142,185
100.0
79,903
56.2
62,282
43.8
61
60
tients. Several studies and projects suggested by
would include the services of either a full or part
Table 80.-Utilization of social work staff in selected activities
the findings of this report are as follows:
time social worker (qualified by at least a Bache-
Table 82.-Number of patients in facilities with policies affecting continuity of
information, by documentation of psychosocial data
Performance/Cost.-Study relating to nutri-
lor's degree) on the staff, or a designated staff
Facilities utilizing
tional care assessment of patients to the fre-
member suited by training and experience to per-
Major social work responsibilities and contributions
social work staff
Facility has transfer
Facility has written
agreements with
quency of visits by dietitian and amount of
form social service functions, or, in the absence of
Number
Percent
Kinds of documentation of psychosocial
discharge planning
local hospitals
data
program
time spent in the facility.
a qualified staff person, an effective arrangement
Number
Percent
Number
Percent
Personnel turnover.-Study to determine ef-
Total facilities with social work staff
3,241
100.0
fective and feasible measures to reduce dietetic
with an individual or with a public or private
Patients' records include social and
agency to provide consultation from a qualified
Participation in patient's admission process to determine
service personnel turnover.
emotional information transferred
psychosocial care needs and treatment approach
2,010
62.0
Assessment tool.-Development and testing
social worker. The team social workers checked
from referring source
Participation in development of patient's care plan and its
98,321
36.5
80,425
40.4
Medical record indicates social and
of a nutritional assessment tool which SNF
job descriptions, qualifications, contracts, records
ongoing evaluation
2,277
70.3
emotional needs
Work with both family and patient concerning continuity of
131,310
48.7
108,592
54.4
personnel and State surveyors can use.
of amount and times of consultation, and services
Medical record indicates social service
family and community ties
2,239
69.1
Cultural/Ethnic preferences.-Project to
findings
performed before deciding that a social work pro-
Participation in staff development programs
2,140
66.0
123,998
46.0
99,300
49.8
identify and determine ways to satisfy cul-
Medical record indicates referrals of
gram was or was not in effect for a particular
social problems to other agencies
29,103
10.8
tural food preferences when patients of an
83,535
41.9
Medical record indicates actions taken
ethnic group represent a small minority of
facility.
913). Documentation of referrals of social prob-
to meet patient's social and emotional
patients in the facility.
needs
Staff resources for social work programs.-
93,306
36.5
21,337
10.8
Time study.-Project to demonstrate time re-
lems to other agencies is particularly minimal, a
Patient records document how patient is
quired for the dietitian to perform all profes-
Based on findings, 3,241 (49.2 percent) of long-
total of 29,907, and of this small total over 90 per-
protected against physical or mental
abuse
104,995
39.0
sional dietetic responsibilities including coun-
term care facilities have staff for social work pro-
83,205
41.8
cent are recorded in facilities having social work
seling a significant number of patients and/
grams. As those reviewing the findings had hy-
program staff. Table 81 illustrates that two-thirds
1 The standard error in calculation was 29 percent.
or their families.
pothesized in advance, the bed size of the facility
Nutritional status.-Study of nutritional sta-
or more of such recording is done in facilities with
affected staffing patterns. Table 79 shows that so-
tus of patients and identification of conditions
social work staff.
contributing to nutritional problems of this
cial work programs are found more frequently in
Flow of psychosocial information.-There is a
population.
facilities of larger bed size. Approximately 1,732
discrepancy between the minimal recording of so-
Patient's perception of care received.-Many pa-
(26.3 percent) of facilities had full time social
cial data and the frequency of written facility
tients are not able, because of degree of illness or
work staff.
SOCIAL SERVICES AND ACTIVITIES PROGRAMS
policies facilitating the admission, discharge, or
disorientation, to report to an interviewer whether
Utilization of social work resources.-The pres-
transfer of patients. For instance, 94.9 percent
they believe they are receiving the care they re-
The quality of life in long-term care institutions
ence of staff to perform social service functions
(269,489) of patients were in facilities having
quire. During the study, 27.1 percent of patients
has become the concern of many groups, including
does not always mean that these staff members are
written transfer agreements with local hospitals
(77,025) were unable to respond. However, 63.1
health professionals, private citizens, community
engaged in activities with or on behalf of the pa-
at the time of the survey. However, surveyor re-
percent of patients (179,134) indicated they were
groups, legislatures, and patients themselves. One
tients that make the most appropriate use of their
views of records coming from these hospitals
receiving the care required, and 9.8 percent (27,-
of the critical issues of care in skilled nursing facil-
skills. Four functions considered to be important
showed excellent data relating to medical and
755) responded negatively. The study determined
ities is the maximum preservation of each person's
in ensuring that patients' psychosocial needs re-
health status, but for only 36.5 percent (98,321) of
ceive staff attention were evaluated. In about two-
for each facility whether or not various policies
lifestyle within the care setting. To implement
the patients was there social and emotional in-
this concept it is necessary that each individual's
thirds of the facilities where staff was available,
formation which might assist the admitting fa-
and programs deemed desirable to support social
lifestyle and psychosocial needs be known by all
they were involved to the maximum, as table 80
cility to make the initial and long-term adjustment
functioning and to create a warm, humane envi-
care personnel, especially nursing, SO that the pa-
shows. This reflects a staff comment frequently
of the patient happier. Table 82 gives the num-
ronment were being implemented. Data on patients
tient can be encouraged and supported in the di-
encountered in facilities. "There is no real time to
ber of patients who are in long-term care facilities
reported as believing they were receiving the care
rection of personal and social autonomy. Major
do anything properly."
with written policies indicating interest in facili-
they required were reviewed to see what relation-
roles in identifying these needs and implementing
Recording of psychosocial data on patients'
tating the continuity of care and the flow of in-
ships might exist between their responses and such
efforts to change the environment belong to social
charts.-Less than one-half of patients in long-
formation, and who have psychosocial data in-
facility policies. These data are shown in table
workers, occupational therapists, therapeutic
term care facilities have psychosocial data re-
cluded on their records.
83.
recreators, and nurses by reasons of training, skill,
corded on their charts (136,765 or less versus 283,-
and commitment. Consequently, how well social,
emotional, economic, and daily activities needs of
Table 81.-Patients in skilled nursing facilities having psychosocial data recorded
Table 79.-Number of SNFs with full and part time social work program
patients were being addressed in skilled nursing
staff by bed size
In facilities with social work
In facilities without social
facilities was assessed.
program staff
work program staff
Kinds of psychosocial data recorded
Bed size
Number
Percent
Number
Percent
Number
Percent
by size
Social Work Programs
Patients' records contain social and emotional information from referring source
70,086
67.9
33,143
32.1
The social workers serving on the survey teams
Total all sizes
3,241
49.2
Medical records indicate social and emotional needs
98,911
72.3
37,854
27.7
Medical records indicate social service findings
100,010
78.6
27,180
21.4
determined after reviewing personnel records
Under 50 beds
487
38.9
Medical records indicate referral of social problems are made to other agencies.
27,305
91.3
2,602
8.7
whether there was a social work program being
50 to 99 beds
1,151
43.0
Medical records indicate actions taken to meet patients' social and emotional needs
82,439
79.8
20,863
20.2
100 beds and over
1,603
60.2
Patients' records document that the facility protects against physical and mental abuse
72,534
67.3
35,529
32.7
implemented in each facility. Such a program
62
63
Table 86.-Space and equipment available in SNFs for activities programs
Table 83.-Number of patients stating they felt they received the care they
Recording of activities data on patient's
required, by SNF programs and policies
charts.-Although more patients were in homes
All facilities having space
Facilities with qualified coordinator
Facilities with qualified consultant
with activities coordinators than in facilities us-
Space and equipment
Number
Percent
Number
Patient response
Percent
Number
Percent
Characteristics of facility programs and policies
Number
Percent
ing consultants (137,400 versus 55,410) there is no
striking difference in the percentage of patients on
Totals
6,591
100.0
2,903
100.0
1,840
100.0
Policies allowing patients to manage their own financial affairs.
71,357
70.0
whose charts activities data are recorded, except
Space:
Program involving continuity of care, beginning with preadmis-
for the actual patient participation in activities
Noisy recreation
5,355
81.2
2,466
84.9
1,419
77.1
sion evaluation and continuing throughout the period the
recorded on the medical record. Recording was
Large spectator
5,347
81.1
2,462
84.8
1,526
82.9
patient is in the facility
95,947
68.5
Outdoor activities
5,226
79.3
2,276
78.4
1,496
81.3
Programs to welcome and orient the patient as a new resident
more apt to be done by the staff person than the
Personal activities
5,116
77.6
2,247
77.4
1,480
80.4
of the nursing home community
145,818
66.9
Storage
4,933
74.8
2,271
78.2
1,636
88.9
Written policies stating how referrals are made for patients
consultant, as shown in table 85.
Preparation
4,521
68.6
2,105
72.5
1,399
76.0
needing financial and other assistance
86,627
66.7
Space and equipment available.-Areas of space
Office
4,521
68.6
2,065
71.1
1,271
69.0
Policies encouraging visits by patients prior to admision
99,568
65.8
Private interview
available (without interfering with meals or other
4,311
65.4
1,938
66.7
1,267
68.9
Program where staff understands the need for an adjustment
Work-type setting
3,865
58.6
1,862
64.1
1,081
58.8
period for both patients and relatives
149,109
65.3
activities) for a variety of group and/or independ-
Equipment: Equipment available for meeting patients,
Policies defining limits for use of physical and chemical re-
interests
4,651
70.6
2,105
72.5
straints for patients
112,001
64.9
ent patient activities, as well as equipment to sup-
1,418
77.0
Policy to give patients or representatives a periodic accounting
if patient does not manage own finances
103,022
62.5
ply patient needs and interests as indicated, were
Written policies that referring agencies must participate in the
surveyed during the study. As illustrated in table
psychological preparation of the patient and family for the
60.4
86, a high percentage of facilities were found to
standard setting. Significant areas of patient needs
scribed as carrying over a hospital orientation and
nursing home experience prior to patient's arrival
35,842
have activity areas available. In fact, more facili-
have been identified; gaps in service described
atmosphere in the operation of the home. The goal
ties had activity areas than had qualified direc-
failure to use best current knowledge observed;
of enriching the daily environment of residents
tion for any activities which might be initiated
and questions for further study raised.
was frequently cited in the policies, but rarely im-
Activities Programs
(70.9 percent). However, in many instances, fa-
A great number of these patients in skilled nurs-
plemented. Facilities in both urban and rural
cilities appear to have qualified staff but not ade-
ing facilities suffer from emotional as well as com-
areas used volunteers or were interested in recruit-
In determining whether a facility had effective
activities direction, the surveyors looked at the
quate space for activity programs. It was noted
plex physical problems. They are members of a
ing them. The volunteer program was most often
qualifications of both the person responsible for co-
that only 65.4 percent of facilities (4,311) had
group whose needs would be difficult to fully
part of the responsibilities of the activities coordi-
ordinating patient activities and the resources for
space for private interviewing. Privacy is an im-
identify and meet completely. One reason is be-
nator and was used to enhance limited staff re-
consultation available. A qualified activities co-
portant consideration in maintaining individual-
cause many of the patients in the sample could
sources and increase the variety of activities of-
ordinator can be an occupational therapist, occu-
ity for residents of long-term care facilities.
not be interviewed because of combined physical/
fered in this program area. Recruitment, program
emotional deterioration.
pational therapy assistant, therapeutic "recrea-
organization, and supervision of volunteers was
tor", a qualified social worker, or a person who has
Psychosocial services.-A number of excellent
recognized as time-consuming, but was also seen as
Summary of Findings
completed an approved course and has had 2 years
facilities were surveyed, where staff expertise com-
one method of interpreting the facility to the
experience in patient activities. If the person re-
The findings and conclusions have been based
bined with warmth and concern to provide indi-
wider community. Facilities in predominantly ru-
sponsible did not meet these qualifications, then
on statistical data from the psychosocial sections
vidualized patient care-covering both physical
ral areas have special problems in arranging for
consultation from an occupational therapist, social
of the survey instrument. The data were obtained
health and social/emotional needs. In such facili-
training opportunities for their staff, in being in-
worker, or therapeutic "recreator" was considered
by review of individual facility policies, proce-
ties efforts were made to provide daily activity at
formed about training resources available, and in
dures, and contracts; patient care plans and med-
each patient's appropriate level of functioning ir-
keeping up-to-date in knowledge. In the majority
necessary.
Staff resources for activities direction.-Activi-
ical records; interviews with staff and patients;
respective of physical condition.
of facilities surveyed, recording of the patient's
ties direction by either qualified coordinators or
and professional observation. The patterns which
However, in the greater number of facilities,
personal history, social and emotional status, in-
consultants was found in 71.9 percent of facilities
have emerged from these analyses while subject
there was very limited understanding of the im-
terests, and adjustment, is either nonexistent in
(4,473) 44 percent (2,903) have staff coordina-
to further validation from subsequent or other
portance of psychosocial services to assist in main-
significant particulars, or if documented is rarely
tors; and 27.9 percent (1,840) use consultants. Ta-
surveys, have been sufficiently consistent to have
taining patient physical, social, and mental health.
in one location SO that staff in daily contact with
ble 84 shows staffing patterns by bed size of
implications for Federal program direction and
In these facilities staff/patient and patient/patient
the patient have ready access to such information.
facility.
interaction was minimal. Many patients were
Patient needs for services.-The survey findings
on patient characteristics pointed out that many
Table 85.-Patients having activities data recorded
found sitting in rows in the facility lobby and
Table 84.-Staffing patterns for activities programs by bed size
halls, not communicating, and waiting for the
patients were withdrawn and noncommunicative.
In facilities with
In facilities with
(See section on patient characteristics.) Only 13.3
Activities direction resources
Kinds of activities
activities coordinator
activities consultant
next meal 1 or 2 hours ahead of time. The activities
data recorded
percent (37,754) of the patients have living
Bed size
Qualified coordinator
Qualified consultant
Number
Percent
Number
Percent
or social programs were directed primarily toward
Number
Number
the active resident.
spouses; 78 percent of the patients surveyed were
Percent
Percent
65 years of age or older, with one-third aged 75-84;
Patients activities needs and
44.0
1,840
27.9
interests on medical record.
65,535
51.0
31,620
50.8
The administrator and/or director of nursing
another third over 85 years of which a hardy 4.8
Total all sizes
2,903
Actual participation in activities
set the climate and working tone in most of the
Under 50 beds
294
24.2
296
23.8
on medical record
60,381
52.3
37.9
percent were over the century mark. The factor of
43,815
homes, affecting significantly the level and quality
50 to 99 beds
1,284
47.4
825
30.7
Response to activities on medi-
longevity, and the large number of patients in the
100 beds and over
1,325
49.7
719
cal record
40,982
48.1
27,223
54.6
27.0
of patient care. A number of facilities were de-
upper age groups pose immediate problems and
65
64
questions in terms of levels of care offered in rela-
except for crisis situations. Hours of work re-
tion to patient care needed. Studies have shown
ported for such staff ranged from 6-14 hours per
Conclusions and Implications
needs and activities participation. Both kinds of
that for many adults over 65 there is actual dimi-
week. Staff members were most likely to be in-
1. There must be recognition of, and implemen-
information are vital to evaluation and indi-
nution of physical capabilities, including a greater
volved in seeking financial reimbursement for pa-
tation at the Federal, State and local levels, of the
vidualization of care.
risk of sensory and language impairment through
tient care, other environmental manipulation, or
importance of the psychosocial dimensions of pa-
Social work and activities personnel need to
vascular and neurological diseases. For example,
in responding to a problem situation in regard to
tient care if the level and quality of such care in
utilize appropriate helping techniques to meet
it is estimated that at least 88 percent of individuals
patient behavioral symptoms which upset the rou-
skilled nursing facilities are to be raised. The social
psychosocial needs, and approaches for creating,
over 65 have some degree of hearing loss (6). This
tine, or involved relatives.
and emotional needs of the patient must receive
supporting, and restoring the lifestyle of the resi-
disability is often a source of deep frustration and
The time spent by social service consultants in
equal attention with that given to the physical and
dent in the direction of personal social autonomy.
embarrassment to many patients, and occurs at
given facilities was generally reported as being
medical aspects. There are great variations among
4. Development of information is needed on re-
the very time that the patient recognizes his need
very limited. A number of these consultants had
States in technical resources and capacity to as-
sources and methods traditional and new for
for assistance in self-care, and when his self-
contracts with from 6-17 facilities in a given geo-
sist facilities in utilizing and providing for psy-
meeting the psychosocial and lifestyle needs of pa-
esteem may be low because of emotional stress.
graphic area, a pattern which is seen in other dis-
chosocial needs of patients. State and local agen-
tients. Surveyors indicate that some techniques
Review of patient records indicated that a pro-
ciplines as well. Services performed were pri-
cies need social work, occupational therapy, and
have been effective in meeting the needs of patients
gressive decline occurs in many patients' mental
marily in providing inservice training as re-
therapeutic recreation leadership (consultants) in
with specific problems. Reality orientation is one
and physical functioning after admission. Phys-
quested, assisting with program direction or care
addition to nursing to monitor programing in fa-
technique which has been documented and in-
ical and emotional rehabilitation or maintaining
consultation, and in some instances, providing
cilities, identify problems and develop corrective
formation about it developed under the President's
patients at a given level is stated as a goal in poli-
supervision for a student or the activities staff.
action programs (consultation, staffing changes,
initiative. Many other such techniques need to be
cies. Relatively few facilities surveyed had quali-
While many came in on a regular basis, there were
training peer review, and standard interpreta-
documented for effectiveness and have informa-
fied rehabilitative or social services staff needed
a number of instances where the consultant was
tion). Surveyors reported instances where social
tion developed and disseminated about them.
to achieve these goals for the SNF patients. Sur-
on "call," with services to be offered unspecified.
service staff had been discharged by a facility
5. Efforts must be made to get more adequate
veyors noted that in a large number of facilities,
In terms of disciplines represented, consultants
when such staff were no longer mandated under
social information on patients coming from hos-
patients' dependency attitudes were reinforced
included social workers with master's degrees in
Federal regulations. Where States required social
pitals. The Department is exploring the need for
continuously by the manner in which staff ad-
social work, sociologists, psychologists, and
work consultants to be available when there were
hospitals participating in Medicare and Medicaid
dressed them by first name and often as though
County Department of Public Welfare Assistance
no social workers on staff, a number of examples
programs to be required to have social workers in-
speaking to a child. This prevalent attitude con-
staff.
were cited of consultant contracts undated and SO
volved in discharge planning which includes con-
trasts sharply with survey data which shows that
Psychosocial needs of patients were frequently
general that there was no specification of the time
sideration of SNF/ICF placement. Survey data
two-thirds of the patients (66.1 percent or
translated into patient activities and recreation.
to be given, or the nature of the services to be
show that 94.9 percent of survey patients were in
187,920) whose "usual living arrangements"
Most facilities had coordinators or aides acting in
provided.
facilities with current transfer agreements with
could be identified had maintained themselves in
that capacity who were helpful and usually re-
2. The Department is exploring the need to re-
hospitals. However, the review of patients' records
the community within the previous 24 months. A
sponsive in terms of patient needs. However, both
vise Federal regulations to emphasize implemen-
coming from the hospital showed that 36.5 percent
more detailed breakdown of community residence
because of inadequate skills and limited numbers
tation of policies and programing, rather than
had information of social and emotional status
underscores again the importance for staff to be
of activities staff, the greatest portion of program
emphasizing the presence of policies and one staff
transferred with them, even though the records
aware of the need to strengthen and maintain the
time was devoted to working with alert, mobile
member or consultant in service areas. The data
contained excellent information on medical and
capacity of patients to make decisions and retain
patients, rather than "problem" or room-bound
indicate many facilities have the appropriate
health status. This points up the need for social
their dignity. About 35.3 percent of patients (or
patients.
policies and minimum staff required by regula-
work involvement in discharge planning on the
39,148) who had lived in a private residence, lived
Survey data indicate that most of the facilities
tion but have not implemented the policy or pro-
part of the referring institution to prepare the
alone; 88.5 percent (or 5,173) of those who lived
surveyed were in the process of developing required
vided enough staff and consultant support to meet
patient and family for placement.
in rooms, lived alone.
patient care plans which set forth individual pa-
patient needs. Activities personnel are identified
As a whole it must be concluded that in a high
tient needs, interests, and goals. However, achieve-
as working with the alert mobile patients. It was
proportion of the facilities surveyed, there are
ment of a regular review of patient status, evalua-
not possible from the data to determine whether
References
many patients with high levels of emotional and
tion of the nature of the care being given, and
or not these patients were alert and mobile be-
1. U.S. Department of Health, Education, and Welfare,
life-adjustment problems; chronic difficulties in
their interpersonal relations, isolated or noncom-
documentation by way of progress notes in the
cause of their participation in activities. Leaving
Public Health Service, National Center for Health
municative, unwilling or unable to accept the fa-
patient record was in a beginning stage in most
the question of whether other patients might have
Statistics. "1973-74 Nursing Home Survey," Monthly
facilities. The implied need to use patient-care
improved, if offered programing to meet their
Vital Statistics Report, Vol. 23, No. 6, Supplement.
cility environment, exhibiting either unacceptable
September 5, 1974, pp. 6-9.
behavior and/or withdrawal and depression.
conferences-a team approach-to assist in the
interests and needs.
2. Cheung, Alan, Ron Kayne, and Margaret M. McCar-
3. Consultants in social work and activities need
ran. A Prospective Study of Drug Preparation and Ad-
Staffing.-While 49.1 percent of the facilities
process of providing individualized patient care
surveyed were reported as having social services
was in evidence primarily only in those facilities
to be more aware of the importance of and inter-
ministration in Extended Care Facilities, Unpub-
lished study. p. 67.
program staff, in only 26.3 percent were they em-
with good patient care and administrative direc-
pretation of information on care plans and ac-
3. Crawley, Henry K., III, Fred M. Eckel, and Don C.
tion and were implemented by trained nursing and
tivities participation. The data indicate that
McLead. "Comparison of a Traditional and Unit Dose
ployed full time. For the part-time staff the time
devoted to direct patient services was very limited,
psychosocial staff.
consultants are not encouraging certain kinds of
Drug Distribution System in a Nursing Home," Drug
recording such as what was done to meet identified
Intelligence and Clinical Pharmacy, 5:166-171, June
1971.
66
67
4. Brady, Edward S. et al, "An Application of Clinical
Dietary Intake and Biochemical Findings, DHEW
CHAPTER 8
Pharmacy in Extended Care Facilities," Drugs and the
Publication No. (HRA) 74-1219-1, Washington, D.C.,
Elderly, Los Angeles, Ethel Percy Andrews Gerontology
U.S. Government Printing Office.
Society, University of Southern California, 1973. pp.
6. Hull, Raymond H., "Presbycusis : An Epidemiological
65-69.
Approach." Paper presented at workshop on Geriatric
5. Preliminary Findings of the First Health and Nutri-
Aural Rehabilitation held in Rockville, Md., February
tion Examination Survey, United States, 1971-72:
25, 1975.
Historical Development of
Surveyor and Provider Training Programs
In 1916, a group of concerned physicians
was essential. Early in 1967, the Division of Medi-
organized and conducted a survey of 2,000 hos-
cal Care Administration (DMCA), U.S. Public
pitals to examine the existing hospital conditions.
Health Service, launched a comprehensive sur-
Response indicated that only 30 percent of these
veyor training program.
hospitals met the physicians' very minimal quali-
This new unit charged with the responsibility
fying standards. From this discouraging and
to perform those health related functions recog-
humble beginning, the Joint Commission on Ac-
nized that these responsibilities included the fur-
creditation of Hospitals (JCAH) was formed.
nishing of health consultation to providers and
State and local health facility licensure laws were
the training of surveyors and other State person-
developed and the present Medicare and Medicaid
nel performing certification functions in order
survey and certification procedures were estab-
to effectively support Medicare activities. The
lished.
Nursing Homes and Related Facilities Branch
Following the enactment of Medicare legisla-
within DMCA was charged with the responsibility
tion in 1965, conditions of participation by health
to develop and quickly implement such a program
facilities in the Medicare program were provision-
on a national scale.
al upon their having met the comprehensive Fed-
Implementation in 1967 of the State-Public
eral health and safety certification standards.
Health Service (PHS) Cooperative Nursing Home
Since Federal certification standards were much
Improvement Program required long-range fund-
more stringent than those for State licensure,
ing and commitment of personnel for success in
many State agencies were unable to meet the
improving surveys and nursing homes. In Au-
added responsibilities brought on by Medicare and
gust 1967, the National Communicable Disease
did not conduct inspections for licensure.
Center, Atlanta, Ga., contracted to develop and
In order to comply with the arrangement, the
conduct a prototype surveyor training course that
States recognized the urgency to organize new
was expected to be utilized by various universities
units to perform the certification functions and
throughout the United States.
to obtain qualified administrative and professional
While this first formal effort to develop and
staffing. However, there was only a short 6 to 8-
conduct a comprehensive course to train surveyors
month period from the signing of the agreement
was in many respects successful, it required con-
by the State to the start of the hospital phase of
siderable modification and new direction. Mean-
the Medicare program on July 1, 1966.
while, other aspects of the State-Public Health
Subsequent experience gained by the State agen-
Service Cooperative Nursing Home Improvement
cies in surveying and certifying extended care
Program continued.
facilities, home health agencies, and independent
In May 1968, the Nursing Home Branch spon-
laboratories showed clearly that a national Fed-
sored the first conference of State Nursing Home
eral Government sponsored program to train
Licensure Personnel which was held in Dallas,
health facility surveyors to conduct surveys and
Tex. Recommendations were made on matters per-
to provide technical assistance to nursing homes
taining to the improvement of the quality of care
to enable them to meet conditions of participation
in nursing homes and similar facilities. All aspects
68
69
588-459 75 -
of the State-PHS Cooperative Nursing Home Im-
to effectively support Medicare depends equally
seminars and workshops for dietitians and other
sumer needs and to provide adequate patient care
provement Program were reviewed and subse-
upon the ratio and availability of well-trained
food service personnel; and (4) a national training
in long-term care facilities, is not only dependent
quently endorsed in their entirety by representa-
individuals and the application of health man-
system for medical record consultants employed
upon the adequate training and cooperative inter-
tives from 47 States, Puerto Rico, and the District
power resources to consumer needs. In order to
by long-term care facilities.
action among surveyors and providers, but is also
of Columbia.
meet these needs, the U.S. Public Health Service
In 1973, six regional training centers were
dependent upon reliable up-to-date knowledge of
Many of the recommendations made at the con-
recognized that those duties include the furnishing
created to train multidisciplinary teams within
existing conditions and patterns of health care in
ference were implemented, including the forma-
of health consultation to providers.
each geographic area with the focus on combined
nursing homes.
tion and establishment of the National Associ-
Responsibility for directing Federal resources
on-the-job and didactic training. In 1974, each of
For the purpose of obtaining this information,
ation of Directors of State Health Facility licen-
toward short-term training of personnel employed
these centers was provided continuation funds
survey and subsequent assessment mechanisms
sure and certification programs. Of major impor-
in long-term care facilities was initiated and con-
allowing for further innovative development and
were developed. Designers of the survey were
tance was that the surveyor training program was
tinues in the Division of Long-Term Care (Na-
implementation of the training programs, includ-
hopeful that the knowledge resulting from this
endorsed and accepted by the States. This was
tional Center for Health Services Research).
ing inservice training for nursing personnel in
survey and future surveys and information from
needed to accelerate its development and imple-
Their goal has been to institute short-term train-
their own facilities and communities. This on-
the Long-Term Care Management Information
mentation as a university-based training program
ing courses, sufficiently diversified geographically
going program has led to modifications which are
System will serve as an evaluation guide to mem-
and to ensure its success as the keystone to the
by discipline, and by types of training methods
responsive to varying regional and State needs
bers of the long-term health care professions. It is
overall nursing home improvement program.
used, and assure an approach and measurable ef-
Also, in 1974, three additional centers were funded
also hoped that those concerned with efforts to im-
On August 6, 1971, President Nixon announced
fect on the upgrading of the abilities of nursing
and two contracts that called for development of
prove long-term care by means of a positive, con-
the Eight-Point Improvement Program which was
home personnel in meeting patient care responsi-
training aids and materials were completed, with
structive program might glean from the data some
designed to significantly improve the quality of
bilities, through improving the quality of care
both programs currently in production. Program
meaningful information upon which improvements
care provided in these homes. Since then, over
given the nursing home patient.
development in 1974 also included the establish-
may be based.
2,000 State and Federal survey and certification
Since the 1970 proposal for a national training
ment of a long-term care media center which will
However, the data should be directly related to
personnel have attended specialized university-
program and the inception of provider training
serve as a central repository for the training and
improving the availability and accessibility of
based surveyor training courses in 10 regions,
activities with the administration's Eight-Point
educational materials developed through con-
long-term health care, and the survey mechanism
ranging from 1,809 participants in the basic course,
Nursing Home Initiatives of 1971 and the subse-
tracts SO that these materials will be more readily
should also provide substantial assistance in as-
255 in the advanced course, and 255 in the super-
quent yearly appropriation by Congress of $1.8
available to providers throughout the country.
suring the eventual achievement of successful col-
visory course.
million, there has been continued growth of train-
Plans for a continuation of the training effort in
laborative local, State, and Federal improvement
Improved performance of health facility sur-
ing opportunities for professional and parapro-
1975 call for activities to be centered in those gen-
efforts.
veyors employed by the States has been ap-
fessional long-term health care personnel. As of
eral areas being brought to focus as a result of
proached in three ways: (1) Establishing mini-
December 1974, approximately 78,000 provider
new skilled nursing facility and intermediate care
IMPLICATIONS FOR PROVIDER TRAINING
mum qualifications for surveyors; (2) providing
personnel within 12 health disciplines are re-
facility regulations. These include training in re-
a uniform training program; and (3) developing
ported as having received training. Of this num-
habilitation skills for all levels of nursing per-
In a statement released August 6, 1971, the
an interim credentialing method for the certifica-
ber, 18,927 were trained as a result of contracts
sonnel, as well as training for community phar-
President outlined a "Plan of Action" to upgrade
tion of surveyors. In addition to the surveyor
with national professional organizations; 14,470
macists, dietary consultants, food supervisors,
the quality of care in the Nation's nursing homes
training program, plans are currently underway
as a result of State-based contracts; 4,013 as a
medical directors to skilled nursing facilities,
that included a new program of short-term train-
to identify and update necessary basic course mod-
result of the nationwide long-term care training
medical record consultants, and social work des-
ing for personnel regularly involved in providing
ifications; to design a new advanced course to in-
system, and the remainder 40,944, as a result of
ignees. By making these training models and pro-
services to residents. He stated, "In too many
clude substantive programmatic concerns and
regional office purchase orders.
totypes available for wide national use, it is hoped
cases, those who provide nursing home care-
specialty needs; to conduct national and regional
In 1974, to further the Department of Health,
that impact will be made on the approximately
though they have been generally well prepared-
conferences for State survey agency directors, su-
Education, and Welfare's efforts toward upgrad-
580,000 employees working in the Nation's nurs-
have not been adequately trained to meet the
pervisors, and consultants. As an interim method
ing the quality of care in nursing homes by im-
ing homes and long-term care facilities.
special needs of the elderly. Our new program
of credentialing surveyors, a contract to validate
proving the skills of those responsible for provid-
To date, there are no requirements for the train-
will help correct this deficiency." In the ensuing
an existing survey task inventory and produce an
ing that care, 16 contracts for State and national
ing of nurse aides in or for nursing home em-
3 years following the President's initiatives, a
occupational analysis was let. From this occupa-
training programs were awarded, totaling almost
ployment. Identification of specific needs in this
variety of training activities designed to upgrade
tional analysis, surveyor performance criteria and
$1.3 million. These programs were designed to
area and initiation of a training program will re-
the knowledge and skills of long-term care pro-
standards will be established and a skills and
include: (1) The instruction of nurse aides em-
quire the collaborative efforts of the Federal Gov-
vider personnel were developed under a variety
knowledge test for credentialing will be developed.
ployed in long-term care facilities in rural areas
ernment, States, surveyors, and providers in order
of auspices. The Department of Health, Educa-
An optimal level of long-term health care is
of four states; (2) the nationwide training of
to continue to strengthen the national long-term
tion, and Welfare allocated a total of more than
dependent not only upon the development and ap-
medical directors in skilled nursing facilities (to
care education system in 1975.
$6 million for this purpose, programed by the
plication of regulatory standards. The ability of
achieve compliance with legislative mandates,
The implementation and enforcement of Fed-
Public Health Service's Health Resources Ad-
the facilities to meet performance criteria needed
mandatory by December 1975) (3) nationwide
eral regulatory policy in an effort to meet con-
ministration (Division of Long-Term Care, Na-
70
71
tional Center for Health Services Research) and
professionals. The concept of an episode of acute
cies, and similar areas to ensure significant im-
periods in a steam table. Employees fail to prac-
the Alcohol, Drug Abuse, and Mental Health
illness coming to an eventual close is not relevant
provement in the management of nursing homes.
tice hygienic food handling techniques." Training
Administration (Division of Manpower and
for long-term care; however, this is the concept
In order to assure an appropriate curriculum, a
courses for cooks in vocational schools as well as
Training Programs, National Institute of Mental
for which most health care personnel have been
study should be made to determine the body of
on the job training should be encouraged.
Health). Training opportunities were provided
educated. All eight of the study team disciplines
knowledge and preparation needed by an admin-
Since 1972 basic orientation courses have been
for over 85,000 provider personnel in all cate-
concerned with health care delivery noted an
istrator to effectively manage a nursing home SO
offered for social workers and activities personnel
gories during 1972, 1973, and 1974. Considering
absence of orientation of personnel toward long-
that it can deliver high quality patient care.
groups under the President's nursing home initi-
the fact that the potential trainee population totals
term rehabilitation concepts and in-depth knowl-
Intensification of the long-term care provider
atives but training has not been of a career devel-
over 1 million persons at any point, and allowing
edge regarding psychosocial needs of patients in
training program is needed to reach as many phar-
opment, in-depth technique training, or program
for the turnover rate of personnel which is esti-
the facilities they studied. These concepts are
macists as possible to assist them in maintaining
development nature. Uniform training curricula
mated to range from 30 percent to over 100 per-
common to all disciplines and are essential to pro-
and improving their professional competence and
and methodologies must be developed. In addition,
cent annually in various categories, it is apparent
viding quality care to residents. The 10 most com-
to keep them informed of various program re-
teachers must be recruited and trained to dissem-
that a strategy for programs of ongoing and con-
mon diagnostic groupings found among the pa-
quirements. Training should be designed and con-
inate the information especially into rural areas.
tinuing education are essential for improvement
tients studied all have rehabilitative and psy-
ducted to improve the quality of pharmaceutical
Some training needs are unique to the role that
of services in the long-term care field.
chosocial implications for training needs of
services and coordination with the nursing and
each discipline plays as a part of the health team;
The Long-Term Care Facility Improvement
patient care personnel. It is particularly note-
medical personnel on appropriate aspects of drug
others will relate to the role the discipline plays
Study findings reinforced the need for continuing
worthy that nearly two-thirds of the patients
storage, distribution, administration, and moni-
in concert with other team members. For example,
and stepped-up training activities for all disci-
studied had diagnoses that related to the nervous
toring. Considerable support should be given to
nutrition consultants, food service supervisors,
plines and levels of provider personnel, both on a
system. These data should indicate the need for
stimulating training programs which will enhance
and dietary aides need specific training in the
single discipline and on a multidiscipline basis.
all personnel to be capable of effectively dealing
the skills of the pharmacist in monitoring the drug
unique nutritional needs of the institutionalized
This need was especially apparent in the area of
with disordered behavior (chronic brain disease,
therapy of specific disease states and improve his
elderly, the impact that inactivity and illness have
quality of life or psychosocial aspects of patient
senility, neurosis and psychosis.)¹
ability to communicate effectively with prescrib-
on appetite, nutritional needs, and spacing of
care. It is significant that the identification of
An additional concept of concern to all disci-
ing physicians.
feedings. In addition, however, knowledge of po-
training needs was an implicit goal of the study.
plines providing care in the long-term care facility
The dietitian's continuing education should in-
tentially hazardous food-drug interaction is essen-
Every study team and each disciplinary group,
is that of psychological impact on the patient as
clude current concepts and practice of diet therapy
tial for adequate planning of dietary regimen and
upon completion of the study, identified areas of
a result of institutionalization. Translocation of a
for the geriatric patient; special patient needs
require collaboration and communication between
needed training. The scope of need is such as to
person from home or hospital to a long-term care
because of physical disabilities or impairments;
dietary, nursing, pharmacy, and medical personnel.
require the concerted efforts of the Federal gov-
facility brings with it a host of "losses" to the
and appropriate learning experiences to help them
The above points indicate both the need for
ernment, States, professional and provider orga-
resident-loss of health, independence, status,
identify and meet dietetic-related training needs
discipline specific training as well as interdiscipli-
nizations, health educators, and consumers.
family, and friends. All or any of these have a
of other SNF staff, improve liaison with medical
nary training. Both these needs are addressed in
potential for precipitating disordered behavior
and nursing staff, document problems and prog-
Federally supported training activities conducted
Training Issues
and depression, factors that must be dealt with
ress appropriately in patients' medical records,
in fiscal year 1975 and planned for fiscal year 1976,
A variety of training issues are identified by this
by all levels of personnel in the facility. Appro-
and indicate goals and action steps in patient care
but maximizing of this training at State and local
study including:
priately designed training programs can prepare
plans.
levels must be planned for by providers in order
staff to be aware of, alert and responsive to the
For both the dietitian and the dietetic service
to impact on service delivery in individual long-
1. multidisciplinary/interdisciplinary concerns;
2. single discipline concerns;
need for psychosocial support that the long-term
supervisor, training in management techniques is
term care facilities.
3. need for resources and opportunities;
care facility can provide as a part of its service.
needed for time economy and to establish work
The report of the social work study members
4. career development and upward mobility op-
This report includes the findings of each of the
priorities. There is a need to promote interagency
provides another example of both discipline-
portunities, especially for paraprofessional
eight disciplines represented on the study team.
efforts on State and local levels to strengthen a
specific and multidisciplinary training needs. The
and support personnel;
Patients in these facilities are probably not re-
network of approved educational programs for
primary responsibility for ensuring that psycho-
5. alternatives needs. for meeting continuing education
ceiving the quality of services to which they are
dietetic service supervisors.
social and continuity of care needs of long-term
entitled. Many nursing home administrators need
Administrators need training to understand nu-
care residents are met, rests with social service per-
As was noted in 1971 by the President, while
technical assistance and training in a number of
tritional needs of patients at this level of care in
sonnel. Although 49.1 percent of the facilities sur-
most personnel in long-term care facilities have
areas such as the fundamentals of nursing home
order to provide adequate staffing, equipment, and
veyed had social work staff, only 26.3 percent
been adequately trained for their specific disci-
administration, personnel management practices,
space for the dietetic services.
(1,732 facilities) employed them on a full-time
pline, most have not received specialized training
the development and maintenance of personnel
Cooks are often employed without prior train-
basis. Since such social service staff are of prime
to meet the needs of the elderly, the predominant
records, the proper utilization of consultants and
ing or experience in quantity food production.
importance in ensuring that psychosocial needs are
population in nursing homes and related long-
outside health care resources, the development and
Comments in surveyors' summary statements fre-
receiving staff attention. The data indicate a need
term care facilities. The majority of elderly per-
implementation of staff training and facility poli-
quently focused on problems of food preparation.
for training of other personnel to fill this gap and
sons suffer from one or more chronic illnesses—
1 The findings of other studies including those of inter-
"Even though only a few patients require sodium
training of social work consultant to impart this
the average for nursing home residents is four
mediate care facilities estimate this figure to be closer to
restriction, all food is prepared without salt. Food
knowledge and skill to the staff. Again, this is an
chronic conditions requiring attention of health
80 percent.
is prepared too far in advance and held for long
area that has been addressed by the Public Health
72
73
Service training contracts and additional work is
job satisfaction related to feelings of adequacy and
essential, especially at the facility level.
competence-both factors of training and job
The essential point is that training needs and a
preparation.
variety of alternatives for accomplishing training
One factor requiring further study is the de-
exist. The Federal Government has supported
gree to which opportunities for upward career mo-
demonstrations of various alternatives, and the
bility, provided by training and education, are a
initial development of training activities, but the
factor in job satisfaction and reduced turnover
accomplishment of an ongoing and continuing pro-
rates. Data would indicate that continual orienta-
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20. Linn, Margaret W. "Predicting Quality of Patient
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4. Verhonick, Phyllis J. "Clinical Studies in Nursing:
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76
77
APPENDIX A
RESIDENT CONTROL RECORD
Page
of
Pages
Nursing Home Name
MFI Bed Size
Nursing Home Id Number
Recode
Total SNF Residents in Home:
residents
Total SNF Residents in Sample:
residents
LIST OF SNF RESIDENTS IN THE FACILITY
Instructions for
Sample
Name of SNF
Line
Sample
Name of SNF
Line
designation
Resident*
No.
designation
Resident*
No.
SW
SW
Selecting a Sample of Residents
TE
TE
b
C
b
C
for the Long-Term Care
a
01
51
02
52
Facility Improvement Campaign
03
53
04
54
05
55
06
56
07
57
The National Center for Health Statistics' staff
08
58
trol record. (A copy of this form is on the next
09
59
devised the method and wrote the instructions for
page.)
10
60
selecting a sample of approximately 40 residents
2. List all SNF residents both Title XVIII and
11
61
per facility for the Long-Term Care Facility Im-
Title XIX) on the form, one resident per line. (See
12
62
provement Campaign. As required, the sampling
13
63
above definition of "resident".) Be careful not to
14
64
instructions can be redesigned to reflect the num-
skip any lines when you are preparing the list. Any
15
65
ber of residents which can be examined during a
manner of recording residents in the list is ac-
16
66
team visit.
ceptable (i.e., names, facility's resident identifica-
17
67
A new form-the Resident Control Record—
18
68
tion number, etc.) as long as the manner allows
was included as part of the packet of question-
19
69
identification of the residents selected for the
20
70
naires for each facility visit and received Office
sample.
21
71
of Management and Budget clearance. It was es-
72
3. The total SNF residents in the facility equals
22
sential to the statistical weighting of the sample
the line number of the last resident entered on the
23
73
that the resident control record is included in the
24
74
resident control record. Enter this number on the
25
75
packet of completed questionnaires. The sampling
line provided at the top of the resident control
26
76
instructions were emphasized during the training
record.
27
77
sessions.
28
78
4. Use table 1 to determine the correct sample
29
79
designation. Select the interval in the column
30
80
HOW TO COMPLETE
headed "Total SNF residents in the home" which
31
81
THE RESIDENT CONTROL RECORD AND
corresponds to the total number of SNF resi-
32
82
SELECT THE SAMPLE OF RESIDENTS
33
83
dents entered on the resident control record. The
34
84
Purpose
sample designation, "Start with" (SW), "Take
35
85
every" (TE), can be found in table 1 by reading
36
86
The resident control record has only one pur-
across the row to the appropriate SW and TE col-
37
87
pose: to list all SNF residents (both Title XVIII
umns. Enter the SW and TE numbers from table 1
38
88
and Title XIX) of the facility for the purpose of
in the appropriate lines in column "a" of the resi-
39
89
40
90
selecting a sample to collect survey data. A resi-
dent control record. Once you have recorded the
41
91
dent is defined as an individual domiciled in the
sample, you can verify its overall accuracy by
42
92
facility for the purpose of receiving specialty
checking the column on table 1 headed "Range for
43
93
care. A resident is not a discharged patient.
44
94
sample of SNF residents". The total number of
45
95
residents in the sample should fall within the
46
96
97
Selecting the Sample
range listed in this column.
47
48
98
1. Enter the name of the nursing home, its iden-
Example.-Assume that you recorded 74 SNF
49
99
residents on the resident control record. Seventy-
50
100
tification number, and the MFI bed size recode on
four falls in the interval between 61-90 in the
Initials, facility identification number, or any other type of identifier can be used in the list as long as the residents chosen for the
the lines provided at the top of the resident con-
first column of table 1. Reading across the table,
sample can be identified so that their records can be examined.
78
79
LIST OF SNF RESIDENTS IN THE FACILITY
LIST OF SNF RESIDENTS IN THE FACILITY
Sample
Name of SNF
Line No.
Sample
Name of SNF
Sample
Name of SNF
Line
designation
Sample
Name of SNF
Line
designation
residents*
designation
resident
No.
designation
resident
No.
SW
1
SW
1
SW
1,2
SW
1,2
TE
2
TE
2
TE
3
TE
3
a
b
C
a
b
a
b
C
a
b
C
Adams
01
Adams
01
Williams
51
App
02
App
02
Vincent
52
Andrews
03
Andrews
03
Yost
53
Art
04
Art
04
Zemil
54
Baker
05
Baker
05
55
Bett
06
Bett
06
56
Bibe
07
Bic
07
57
Bic
08
Bitten
08
58
Bitten
09
Cobb
09
59
Bauer
10
Coby
10
60
Cobb
Consent
11
61
Colby
12
Core
12
62
13
Corr
13
63
14
Cott
14
64
15
Dee
15
65
ILLUSTRATION 1: Partial View of Resident Control Record
Dint
16
66
Dor
17
67
the SW would be 1, the TE would be 2, and the
Table 1.-Sample designations for obtaining a sample of SNF residents in
Farr
18
68
nursing homes
Finch
19
69
number of sample residents will fall somewhere
Fizz
20
70
between 31-45.
Total SNF residents
Start with
Take every
Range for sample of
Flair
21
71
in home
SNF residents
5. The sampling procedure is as follows: start
Gale
22
72
Gamel
23
73
with the number of the line designated as SW and
1-45
1
Take all
1-45
Gore
24
74
circle the line number in column "c" of that person
46-60
1,2
3
31-40
Hill
25
75
61-90
1
2
31-45
as the individual first selected for the sample. Next,
91-120
3
3
30-40
Hope
26
76
121-160
3
4
30-40
Horn
27
77
count down from that line the number of lines
161-200
4
5
32-40
Jackson
28
78
designated in the TE instruction, circle the line
201-240
3
6
34-40
Jones
29
79
241-280
1
7
35-40
number in column "C" and so on until you have
June
281-320
30
8
8
35-40
80
gone through the entire list of residents of the
321-360
2
9
36-40
Kain
31
81
361-400
3
10
36-40
Keets
32
82
home.
401-440
9
11
36-40
King
33
83
441-480
10
12
36-40
Example.-When the SW number is 1 and TE
Kole
34
84
481-520
7
13
37-40
number is 2, you would start with resident num-
521-560
9
14
37-40
Lambert
35
85
561-600
2
15
38-40
Long
36
86
ber 01. Circle that resident's line number and
601-640
1
16
38-40
Lost
37
87
count down 2 lines to line 03, circle line 03, and
641-680
1
17
38-40
McKay
38
88
681-720
7
18
38-40
count down 2 more lines to line number 05, circle
721-760
10
19
38-40
Mang
39
89
761-800
14
20
38-40
Melton
40
90
line number 05 and SO on until you have gone
801-840
11
21
38-40
Moore
41
91
through the entire list of residents of the home.
841-880
7
22
38-40
Nickel
42
92
881-920
2
23
39-40
The resident line numbers that you have circled
Norman
921-960
9
24
39-40
93
are the persons who will be included in the
961-1000
4
25
39-40
Raft
44
94
1001-1040
5
26
39-40
Rick
45
95
sample. See illustration 1 for an example of the
1041-1080
10
27
39-40
Rust
96
resident control record when SW is 1 and TE
1081-1120
13
28
39-40
Sills
47
1121-1160
25
29
38-40
97
is 2.
1161-1200
9
30
39-40
Smith
48
98
1201-1240
29
31
38-40
Tackel
49
99
6. Count the total number of sample residents
1241-1280
17
32
39-40
Tucker
50
100
(i.e., the line numbers circled in column "c") and
1281-1320
13
33
39-40
1321-1360
24
34
39-40
ILLUSTRATION 2: Example of Step 1 for Selecting a Resident Sample When SW Is 1, 2 and TE 18 3.
enter this on the appropriate line at the top of the
1361-1400
14
35
39-40
resident control record.
1401-1440
26
36
39-40
1441-1480
34
37
39-40
7. It is very important to do this sampling care-
1481-1520
32
38
39-40
1521-1560
14
39
39-40
fully and correctly as this will affect the variation
1561-1600
36
40
39-40
in the national estimates.
1601-1640
8
41
39-40
81
80
LIST OF SNF RESIDENTS IN THE FACILITY
Regardless of the number of SNF residents, the
When More Form(s) Are Needed
Sample
Name of SNF
Line
Sample
Name of SNF
Line
sample selection is done in exactly the same way,
designation
resident
No
designation
resident
No.
with only the SW and TE numbers changing.
The resident control record has room for listing
SW
1,2
SW
1,2
TE
3
However, the sampling of residents for facilities
100 residents if more lines are needed, use another
TE
3
C
which have 46-60 SNF residents represent a "spe-
resident control record and renumber the lines be-
a
b
C
a
b
ginning with 101. If a 3rd record is needed, re-
Adams
01
Williams
51
cial case" in that it is done in the same way but in
App
02
Vincent
two steps.
number starting with 201, and SO on until all SNF
52
Andrews
03
Yost
53
Example.-Assume that you recorded 54 SNF
resident's names have been recorded.
Art
04
Zemil
54
residents on the residents control record. Fifty-
The nursing home name, identification number,
Baker
05
55
56
four falls in the interval of 46-60 in the column
MFI bed size recode, total SNF residents in the
Bett
06
Bic
07
57
head "Total SNF residents" in table 1. Reading
home and in the sample, the SW and TE numbers
Bitten
08
58
across table 1, the SW numbers are 1 and 2, the
should be completed on the additional form (s),
Cobb
09
59
the same as on the first form. Recording this infor-
10
60
TE number is 3 and number of sample residents
Coby
mation is essential, because it will be impossible to
Consent
61
will fall somewhere between 31-40. Since there
identify the facility without it. The TE number
Core
12
62
are two SW numbers, the sampling is done in
13
63
will run past the first to the second form, past the
Corr
two steps. In step 1, you start with 1 and take
Cott
14
64
second form to the third, and SO on. For example,
15
65
Dee
every 3. Thus, you would start with resident 01,
when the TE number is 10 and the last resident
Dint
16
66
circle his line number, take every third resident
number sampled was 93, seven lines will be counted
Dor
17
67
thereafter and circle their line numbers (i.e., cir-
Farr
18
68
on page 1 and three lines on page 2, and the 103d
Finch
19
69
cle line numbers 04, 07, 10, 13, 16, * * 43, 46,
resident selected for the sample.
Fizz
20
70
49, 52). See illustration 2 for the example of
Flair
21
71
step 1.
Gale
22
72
Selecting the Subsample for the
Gamel
23
73
In step 2, you would return to the beginning
Densen Patient Classification Instrument
Gore
24
74
of the list, start with resident 02, circle his line
Hill
25
75
number and take every third resident thereafter
The subsampling procedure is as follows: start
Hope
26
76
and circle their line numbers (i.e., circle line
with the first SNF resident selected in the sample
Horn
27
77
28
78
numbers 05, 08, 11, 17, ** 44, 47, 50, 53).
(i.e., the first resident whose line number is
Jackson
circled). Put a second circle around that resident's
Jones
29
79
As noted above, the number of sample residents
June
30
80
will fall somewhere between 31-40. If you count
line number and count down 10 sample residents
Kain
31
81
(10 circled resident line numbers), put a second
32
82
the number of circled lines in illustration 3, the
Keets
circle around that resident's line number and so on
King
33
83
precise number of sample residents is 36.
until you have gone through the entire sample of
Kole
34
84
8. After the sample is selected, remember to in-
Lambert
35
85
residents (circled line numbers only). The sample
clude the resident control record in the packet with
Long
36
86
resident line numbers that you have put a second
Lost
37
87
all the other questionnaires. Its inclusion is
circle on are the persons who will be in the sub-
McKay
38
88
extremely important because the information on
sample for the Densen Patient Classification In-
Mang
39
89
the resident control record is essential to the sta-
strument. The number of residents in this subsam-
Melton
40
90
Moore
91
tistical weighting of the sample so that the data
ple will never be less than one or more than five.
Nickel
42
92
will represent information on all SNF residents
The number of residents will usually be three or
Norman
43
93
in the Nation.
four.
Raft
44
94
Rick
45
95
Rust
46
96
Sills
47
97
Smith
48
98
Tackel
49
99
Tucker
50
100
ILLUSTRATION 3: Example of the Completed Sample Selection (i.e., Step 2 Is Completed) When SW Is
1, 2 and TE Is 3.
82
83
B
W₂ₙᵢ=the second stage weight for in-scope
procedure, two pseudo PSU's must be formed in
sample residents in the ith home of
each of the three bed-size stratum. The bed size
the hth stratum.
stratum is indicated by the bed size recode, which
nₙᵢ=number of in-scope sample residents
is 1, 2, or 3. Within each stratum arrange the homes
from the ith home of the hth stratum.
by region, alphabetical by State within region,
nₙᵢ=number of responding in-scope sample
alphabetical by county within State, alphabetical
Estimation and Variance Specifications
residents from the ith home in the
by city within county, and alphabetical by name
for the Long-Term Care
hth stratum.
within city. The pseudo PSU A will contain the
Nₕᵢ=total number of in-scope residents in
first listed home in the stratum and every second
Facility Improvement Campaign
the i'ⁿ home of the hth stratum.
home after that, i.e., the first, third, fifth, and so
The estimator X" is the estimator for an
on. The pseudo PSU B in the stratum will contain
aggregate. Similar estimates for proportions,
the remaining homes, i.e., the second, fourth, sixth,
ratios, etc., are computed as follows:
and SO on.
The following section specifies the estimation
where:
For a proportion, the numerator would be X" as
To construct a variance estimate for resident
and variance specifications for the Long-Term
Zₙᵢ=the measure of characteristic for the ith
computed above with:
type estimates, first compute an estimate of the
Care Facility Improvement Campaign as de-
home in the hth stratum.
if the jth in-scope resident of the
form Xₖ" from the Kth half-sample. This estimate
veloped by the National Center for Health Statis-
Then the estimated ratio is R' = X'/Z'.
ith home in the hth
is like X" computed from the whole sample (see
tics. The following instructions for calculation of
stratum has the characteristic.
For a proportion of homes having a particular
resident type estimates), except that all records
the variance estimates require information on the
0 otherwise.
characteristic, the numerator would be X' as
should be weighted by 2 before summing. Then,
region, State, county, and city of the facility to
computed above with
The denominator would be computed by the
given an estimate Xₖ" from each replication, the
be maintained on the data tape.
formula
1 if the ith home in the hth stratum
variance of X" is estimated by
Xₕ=
has the characteristic.
8
ESTIMATION AND VARIANCE
0 otherwise.
(Xₖ"-X")².
SPECIFICATIONS FOR 1974 ONHA SURVEY
The denominator would be computed as follows:
where
Home Type Estimates
for residents who are in-scope and
The variance for home type estimates is com-
3 mₙ Xₙᵢ
Xₘⱼ=
in the ith home of the hth stratum
puted in the same way as the variance for resident
The estimator recommended for use in the
otherwise
type estimates except Xₖ' is like X' for home type
ONHA survey is an inflation estimator. Specifically,
where
For a ratio statistic of the form R=X/Z, the
estimates with all records being weighted by 2 be-
1 if the ith home in the hth stratum is
estimate X would again be X", and for Z use
fore summing.
in-scope.
These procedures should also be used for esti-
where:
otherwise
mating the variance of rates, percentages, and so
Xₙᵢ=measure of characteristic for the i''
Then P'=X'/M'.
where
on, as well as aggregates.
home in the hth stratum.
W₁ₙ₁=The first stage weight of the ith home
Zₙᵢⱼ=the measure of characteristic for the
in the hth stratum.
jth sample resident of the ith home in
Resident Type Estimates
the hth stratum.
Table 2.-ONHA survey replicate indicators
NOTE:-The weights W₁ₕᵢ are given in table 1
of this document.
The estimator recommended for use is again
Then the estimated ratio is R"=X"/Z.
Stratum
Pseudo PSU
Replicate indicators
mₙ =number of in-scope sample homes re-
an inflation estimator.
sponding in the hth stratum, where a
A
11101000
home is in scope if it is a skilled nursing
That is:
Variance Estimate
1
B
00010111
home.
A
01110100
2
mₙ'=number of sample homes clarified as
The variance estimation procedure to be used is
B
10001011
A
00111010
being in-scope at survey time in the
the balanced half-sample replication procedure.
3
B
11000101
hth stratum.
mₙ =number of sample homes selected from
There will be eight balanced half-sample replicates
Example: The first half sample replicate contains PSU A from stratum 1, PSU B from
the hth stratum.
whose composition is shown in table 2. For the
statum 2, and PSU B from stratum 3.
The estimator X' is the estimator of an aggre-
gate. The estimator for proportions, ratios, etc.,
where:
are computed as follows.
Xrᵢⱼ=the measure of characteristic for the
For a ratio statistic of the form R=X/Z, the
estimate of X would be X' shown above and for
jth in-scope sample resident in the
Z use the estimator
ith home of the hth stratum. (An
in-scope resident is a resident receiv-
ing skilled nursing care under the
Medicare or Medicaid programs.)
LIBRARY
84
85
588-459
APPENDIX C
Diagnostic category
ICDA Code
13. Diseases of digestive system
Disease of esophagus, stomach and duodenum (530-537).
Hernia of abdominal cavity (550-553).
Other diseases of intestine and peritoneum (560-569).
Disease of liver, gall bladder, and pancreas (570-577).
Symptoms referable to upper GI tract (784).
Symptoms referable to abdomen and lower GI tract (785).
Preparation of the Data for Analysis
14. Diseases of genitourinary sys-
Diseases of genitourinary system (580-629).
tem.
Symptoms referable to genitourinary system (786).
Uremia (792).
15. Diseases of eye and ear
Other diseases and conditions of eye (370-379).
DIAGNOSTIC CATEGORIES
Diseases of ear and mastoid process (380-389).
Combined blindness and deafness (special code).
Team physicians transcribed the actual di-
all diagnoses on returned questionnaires by a
16. Other
Other category includes:
agnoses to the survey form as they appeared on
group of three physicians, who mutually clarified
Disease of thyroid gland (240-246).
patients' charts, identifying primary and second-
non-specific diagnoses and agreed on the diagnostic
Disease of other endocrine glands excluding diabetes mellitus (250-258).
ary diagnoses on admission and other diagnoses
groups used in the reported tables. The diagnostic
Avitaminosis and other nutritional deficiencies (260-269).
Congenital disorders of amino acid metabolism (270-279).
postadmission. To assure consistent coding the
categories used with appropriate ICDA Code are
Disease of the blood and blood-forming organs (280-289).
corresponding ICDA designation was assigned to
shown below.
Infections of skin and subcutaneous tissue (680-686).
Other inflammatory conditions of skin and subcutaneous tissue (690-698).
Diagnostic category
ICDA Code
Chronic ulcer of skin (707).
1. Heart Disease
Chronic rheumatic (393-398).
Hypertensive (402, 404).
Ischemic (410-414).
Other forms (420-429).
2. Chronic brain disease
Mental disorders not specified as psychotic associated with physical condition
(309).
Other disease of brain (347).
Generalized ischemic cerebrovascular disease (437).
Senility without mention of psychosis (794).
3. Stroke
Cerebrovascular disease (except generalized ischemic) (430-436, 438).
4. Fractures
Fractures (800-829).
Dislocations without fracture (830-839).
5. Neurological disease
Late effects of acute poliomyelitis (044).
Syphilis of central nervous system (094).
Inflammatory disease of central nervous system (320-324).
Hereditary and familial disease of nervous system (330-333).
Other diseases of central nervous system (340-349).
Disease of nerves and peripheral ganglia (350-358).
Congenital anomalies of brain and spinal cord (740-743).
Down's disease (759).
6. Generalized arteriosclerosis
Hypertensive disease (400-401).
and hypertension.
Disease of arteries, arterioles and capillaries (440-448).
Diseases of veins and lymphatics and other diseases of circulatory system (450-
458).
7. Neuroses and psychoses
Psychoses (290-299).
Neuroses, personality disorders and other nonpsychotic mental disorders (300-309).
8. Diabetes
Diabetes Mellitus (250).
9. Diseases of musculoskeletal
Diseases of musculoskeletal system and connective tissue (710-738).
system.
10. Mental retardation
Mental retardation (310-315).
11. Neoplasms
Neoplasms-all sites (140-239).
12. Diseases of respiratory sys-
Pulmonary embolism and infarction (450).
tem.
Acute respiratory disease except influenza (460-466).
Influenza (470-474).
Pneumonia (480-486).
Bronchitis, emphysema and asthma (490-493).
Other diseases of respiratory system (510-519).
Symptoms referable to respiratory system (783).
86
87
APPENDIX D
2. Conduct survey of records of patients in the
2. Conduct survey of records of patients in the
sample using the rehabilitative patient specific
sample using the psychosocial patient specific cri-
criteria forms.
teria forms.
3. Conduct observation/interview of patients in
3. Conduct observation/interview of patients in
the sample using the rehabilitative patient specific
the sample using the psychosocial patient specific
criteria forms.
criteria forms.
General Instructions for
Members of the Survey Team
Pharmacist Responsibilities
Fire Safety Engineer Responsibilities
1. Conduct the pharmaceutical facility specific
1. Conduct life safety code survey.
criteria survey.
2. Assist other surveyors as necessary.
2. Conduct the pharmaceutical patient specific
A SUMMARY
paring the work sheets. This condition responsibil-
criteria survey on the patients in the sample.
ity will require implementation of activities which
Administrative Surveyor Responsibilities
1. The random selection and the survey team is
will enable the members of the team to review each
to concern itself only with SNF patients in the
of the selected patient's medical record and to
Dietitian Responsibilities
As team leader for the survey
Title XVIII and Title XIX programs. No ICF
conduct necessary interviews and observations.
1. Conduct nutrition and dietetics facility sur-
1. Responsible for the overall survey effort.
patients. No private patients.
2. Act as a consultant to the team members to
vey using the nutrition and dietetics facility spe-
2. Entry and exit conference.
2. If facility has no SNF XVIII/XIX patients
assist in finalizing judgments concerning the medi-
cific criteria forms.
3. Survey schedule for survey.
do all of the survey except the patient specific
cal condition of a patient.
2. Conduct survey of records of patients in the
4. Management section of quality of care survey
criteria sections and the patient assessment work-
3. Review the medical record and assist in con-
sample using the nutrition and dietetics patient
form.
sheets.
ducting interviews and observation of the ran-
specific criteria forms.
5. Financial information survey.
3. You are to survey for the current status of
domly selected patients.
3. Conduct observation/interview of patients in
6. Control over all survey forms and security of
the facility and its SNF patients. Review records
4. Survey patient care policies of the survey.
confidentiality.
of the randomly selected patients only.
the sample using the nutrition and dietetics pa-
5. Survey the medical unit of the survey.
tient specific criteria forms.
7. Collecting, assembling, and reviewing for ac-
4. This is a fact-finding survey, not a certifica-
6. For each randomly selected patient, prepare
curacy and completion (all forms).
tion or licensure survey. Be tactful.
that portion of the patient assessment worksheet
8. Select patients for record review, observa-
5. All report forms and other information is
which pertains to the current primary diagnosis
Social Worker Responsibilities
tion and interview.
confidential. Do not lose any forms or instructions
(or if not available, the primary admitting diag-
or other material provided. Keep the material
1. Conduct psychosocial facility survey using the
9. Complete the LTCFI survey identification
nosis) and each current secondary diagnosis. In
secure at all times.
psychosocial facility specific criteria forms.
sheet for each facility.
addition, record the drugs currently prescribed for
6. Definitions appearing in the FEDERAL REG-
the patient which fall within the categories listed.
ISTER of Jan. 17, 1974 are to be used for this survey.
7. Review for accuracy and completeness the
7. Identification Procedures-use code numbers
patient assessment report.
only for all forms. Names of Facility, patients,
personnel, city, State or any other information is
not to be entered on the forms with the exception
Registered Nurse Responsibilities
of the patient selection form. Your forms are al-
1. Conduct nursing facility survey using the
ready coded. After patients have been selected
nursing facility specific criteria forms.
use only the number opposite the patient's name
2. Conduct survey of records of patients in the
appearing on the patient selection form, on the
sample using the nursing patient specific criteria
patient specific criteria form and patient assess-
forms.
ment worksheet.
3. Conduct observation/interview of patients in
the sample using the nursing patient specific cri-
Instructions for Physician Member of Team
teria forms.
4. Conduct assessment of selected patients in
The physician member of the survey team will be
sample using patient assessment worksheet.
responsible for the overall patient assessment ac-
tivity and in that regard will:
1. Coordinate the survey activities of the other
Rehabilitative Responsibilities
professional specialists in conducting the patient
1. Conduct rehabilitative facility survey using
specific criteria sections of the survey and in pre-
the rehabilitative facility specific criteria forms.
88
89
APPENDIX E
Ms. Mary Lou Lane, Director
PARTICIPANTS
Office of Long-Term Care Standards
Miss Jean Bainter
Enforcement
Nurse Consultant
Region VI
Research and Development Branch
Dallas, Tex.
Division of Long-Term Care
Miss Carol Larson, R.N.
Rockville, Md.
Health Services Administration
Mr. William Cox
Acknowledgments
Bureau of Quality Assurance
Physical Therapy Consultant
Rockville, Md.
Division of Provider Standards and Certification
Mr. Benjamin Latt
Bureau of Quality Assurance
Health Resources Administration
Rockville, Md.
Division of Long-Term Care
The Office of Nursing Home Affairs gratefully
Mr. Phillip Bettendorf
Mr. Charles U. Erdeljon
Rockville, Md.
acknowledges the splendid cooperation and the
Tulane University
Health Services Administration
New Orleans, La.
Miss Mary R. Lester
Indian Health Service
significant contribution of all persons who directly
Office of the Secretary
Rockville, Md.
Ms. Leah Bigelow
or indirectly participated in the Long-Term Care
Office of the Regional Director
Office of Nursing Home Certification
Mrs. Bernice Harper, Director
Office of Long-Term Care Standards
Region x
Social Worker
Facility Survey and the preparation of this report.
Seattle, Wash.
Enforcement, Region II
Division of Long-Term Care
Without their breadth of experience and expertise
New York, N.Y.
Mrs. Barbara McNitt, R.N.,
Rockville, Md.
in a wide number of health fields and in long-term
Ms. Martha E. Clark
Associate
Dr. William Jesse
care, this study would have been impossible. We
Division of Quality Standards
Harvard Center for Community Health and Medical Care
Health Services Administration
Region VI
Boston, Mass.
Division of Peer Review
have attempted to list the names of those who par-
ticipated directly to whom we are indebted for as-
Dallas, Tex.
Mr. Michael J. Oliva.
Rockville, Md.
Ms. Betty Cornelius
Office of the Regional Director
Mr. Nicholas Olimpio
sistance. This brief list does not reveal their ex-
Division of Long-Term Care
Office of Long-Term Care Standards Enforcement
National Institutes of Health
tensive academic credentials.
National Center for Health Services
Region VIII
Bethesda, Md.
At this time we also wish to express our sincere
Research and Development
Denver, Colo.
Ms. Charlotte Smith
appreciation to all programs and agencies and the
Rockville, Md.
Dietitian Advisor
Dr. Claire F. Ryder, Chief
many individuals who indirectly supported the
Mr. William Cox
Division of Policy Development
Division of Provider Standards and Certification
Physical Therapy Consultant
Office of Nursing Home Affairs
Bureau of Quality Assurance
survey in other countless ways. The interest and
Division of Provider Standards
Rockville, Md.
Rockville, Md.
enthusiasm envidenced by all who participated
and Certification
Dr. Hugh Sloan
directly and indirectly in the survey and in the
Bureau of Quality Assurance
LIFE SAFETY CODE TASK FORCE
Office of the Regional Director
Rockville, Md.
preparation of this introductory report indicate
Office of Long-Term Care Standards Enforcement
Mr. Michael Morelli, Chairman
Mrs. Angela Ernitz, Associate
that steady progress will continue to be made in
Region IX
Social Science Analyst
Harvard Center for Community Health
San Francisco, Calif.
Office of Nursing Home Affairs
improving long-term care in the Nation.
and Medical Care
Rockville, Md.
Ms. Charlotte Smith
Boston, Mass.
Bureau of Quality Assurance
Mr. Richard Hall
PARTICIPANTS
Rockville, Md.
ORIENTATION AND TRAINING PROGRAM
Division of Quality Standards
Mr. Richard Amerikian
Region V
Mr. Michael Spodnik, Jr.
Health Services Administration
Mr. Ronald Eggers, Coordinator
Chicago, Ill.
Division of Provider Standards and Certification
Bureau of Quality Assurance
Deputy Director
Dr. Steven D. Helgerson
Bureau of Quality Assurance
Rockville, Md.
Office of Long-Term Care Standards Enforcement
Division of Quality Standards
Rockville, Md.
Mr. Donald Brooks, Chairman
Region VI
Region x
Mr. Roger W. Turenne
Office of Facilities, Engineering and Property Manage-
Dallas, Tex.
Seattle, Wash.
Office of the Regional Director
ment and Technical Standards Committee
Dr. Samuel Kidder
Office of Long-Term Care Standards Enforcement
Washington, D.C.
PARTICIPANTS
Pharmacist
Region IV
Mr. Richard Davidson
Bureau of Quality Assurance
Atlanta, Ga.
Dr. Thomas Antone
Social and Rehabilitation Service
Deputy Chief
Rockville, Md.
Mr. David E. Watson, Director
Medical Services Administration
Division of Standards Enforcement
Mr. John Kerns
Office of Long-Term Care Standards Enforcement
Washington, D.C.
Administrator
Region VII
Coordination
Mr. Howard Nickelsen
Office of Nursing Home Affairs
Bureau of Quality Assurance
Kansas City, Mo.
Social Security Administration
Rockville, Md.
Baltimore, Md.
Rockville, Md.
Mr. Ronald E. LaNeve
QUALITY OF CARE TASK FORCE
Mr. Julian Smariga, Deputy Director
Mr. Donald E. Baker
Office of the Regional Director
Office of Architecture and Engineering
Pharmacist
Office of Long-Term Care Standards
Mr. Arthur Barker, Chairman
Division of Facilities Utilization
Division of Quality Standards
Enforcement
Nursing Home Specialist
Health Care Facilities Service
Region IV
Region III
Office of Nursing Home Affairs
Bureau of Health Resource Development
Atlanta, Ga.
Philadelphia, Pa.
Rockville, Md.
Rockville, Md.
90
91
SELECTION OF PERSONNEL TASK FORCE
Mrs. Angela Ernitz, Associate
Mr. Maurice Hartman, Chief
Ronald S. Eggers
LONG-TERM CARE
Harvard Center for Community Health and Medical Care
Fiscal and Administration Branch
Office of the Regional Director
Boston, Mass.
Social Security Administration
Office of Long-Term Care Standards Enforcement
Miss Helen Foerst, Chairman
Baltimore, Md.
Region VI
Assistant Chief Nurse Officer
Dr. Charles D. Flagle, Professor
Dallas, Tex.
Office of Nursing Home Affairs
Department of Public Health Administration
Mr. Keith Hoffman
Rockville, Md.
Johns Hopkins University
Technical Services Branch
Sidney V. Gottlieb
School of Hygiene and Public Health
Division of Health Resources
Public Health Service
Baltimore, Md.
Mathematic Statistician
National Institutes of Health
PARTICIPANTS
Mrs. Ellen W. Jones, Assistant Director
Rockville, Md.
Bethesda, Md.
Ms. Dorothy Aird
Harvard Center for Community Health and Medical Care
Robert G. Griffiths
Mr. Michael Spodnik, Jr.
Health Services Administration
Boston, Mass.
Acting Director
Public Health Service
Bureau of Quality Assurance
Dr. Sidney Katz, Professor and Director
Division of Provider Standards and Certification
Health Resources Administration
Rockville, Md.
Bureau of Quality Assurance
Bureau of Health Planning and Resource Development
Office of Health Services, Education and Research
Michigan State University
Rockville, Md.
Rockville, Md.
Mrs. Louise Anderson, Chief
Health Manpower Development Branch
East Lansing, Mich.
F. Gene Headley
Mrs. Joan Van Nostrand, Acting Chief
Commissioned Corps Personnel
Public Health Service
Mrs. Barbara McNitt, R.N.
Long-Term Care Statistics Branch
Rockville, Md.
St. Elizabeth's Hospital
Associate
Division of Health Resources
Alcohol, Drug Abuse, and Mental Health Administration
Miss Mary Ann Fugitt
Harvard Center for Community Health and Medical Care
Utilization Statistics
Washington, D.C.
Nursing Home Specialist
Boston, Mass.
Rockville, Md.
Office of Nursing Home Affairs
Robert F. Hickman
Rockville, Md.
Ms. Beverlee Myers, Deputy Commissioner
Dr. Eugene W. Veverka, Deputy Director
Office of the Regional Director
Division of Medical Assistance
Regional Programs Implementations
Office of Long-Term Care Standards Enforcement
Dr. William Munier
Department of Social Services
Office of Regional Affairs
Health Services Administration
Region VIII
Albany, N.Y.
Washington, D.C.
Bureau of Quality Assurance
Denver, Colo.
Rockville, Md.
Dr. Anthony Robbins, Commissioner of Health
Sylvestre Lee
Vermont State Health Department
Dr. Hugh Sloan
Burlington, Vt.
ADMINISTRATORS
Office of the Regional Director
Health Resources Administration
Office of Long-Term Care Standards Enforcement
Bureau of Health Services Research
Mr. Glenn C. Williams, Chief
David L. Allen
Region IX
Rockville, Md.
Nursing Home Rate Setting Division
Office of the Regional Director
San Francisco, Calif.
Bureau of Health Care Administration
Office of Long-Term Care Standards Enforcement
Rowland W. McDermott
Michigan Department of Public Health
Region V
Office of the Regional Director
COST TASK FORCE
State of Michigan
Chicago, Ill.
Office of Long-Term Care Standards Enforcement
Lansing, Mich.
Reuben A. Baybars
Region IV
Dr. Michael Fitzmaurice, Chairman
Economist
Public Health Service
Atlanta, Ga.
Health Insurance Studies
EXECUTIVE COMMITTEE
Health Services Administration
Hugh Miller
Social Security Administration
Indian Health Service
Office of the Regional Director
Bethesda, Md.
Mr. Ronald Eggers, Chairman
Rockville, Md.
Office of Long-Term Care Standards Enforcement
Deputy Director
Region IV
Eugene Burger
PARTICIPANTS
Office of Long-Term Care Standards Enforcement
Atlanta, Ga.
Office of the Regional Director
Mr. Al Baker
Region VI
Office of Long-Term Care Standards Enforcement
Paul O'Donnell, Jr.
Special Assistant for Cost Monitoring
Dallas, Tex.
Region II
Office of the Regional Director
Office of the Deputy Assistant Secretary for Planning and
New York, N.Y.
Office of Long-Term Care Standards Enforcement
Evaluation-Health
Region III
PARTICIPANTS
Washington, D.C.
Rolland L. Cox
Philadelphia, Pa.
Dr. Rita Chow, Deputy Director
Mr. Willis W. Atwell
Office of the Regional Director
Paul Panneton
Field Liaison Staff
Office of Long-Term Care Standards Enforcement
Office of Nursing Home Affairs
Region VII
Public Health Service
Rockville, Md.
Administration on Aging
Washington, D.C.
Kansas City, Mo.
Health Resources Administration
Bureau of Health Manpower
Mrs. Joan Van Nostrand, Acting Chief
Long-Term Care Statistics Branch
Dr. Jonathan Bates
Harvey Demsky
Rockville, Md.
Division of Health Resources
Special Assistant to Deputy Assistant Secretary for
Office of the Regional Director
James W. Rolofson
Utilization Statistics
Health
Office of Long-Term Care Standards Enforcement
Public Health Service
Rockville, Md.
Office of the Assistant Secretary for Health
Region II
Food and Drug Administration
Washington, D.C.
New York, N.Y.
Rockville, Md.
Ms. Mary Jo Gibson
Howard E. Dickinson
AD Hoc ADVISORY COMMITTEE
Gary M. Silman
Special Assistant to the Director
Office of the Regional Director
Public Health Service
Dr. Paul M. Densen, Director
Utilization Control Division
Office of Long-Term Care Standards Enforcement
Division of Financing and Health Economics
Harvard Center for Community Health and Medical Care
Social and Rehabilitation Service
Region VIII
Region VI
Boston, Mass.
Washington, D.C.
Denver, Colo.
Dallas, Tex.
92
93
588-459
Jerry B. Thompson
Nelson L. Hettler
Philip R. Paul
Frances J. Contreras
Office of the Regional Director
Office of the Regional Director
Office of the Regional Director
Office of the Regional Director
Office of Long-Term Care Standards Enforcement
Regional Office of Facilities Engineering and Construction
Regional Office of Facilities Engineering and Construction
Office of Long-Term Care Standards Enforcement
Region x
Region II
Region III
Region IX
Seattle, Wash.
New York, N.Y.
Philadelphia, Pa.
San Francisco, Calif.
Donald W. Trent
Keith S. Hord
William V. Phillips
Mary Eileen G. Damian
Office of the Regional Director
Public Health Service
Office of the Regional Director
Office of the Regional Director
Office of Long-Term Care Standards Enforcement
Office of Long-Term Care Standards Enforcement
Office of Long-Term Care Standards Enforcement
National Institutes of Health
Region IV
Bethesda, Md.
Region VI
Region III
Atlanta, Ga.
Myron S. Hurwitz
Dallas, Tex.
Philadelphia, Pa.
Nancy Damich
Ernest A. Weinerman
Public Health Service
Richard S. Pike
Public Health Service
Office of the Regional Director
Health Resources Administration
Office of the Regional Director
National Institutes of Health
Office of Long-Term Care Standards Enforcement
Bureau of Health Planning and Resource Development
Regional Office of Facilities Engineering and Construction
Bethesda, Md.
Region I
Rockville, Md.
Region II
New York, N.Y.
Elizabeth J. Federer
Boston, Mass.
Jeremiah C. Iandolo
Office of the Regional Director
Kenneth L. Winters
Office of the Regional Director
Harold H. Rhodes
Office of Long-Term Care Standards Enforcement
Public Health Service
Regional Office of Facilities Engineering and Construction
Office of the Regional Director
Region V
Division of Quality Standards
Region III
Regional Office of Facilities Engineering and Construction
Chicago, Ill.
Region VI
Philadelphia, Pa.
Region II
Fred D. Garcia
Dallas, Tex.
New York, N.Y.
Daniel Jacobs
Office of the Regional Director
Office of the Regional Director
Charles M. Slaymaker, Jr.
Office of Long-Term Care Standards Enforcement
Regional Office of Facilities Engineering and Construction
Office of the Regional Director
Region VIII
FIRE SAFETY ENGINEERS
Region V
Regional Office of Facilities Engineering and Construction
Denver, Colo.
Chicago, Ill.
Region V
Lester Arnow
Nona Gish
Chicago, Ill.
Office of the Regional Director
Donald E. Kelley
Office of the Secretary
Office of the Secretary
Strone Sparks
Office of Nursing Home Certification
Regional Offce of Facilities Engineering and Construction
Region II
Office of Facilities Engineering and Property Management
Public Health Service
Region x
Washington, D.C.
Health Resources Administration
Seattle, Wash.
New York, N.Y.
Bureau of Health Manpower
Franz W. Krebs
Maxie Hardin
Tommie L. Bowen
Rockville, Md.
Office of the Secretary
Office of the Regional Director
Office of the Regional Director
Office of Facilities Engineering and Property Management
Burt L. Utt
Office of Long-Term Care Standards Enforcement
Regional Office of Facilities Engineering and Construction
Washington, D.C.
Office of the Regional Director
Region VI
Region IV
Regional Office of Facilities Engineering and Construction
Dallas, Tex.
George W. LaRoe
Atlanta, Ga.
Region VII
Office of the Regional Director
Beverly J. Higgins
Kansas City, Mo.
Clyde H. Dorsett
Office of Long-Term Care Standards Enforcement
Office of the Regional Director
Public Health Service
George F. Winn
Office of Long-Term Care Standards Enforcement
Region VI
National Institute of Mental Health
Office of the Regional Director
Region VII
Dallas, Tex.
Bethesda, Md.
Regional Office of Facilities Engineering and Construction
Kansas City, Mo.
Daniel A. McNiven
Region I
Arlene Kanai
Stanley R. Dube
Office of the Regional Director
Boston, Mass.
Public Health Service
Public Health Service
Regional Office of Facilities Engineering and Construction
Health Services Administration
Health Resources Administration
Region IX
Indian Health Service
Bureau of Health Manpower
San Francisco, Calif.
NURSES
Rockville, Md.
Rockville, Md.
Martin T. Moffitt
Joanne C. Kremer
Raymond B. Eakle
Marcile Backs
Office of the Regional Director
Office of the Regional Director
Office of the Regional Director
Public Health Service
Regional Office of Facilities Engineering and Construction
Office of Long-Term Care Standards Enforcement
Health Resources Administration
Regional Office of Facilities Engineering and Construction
Region VII
Region II
National Center for Health Services Research
Region VIII
New York, N.Y.
Kansas City, Mo.
Rockville, Md.
Denver, Colo.
Nina Lee
Charles Dee Moore
Leah Bigelow
Public Health Service
Donald Gooch
Office of the Regional Director
Office of the Regional Director
Health Services Administration
Office of the Secretary
Nursing Home Certification
Office of Long-Term Care Standards Enforcement
Bureau of Community Health Services
Office of Facilities Engineering and Property Management
Region x
Region II
Division of Clinical Services
Washington, D.C.
Seattle, Wash.
New York, N.Y.
Bethesda, Md.
V. Richard Hale
Bernard J. Parodi
Mildred R. Burns
Mary R. Lester
Office of the Regional Director
Office of the Regional Director
Public Health Service
Office of the Secretary
Regional Office of Facilities Engineering and Construction
Regional Office of Facilities Engineering and Construction
Division of Quality Standards
Office of Nursing Home Certification
Region IV
Region II
Region IV
Region x
Atlanta, Ga.
New York, N.Y.
Atlanta, Ga.
Seattle, Wash.
94
95
Goldie C. Moore
Rebecca Kay Dillon
Audrey Paulbitski
Donald E. Baker
Public Health Service
Public Health Service
Public Health Service Hospital
Public Health Service
National Institutes of Health
Health Services Division
Region IX
Division of Quality Standards
Bethesda, Md.
Region II
San Francisco, Calif.
Region IV
Margaret Petruzzo
New York, N.Y.
Jo Ann Pegues
Atlanta, Ga.
Public Health Service
Anne Claire Donovan
Office of the Regional Director
John S. Cipriano
National Institutes of Health
Public Health Service
Aging Services
Public Health Service
Bethesda, Md.
Health Resources Administration
Region VIII
Food and Drug Administration
Bureau of Health Planning and Resource Development
Denver, Colo.
Rockville, Md.
Judy Rossow
Public Health Service
Rockville, Md.
Marian Petkoff
Lou Coccodrilli
St. Elizabeth's Hospital
Public Health Service
Public Health Service
Cora Beth Duncan
Alcohol, Drug Abuse, and Mental Health Administration
St. Elizabeth's Hospital
Health Resources Administration
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration
Division of Health Resources
Washington, D.C.
Division of Health Services
Washington, D.C.
Development
Bernice Szukalla
Region IV
Geraldine M. Piper
Region II
Office of the Regional Director
Atlanta, Ga.
Public Health Service
New York, N.Y.
Office of Long-Term Care Standards Enforcement
Marilyn Farrand
Division of Resources Development
Thomas D. DeCillis
Region VIII
Public Health Service
Health Manpower and Development Branch
Public Health Service
Denver, Colo.
National Institutes of Health
Region IV
Food and Drug Administration
Helen M. Tate
Bethesda, Md.
Atlanta, Ga.
Rockville, Md.
Office of the Regional Director
Marie L. Goulet
Elizabeth A. Prendergast
Robert Eaton
Office of Long-Term Care Standards Enforcement
Public Health Service
Public Health Service
Public Health Service
Region IV
Division of Quality Standards
Division of Health Services
Food and Drug Administration
Atlanta, Ga.
Region II
Region II
Rockville, Md.
Violet D. Wright
New York, N.Y.
New York, N.Y.
Charles U. Erdeljon
Public Health Service
Mary Lou Haskins
Jeanne M. Reid
Public Health Service
Division of Health Services
Office of the Reigonal Director
Public Health Service
Health Services Administration
Region VI
Office of Long-Term Care Standards Enforcement
National Institutes of Health
Indian Health Service
Dallas, Tex.
Region I
Bethesda, Md.
Rockville, Md.
Boston, Mass.
Lois R. Seidler
George Freedman
Public Health Service
Public Health Service
NUTRITIONISTS
Ramona Higgins
Division of Quality Standards
Health Resources Administration
Public Health Service
Region VII
Bureau of Health Planning and Resource Development
R. LaJeune Bradford
Region III
Kansas City, Mo.
Rockville, Md.
Office of the Regional Director
Philadelphia, Pa.
Charlotte Smith
Santos L. Garza
Office of Long-Term Care Standards Enforcement
Debra S. Kessler
Public Health Service
Public Health Service
Region VIII
Public Health Service
Bureau of Quality Assurance
Division of Health Services
Denver, Colo.
Food and Drug Administration
Rockville, Md.
Region VI
Mary Bruchac
Rockville, Md.
Florence Smith
Dallas, Tex.
Public Health Service Hospital
Julia J. Kula
Office of Human Development
John T. Gimon
Region IX
Public Health Service
Administration on Aging
Office of the Regional Director
San Francisco, Calif.
Health Resources Administration
Washington, D.C.
Office of Long-Term Care
National Center for Health Services Research
Alice M. Stang
Standards Enforcement
H. Mariel Caldwell
Rockville, Md.
Public Health Service
Region III
Public Health Service
Health Resources Administration
Philadelphia, Pa.
Division of Health Services
Doris E. Lauber
Indian Health Service
Barry Gordon
Maternal and Child Health
Office of the Regional Director
Rockville, Md.
Public Health Service
Region V
Office of Long-Term Care Standards Enforcement
Region IX
Dorothy Stringfellow
Division of Health Services
Chicago, Ill.
Public Health Service
Region II
San Francisco, Calif.
Martha E. Clark
Food and Drug Administration
New York, N.Y.
Public Health Service
Sallie Norcott
Rockville, Maryland
Richard Hall
Public Health Service
Public Health Service
Division of Quality Standards
Health Resources Administration
Diviison of Quality Standards
Region VI
Bureau of Health Manpower
PHARMACISTS
Region V
Dallas, Tex.
Rockville, Md.
Chicago, Ill.
Mary Brice Deaver
Isabel Patterson
Mary Lou Anderson
Paul H. Honda
Public Health Service
Public Health Service
Office of the Regional Director
Office of the Regional Director
Regional Health Administrator
Division of Health Services
Office of Long-Term Care
Office of Long-Term Care
Office of the State Coordinator
Maternal and Child Health
Standards Enforcement
Standards Enforcement
Region VI
Region III
Region I
Region VIII
Dallas, Tex.
Boston, Mass.
Philadelphia, Pa.
Denver, Colo.
96
97
Juanita P. Horton
Sam G. Wynn, Jr.
Jimmy Ray Jones
Johnathan T. Spry
Public Health Service
Office of the Regional Director
Public Health Service
Office of Personnel Management
Division of Financing and Health
Office of Long-Term Care
San Francisco, Calif.
Commissioned Personnel Operations Division
Economics
Standards Enforcement
Rockville, Md.
Thomas Ray Jones
Dallas, Tex.
Region VI
Office of the Regional Director
Eleanor A. Stapin
Gwendolyn Johnson
Dallas, Tex.
Office of Long-Term Care Standards Enforcement
Public Health Service
Public Health Service
Region VIII
National Institutes of Health
Food and Drug Administration
Denver, Colo.
Bethesda, Md.
PHYSICAL THERAPISTS
Rockville, Md.
Marsha H. Lampert
Lynn A. Talbot
Richard M. King
John B. Allis
Public Health Service
Public Health Service
Office of the Regional Director
Office of the Regional Director
National Institutes of Health
Office of the Secretary
Office of Long-Term Care
Office of Long-Term Care
Bethesda, Md.
Assistant Secretary for Health
Standards Enforcement
Standards Enforcement
Commissioned Personnel Operations Division
Ronald E. LaNeve
Region IX
Rockville, Md.
Region VIII
Office of the Regional Director
San Francisco, Calif.
Denver, Colo.
Office of Long-Term Care Standards Enforcement
John M. Tuveson
John P. Koclanes
Robert K. Baus
Region III
Public Health Service Hospital
Office of the Regional Director
Public Health Service
Philadelphia, Pa.
San Francisco, Calif.
Office of Long-Term Care
Indian Health Service
John Larson
William Wallis
Standards Enforcement
Alaska Native Health Service
Public Health Service Hospital
Office of the Regional Director
Region VIII
Rockville, Md.
San Francisco, Calif.
Office of Long-Term Care Standards Enforcement
Denver, Colo.
Louise Bezdek
Region VI
Ronald F. Leonard
Ramona McCarthy
Dallas, Tex.
Public Health Service
Office of the Regional Director
Public Health Service
National Institutes of Health
Office of Long-Term Care Standards Enforcement
Wendy Wheat
Food and Drug Administration
Bethesda, Md.
Region IX
Office of the Regional Director
Rockville, Md.
James Wolfe Bredon
San Francisco, Calif.
Office of Long-Term Care Standards Enforcement
Samuel Merrill
Region VIII
Bureau of Medical Service
Roger Nelson
Public Health Service
Denver, Colo.
Division of Hospitals and Clinics
Public Health Service Hospital
Division of Quality Standards
Region IV
San Francisco, Calif.
Region I
Atlanta, Ga.
Michael J. Oliva
PHYSICIANS
Boston, Mass.
William E. Cox
Office of the Regional Director
Nicholas Olimpio
Public Health Service
Office of Long-Term Care Standards Enforcement
Gordon Allen, M.D.
Public Health Service
Bureau of Quality Assurance
Public Health Service
Region VIII
National Institutes of Health
Rockville, Md.
National Institutes of Health
Denver, Colo.
Bethesda, Md.
Bethesda, Md.
Harold Egbert
Gordon S. Pocock
William B. Sisco
Bureau of Medical Services
Lenore Bajda, M.D.
Office of the Regional Director
Public Health Service Hospital
Public Health Service Hospital
Public Health Service
Office of Long-Term Care Standards Enforcement
Region IX
Seattle, Wash.
National Institutes of Health
Region IX
San Francisco, Calif.
Bethesda, Md.
Perry S. Esterson
San Francisco, Calif.
James L. Snowden
Public Health Service
Jonathan R. Bates, M.D.
Jon R. Robinson
Public Health Service
Office of Assistant Secretary for Health
Outpatient Clinic
Public Health Service
National Institutes of Health
Washington, D.C.
Washington, D.C.
Division of Health Services
Bethesda, Md.
Region VII
John M. Boyce, M.D.
Neil Hartman
Center for Disease Control
H. C. Skip Watters
Office of the Regional Director
Kansas City, Mo.
Public Health Service
Bureau of Epidemiology
Office of Long-Term Care Standards Enforcement
Joseph R. Scally
Atlanta, Ga.
Division of Quality Standards
Region V
Office of the Regional Director
Region V
William R. Budge, M.D.
Chicago, Ill.
Chicago, Ill.
Office of Long-Term Care Standards Enforcement
Center for Disease Control
Kirk Hillman
Region IX
Atlanta, Ga.
Donald H. Williams
Public Health Service
San Francisco, Calif.
Office of the Secretary
Robert Chandler, M.D.
Office of Nursing Home
Health Services Administration
Walter Schneiderwind
Office of the Regional Director
Certification
Bureau of Medical Services
Public Health Service
Office of Long-Term Care Standards Enforcement
Region x
Public Health Service Hospital
Health Services Administration
Region VIII
Seattle, Wash.
Staten Island, N.Y.
Region II
Denver, Colo.
New York, N.Y.
Bobbie L. Wolf
James C. Hufsey
Philomen P. Ciarla, M.D.
Public Health Service
Public Health Service
Andrew L. Smith
Public Health Service
Division of Quality Standards
Division of Health Services
Public Health Service
Food and Drug Administration
Region VII
Region VI
Outpatient Clinic
Division of Drug Experience
Kansas City, Mo.
Dallas, Tex.
Washington, D.C.
Rockville, Md.
98
99
Harold T. Conrad, M.D.
David Kneapler, M.D.
Roland B. Williams, M.D.
Walter Levi
Office of the Regional Director
Public Health Service
Health Services Administration
Public Health Service
Office of Long-Term Care Standards Enforcement
Food and Drug Administration
Bureau of Quality Assurance
Health Resources Administration
Region IX
Rockville, Md.
San Francisco, Calif.
Rockville, Md.
Bureau of Health Planning and Resource Development
Randall H. Lortscher, M.D.
Rockville, Md.
J. Lyle Conrad, M.D.
Public Health Service
Center for Disease Control
Douglas A. Mahy
Region VIII
SOCIAL WORKERS
Bureau of Epidemiology
Office of the Regional Director
Denver, Colo.
Atlanta, Ga.
Office of Long-Term Care Standards Enforcement
Frank Melewicz, M.D.
Mari Alsop
Region v
Emmett Cooper, M.D.
Center for Disease Control
St. Elizabeth's Hospital
Chicago, Ill.
Public Health Service
Laboratory Bureau
Alcohol, Drug Abuse, and Mental Health Administration
National Institutes of Health
Atlanta, Ga.
Washington, D.C.
Norma A. Marler
Social and Rehabilitation Service
Bethesda, Md.
Roger J. Meyer, M.D.
C. Ellis Barnham
Assistance Payments Administration
Ernest S. Cunningham, M.D.
Social and Rehabilitation Service
Public Health Service
Region VI
Public Health Service
Office of Regional Commissioner
Division of Health Services
Dallas, Tex.
Division of Health Services
Region V
Region VII
Anne L. Martin
Region VI
Chicago, Ill.
Kansas City, Mo.
Public Health Service
Dallas, Tex.
David C. Miller, M.D.
Division of Health Services
Audrey T. Barker
Leslie G. Ford, M.D.
Center for Disease Control
Alcohol, Drug Abuse, and Mental Health Administration
Office of the Regional Director
Health Services Administration
Bureau of Smallpox Eradication
Rockville, Md.
Office of Long-Term Care Standards Enforcement
Bureau of Quality Assurance
Atlanta, Ga.
Region IX
Minnie O. McBeth
Rockville, Md.
William Niemeck, M.D.
San Francisco, Calif.
Social Security Administration
Bernard Frankel, M.D.
Public Health Service
Bureau of Disability Insurance
Public Health Service
Lawrence T. Barrett
Division of Health Services
Region IV
National Institutes of Health
Public Health Service
Region VI
Atlanta, Ga.
Bethesda, Md.
Health Resources Administration
Dallas, Tex.
Marjorie E. McKinney
National Center for Health Services Research
Joseph M. Gambrell, M.D.
Public Health Service
Fred J. Payne, M.D.
Rockville, Md.
Public Health Service
National Institutes of Health
Public Health Service
Health Services Administration
Catherine M. Casey
Bethesda, Md.
Health Resources Administration
Region IV
Bureau of Health Manpower
Public Health Service
Darlene Morris
Atlanta, Ga.
Rockville, Md.
Division of Health Services
Office of the Regional Director
George C. Gardiner, M.D.
Region II
Office of Long-Term Care Standards Enforcement
Public Health Service
Michael Peterson, M.D.
New York, N.Y.
Region V
Public Health Service
Office of Regional Health Administrator
Chicago, Ill.
Region III
Food and Drug Administration
Michael B. Casey
Philadelphia, Pa.
Rockville, Md.
Office of the Regional Director
Dave Ragan
Office of Long-Term Care Standards Enforcement
Public Health Service
Peter Graze, M.D.
Richard V. Phillipson, M.D.
Region VIII
Alcohol, Drug Abuse, and Mental Health Administration
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration
Food and Drug Administration
National Institute on Drug Abuse
Denver, Colo.
National Institute of Mental Health
Region V
Rockville, Md.
Division of Resource Development
Harold Feldman
Chicago, Ill.
Rockville, Md.
Michael A. Hattwick, M.D.
Public Health Service
Bennie Robinson
Center for Disease Control
Kenneth E. Powell, M.D.
Alcohol, Drug Abuse, and Mental Health Administration
Social and Rehabilitation Service
Bureau of Epidemiology
Center for Disease Control
Region I
Region V
Atlanta, Ga.
Bureau of Epidemiology
Boston, Mass.
Chicago, Ill.
Atlanta, Ga.
Steven D. Helgerson, M.D.
Janet O. Frank
Sandra Rothman
Public Health Service
Robert T. Rutherford, M.D.
Alcohol, Drug Abuse, and Mental Health Administration
Office of the Regional Director
Division of Quality Standards
Public Health Service
Rockville, Md.
Aging Service
Region x
Food and Drug Administration
Region VIII
Seattle, Wash.
Rockville, Md.
Sharon Gambo
Denver, Colo.
Joseph T. Herbelin, M.D.
John D. Stroud, M.D.
Office of Human Development
Cheryl Santos
Public Health Service
Public Health Service
Administration on Aging
Social and Rehabilitation Service
Division of Quality Standards
Division of Resource Development
Region V
Medical Services Administration
Region VII
Region V
Chicago, Ill.
Region I
Kansas City, Mo.
Chicago, Ill.
Boston, Mass.
Jewel L. Jackson
William F. Jesse, M.D.
Karl A. Western, M.D.
Jesna Swan
Social and Rehabilitation Service
Health Services Administration
Center for Disease Control
Office of the Regional Director
Community Services Administration
Bureau of Quality Assurance
Office of Long-Term Care Standards Enforcement
Bureau of Epidemiology
Region VI
Rockville, Md.
Region III
Atlanta, Ga.
Dallas, Tex.
Philadelphia, Pa.
100
101
Hugh Sloan
OFFICE OF NURSING HOME AFFAIRS
APPENDIX F
Office of the Regional Director
Staff
Office of Long-Term Care Standards Enforcement
Region IX
Florence E. Gareau, Special Assistant
San Francisco, Calif.
Guy Harriman, Chief
Stewart M. Swayze
Division of Standards Enforcement Coordination
Public Health Service
Health Services Administration
Margaret Ouelette, Program Analyst
Rockville, Md.
James Pinto, Computer Systems Analyst
Social Security Amendments of 1972
Roger W. Turenne
Public Law 92-603
Office of the Regional Director
Office of Long-Term Care Standards Enforcement
Support Staff
Region IV
Deloris Agee
Barbara Dwiggins
Atlanta, Ga.
Reta C. America
Sylvia G. Fisher
Joyce Sutton Zutell
Janet Blanken
Juliette Gross
SUMMARY OF SECTIONS AFFECTING
Public Health Service
Naomi Danzig
Polly Kuzminski
practical matter, can only be provided in a skilled
LONG-TERM CARE FACILITIES
Region II
Constance DeVries
Judy Sander
nursing facility on an inpatient basis.
New York, N.Y.
Marie Wharen
Sections 246 and 247
Institutional Standards:
Skilled Nursing Facilities
Sections 265, 267, and 277
Professional Services:
These H.R. 1 sections establish a common defini-
Skilled Nursing Facilities
tion of care and a single set of health, safety, en-
vironmental, and staffing standards for institu-
These H.R. 1 sections change the requirements
tions (redesignated Skilled Nursing Facilities
for certain professional services as conditions of
under section 278) formerly identified as Extended
participation for skilled nursing facilities. Au-
Care Facilities under Medicare and Skilled Nurs-
thorizes States to provide specialized consultation
services.
ing Homes under Medicaid.
Section 265.-Specifies that provision of medical
Section 246.-Requires, effective July 1, 1973,
social services will not be required as a condition
uniform standards for the participation of skilled
of participation for skilled nursing facilities under
nursing facilities under both Medicare and Medic-
Medicare. Amends section 1861(j). Effective upon
aid. It incorporates the present Medicare re-
enactment.
quirements and adds certain additional require-
Section 267.-Provides that to the extent that
ments: a skilled nursing facility must: (a) Sup-
law or regulation requires the presence of a reg-
ply complete information to the Secretary as to
istered nurse for more than 40 hours a week the
facility ownership; (b) cooperate in a program
Secretary may grant a waiver of such requirement
of independent medical evaluation and audit of
if: (1) The facility is located in a rural area and
patients; (c) adhere to the Life Safety Code; (d)
supply of skilled nursing facility services in such
make all information required to be filed with the
area is insufficient to meet needs of patients re-
Secretary available to Federal and State employ-
siding therein; (2) the facility has one full-time
ees for administration of Title XVIII and XIX;
RN who is regularly on duty 40 hours a week;
and (e) meet the institutional planning require-
(3) the facility is caring only for patients whom
ments of section 234 (effective April 1, 1973)
under Medicare.
physicians have certified can go without RN serv-
ices for a 48-hour period; and (4) if the facility
Section 247.-Establishes, effective January 1,
has patients for whom physicians have indicated
1973, a common definition of care requirement for
a need for daily skilled nursing services, the facil-
services provided in skilled nursing facilities. The
Medicare definition of covered extended care serv-
ity has made arrangements for an RN or physician
ices is broadened and the section makes the same
to spend time at the facility as needed to provide
definition applicable for skilled nursing services
services on uncovered days. Amends section 1861
under Medicaid. Skilled nursing facility services
(j). Effective upon enactment.
are defined as those services provided directly by
Section 277.-Permits State agencies to provide
or requiring the supervision of skilled nursing
specialized consultant services for Medicare pa-
personnel or skilled rehabilitation services which
tients in SNF's, upon request by the SNF. Amends
the patient needs on a daily basis and which, as a
section 1864(a). Effective upon enactment.
102
103
Sections 239 (Part), 249A, 249B, 299L
for other requirements concerning medical cer-
Section 298.-Technical amendment to Public
days following completion of each survey, the per-
Certification Functions:
tifications and utilization controls.
Law 92-223 under section 1902(a) (31) (A) to
tinent findings of surveys of any health care fa-
Skilled Nursing and Intermediate Care Facilities
Section 207 (part).-Adds a new section 1903
eliminating the phrase "which provides more than
cility, laboratory, clinic, agency, or organization.
(g) to provide for a reduction in Federal match-
a minimum level of health care services."
These H.R. 1 sections broaden the authority of
the Secretary to certify skilled nursing facilities
ing for institutional services for Medicaid eligibles
Sections 228, 249, and 299
for participation in Medicare and Medicaid, and
after a specified number of days unless the State
Section 246 (part),
Reimbursement Requirements:
prescribe related functions for State health
agency makes a satisfactory showing that it has
249A (part), 249C, 299A, 299D
Skilled Nursing and Intermediate Care Facilities
agencies.
in effect an effective system of utilization controls,
Disclosure Requirements:
Section 239.-Effective January 1973, this sec-
meeting requirements set forth in this section; and
Skilled Nursing and Intermediate
These H.R. 1 sections add additional require-
to require the Secretary to validate a State's utili-
Care Facilities
tion specifies the same State Health Agency (or
ments relating to reimbursement levels for skilled
other appropriate medical agency) shall be re-
zation control procedures by sample on-site sur-
These H.R. 1 sections require disclosure of vari-
nursing homes and intermediate care facilities.
sponsible for certifying facilities for participation
veys (as referenced to by sections 238, 239, 246).
ous types of information by the Secretary to ap-
Section 228.-For purposes of making payment
in Medicare and Medicaid.
Section 228.-Requires advance coverage ap-
propriate State agencies, by the Secretary and
for services, the Secretary is authorized to estab-
Section 249A.-Authorizes the Secretary to cer-
proval of length of stays in skilled nursing facili-
State agencies to the public, and by providers to
lish, by diagnosis or medical condition, minimum
tify for participation in Title XIX those facilities
ties and for the need of home health agency serv-
the Secretary and State agencies.
periods of time after hospitalization during which
which he certifies under Title XVIII. Makes uni-
ices based upon diagnosis, plan of treatment, and
Section 246 section 1861
a patient would be presumed eligible under Medi-
other requirements of eligibility. Effective date
Effective July 1, 1973, requires all skilled nursing
care for skilled nursing facility and home health
form the term of agreements. Under Section 246,
July 1, 1973.
the Secretary is also given authority to waive Life
facilities participating in Title XVIII to disclose
care benefits. The attending physicians will certify
Section 237.-Amends new section 1903(1) to
Safety Code requirements under Title XVIII and
to the Secretary or his delegate full and complete
prior to or on admission to SNF or home health
require participating hospitals and skilled nursing
information as to ownership and to report any
services that the condition is one designated in
XIX.
facilities to have Title XIX cases reviewed by the
changes in ownership. It also requires that all in-
the regulations and furnish a plan of treatment.
Section 249B.-From October 1, 1972 to July 1,
same utilization review (UR) committee that re-
formation obtained under this section be made
Certification and patient stays are to be reviewed
1974 authorizes 100 percent reimbursement for
views Title XVIII cases, or one that meets Title
available to Federal and State employees for pur-
and the provisions may be suspended for the
costs incurred in surveying skilled nursing facili-
XVIII standards; and permits the Secretary to
poses consistent with effective administration of
physician involved if there is abuse of the advance
ties and intermediate care facilities under Med-
waive this requirement if the State demonstrates
the Medicare and Medicaid programs.
approval procedure. The section specifically re-
icaid.
it has a superior alternative (as required in sec-
Section 249A (part).-Requires the Secretary to
stricts the retroactive application of regulations
Section 299L.-Authorizes the Secretary to cer-
tion 207).
notify the Sate agency administering the Medic-
pertinent to these provisions. The effective date is
tify, under Medicaid, intermediate care facilities
Section 238.-Amends 1814(a) (7) and 1861
aid program, of his approval or disapproval of
January 1, 1973.
and skilled nursing facilities located on Indian
(4) by adding to the utilization review require-
any institution which applies for certification as
Section 249.-Requires the States to develop
reservations.
ment, "including any finding made in the course of
a skilled nursing facility under Title XVIII. This
methods of reimbursing SNF's and ICF's on a
a sample or other review of admissions to the in-
provision is effective with respect to agreements
basis reasonably related to cost, and to implement
stitution". (as referenced to by sections 207, 239,
filed under section 1866, on, or after enactment but
these methods under Medicaid after approval by
Section 269
246).
accepted by the Secretary on or after enactment.
the Secretary, by July 1, 1976. Reimbursement
Qualifications of Health Personnel:
Skilled Nursing Facilities
Section 239 (part).-Amends section 1902(a)
Section 249C.-Requires the Secretary to make
methods found acceptable by the Secretary for
(9) to require the State Health Agency, or equiv-
available to State agencies administering Title
Medicaid would be adapted for the purpose of
Permits States to waive permanently licensure
alent to establish a plan for advising the single
XIX and to the public, certain information ob-
Medicare reimbursement. The Secretary may ad-
requirements for persons who served as nursing
State agency with respect to conduct of utilization,
tained by him regarding the performance of car-
just the rates upward (not to exceed 10 percent)
home administrators for the 3-year period prior to
medical, and independent professional review.
riers, intermediaries, State agencies, and providers
for requirements under Medicare not otherwise
the establishment of the State's licensing program.
of services under Medicaid and Medicare. This re-
taken into account in computation of Medicaid
Section 246 (part).-Part of this section re-
quirement is effective with respect to reports com-
rates. Percentage adjustments may be made on a
Amends section 1908(d). Effective upon enact-
quires skilled nursing facilities under both Medi-
geographic basis of classes of facilities rather than
ment.
care and Medicaid to institute a common program
pleted after the third calendar month following
on an institution-by-institution basis.
of independent professional evaluation and audit
enactment (February 1973).
Section 299.-Provides that for Federal match-
of all patients in the skilled nursing facility. Ef-
Section 299A.-Effective January 1, 1973, re-
Sections 207 (part), 228, 237,
ing purposes under Medicaid, until January 1,
fective date July 1, 1973.
238, 239 (part), 246 (part), 248, and 298
quires any intermediate care facility participating
1975, a State may not reduce non-Federal expendi-
Medical Audit and Utilization Review:
Section 248.-Authorizes extension of the 14-
in Title XIX to disclose to the State licensing
tures for patients receiving intermediate care serv-
Skilled Nursing and Intermediate Care Facilities
day transfer requirement for skilled nursing facil-
agency full and complete information as to the
ices in public institutions for the mentally re-
ity medicare benefits to 28 days if appropriate bed
These H.R. 1 sections require a common pro-
ownership of such facility and to report any
tarded below the average amount expended for
space is not available in the geographical area, in
gram of independent professional evaluation of all
changes of ownership.
such services in these institutions in the four
which a patient resides, or longer than 28 days if
patients in skilled nursing facilities and inter-
Section 299D.-Effective before May 1, 1973, re-
the patient's condition is not appropriate for im-
quarters immediately preceding the quarter in
mediate care facilities, identify certain State re-
mediate provision of skilled nursing services. Ef-
quires the Secretary and the appropriate State
which the State elects to provide such services
sponsibilities for utilization review, and provide
fective upon enactment.
agency to make available to the public, within 90
under Title XIX.
105
104
and 297
1972, did not have a Medicaid program in oper-
THURSDAY, JANUARY 17, 1974
Requirements:
ation. Exempts transfer of ICF's from Title XI
Care Facilities
to Title XIX in these instances until the State has
WASHINGTON, D.C.
a Title XIX program in effect. Effective date: Oc-
1 sections clarify coverage for ICF
tober 30, 1972.
Volume 39
Number 12
Medicaid and provide technical
Section 297.-Provides coverage for intermedi-
NATIONAL ARCHIVES OF THE UNITED
to Public Law 29-223.
ate care furnished in mental and tuberculosis in-
PART III
THE 1934 SHIPS
92.-Allows Federal matching for in-
stitutions to individuals age 65 or older. Effective
care in States which, on January 1,
date: January 1973.
DEPARTMENT OF
HEALTH,
EDUCATION, AND
WELFARE
Social and Rehabilitation
Service
federal
Social Security Administration
SKILLED NURSING
FACILITIES
Standards for Certification and
Participation in Medicare and
Medicaid Programs
No. 12-Pt. III-1
107
2238
RULES AND REGULATIONS
RULES AND REGULATIONS
2239
Title 20-Employees' Benefits
(1) The director of nursing services
comes of age under State law. The regu-
action could be taken to reinstate this
FR 18620) are adopted, with the noted
factorily completed or that the facility
CHAPTER III-SOCIAL SECURITY ADMIN-
may not serve as a charge nurse in a
lations had been silent on this point.
as a mandatory requirement without fur-
changes. In addition, some parts of the
has made substantial effort and progress
ISTRATION, DEPARTMENT OF HEALTH,
facility with an average daily total OC-
State laws typically provide opportunity
ther legislative action.
regulations were redrafted for clarifica-
in correcting such deficiencies and has
EDUCATION, AND WELFARE
cupancy of 60 or more. This require-
for an individual to personally enforce
ment had been an average daily occu-
(6) The suggestion that there be a
tion purposes, in line with the comments
resubmitted in writing a plan of correc-
[Regs. 5, further amended]
rights accruing during their minority
specific ratio of nursing staff to patients
received.
tion acceptable to the Secretary.
pancy of 50 or more. This brings the re-
once majority is reached. While this
PART 405-FEDERAL HEALTH INSUR-
quirement in line with most other Fed-
was not accepted because the variation
change may require retention of records
(Secs. 1102, 1814, 1832, 1833, 1861, 1863, 1865,
(b) (1) Where the Secretary deter-
ANCE FOR THE AGED AND DISABLED
eral and State standards.
from facility to facility in the composi-
1866, 1871, 49 Stat. 647, as amended, 79 Stat.
mines that the health and safety of pro-
for a considerable length of time, protec-
Skilled Nursing Facilities
(2) In the case of patients needing
tion of its nursing staff, physical layout,
294, as amended, 79 Stat. 313-327, as
gram beneficiaries will not be jeopar-
tion for both the minor patient and the
laboratory and radiological services in a
patient needs and the services necessary
amended, 79 Stat. 331 (42 U.S.C. 1302, 1395f,
dized thereby, the term of an agreement
facility is provided, should litigation
On July 12, 1973, there was published
facility not providing such services, the
to meet those needs precludes setting
1395k, 13951, 1395x, 1395z, 1395bb, 1395cc,
may be extended for a period of 2 full
occur.
such a figure. A minimum ratio could re-
1395hh))
calendar months, if the Secretary finds
in the FEDERAL REGISTER (38 FR 18620) a
requirement was added that the facility
The following summarizes those sub-
notice of proposed rulemaking which set
sult in all facilities striving only to reach
Effective date. These amendments
that such extension is necessary to:
assist the patient in arranging for trans-
stantive comments that were not
forth proposed amendments to regula-
that minimum and could result in other
shall be effective February 19, 1974.
(i) Prevent irreparable harm to such
portation to the provider of such
accepted.
facilities hiring unneeded staff to satisfy
facility; or
tions relating to the conditions of par-
services. This addition reflects a similar
(1) The suggestion that the time for
(Catalog of Federal Domestic Assistance Pro-
requirement for dental services; as with
an arbitrary ratio figure. However, as a
(ii) Prevent hardship to the program
ticipation for skilled nursing facilities,
consultation for the dietitian or phar-
gram No. 13.800, Health Insurance for the
means of closely monitoring the ade-
beneficiaries being furnished items and
the certification procedures for providers
the dental services provision, transpor-
macist consultant be specified either in
Aged and Disabled-Hospital Insurance)
and suppliers of services, the provider
tation of patients for laboratory and
quacy of staffing in skilled nursing facil-
services by such facility; or
hours or number of visits weekly was not
and supplier appeals processes, and im-
radiological services is not covered under
ities, Medicare has adopted a provision
Dated: December 19, 1973.
(2) If the Secretary finds it imprac-
accepted because a rigidly accepted num-
plementation of provisions of the Social
Medicare.
that now appears in title XIX regula-
J. B. CARDWELL,
ticable within such term to determine
ber of hours or visits is no assurance of
Security Amendments of 1972 (Pub. L.
(3) The paragraph concerning ap-
tions thereby further achieving uniform-
Commissioner of Social Security.
whether such facility is complying with
quality of the service provided. The regu-
92-603) affecting the foregoing.
proved drugs and biologicals which lack
ity between the two programs. This pro-
the provisions of the Act and regulations
lations are, to the extent possible, per-
Interested parties were given the op-
vision calls for the facility to submit
Approved: December 27, 1973.
issued thereunder.
substantial evidence of effectiveness for
formance standards, and rely upon the
portunity to submit within 30 days data,
quarterly staffing reports to the State
CASPAR W. WEINBERGER,
(c) (1) Except as provided in para-
all indications has been deleted. Depart-
professional judgment of the surveyor in
views, or arguments on the proposed
ment-wide regulations on this subject,
agency, and this is reflected in these
Secretary of Health, Education,
graph (b) of this section, the term of an
determining whether quality service in-
amendments. The comment period was
amendments in Subpart K, § 405.1121
and Welfare.
agreement may not be extended and such
applicable to all providers and suppliers
herent in the standard has been achieved.
extended by the Secretary for an addi-
(b)
agreement shall terminate at the close
participating in Federal programs, will
(2) Concern was expressed about the
be published in the near future. In the
(7) Several suggestions were made
Regulation No. 5 of the Social Security
of the last day of its specified term and
tional 30 days to September 13, 1973, and
requirement that a facility assume finan-
notice of this extension appeared in the
that there was insufficient provision for
Administration, as amended (20 CFR
will not be automatically renewable from
meantime, current regulations and poli-
cial responsibility when arranging with
FEDERAL REGISTER of August 14, 1973.
protection of the patient's rights. The
Part 405), are further amended as set
term to term.
cies relating to drugs and biologicals re-
an outside resource to provide therapy
forth below:
Comments were received from many
main in effect.
regulations do specifically provide that
(2) The nonrenewal of an agreement
and certain other services. It was sug-
sources (including representatives of na-
the facility must have rules on the pro-
Subpart F-Agreements, Elections,
under the conditions described in this
(4) Those provisions concerning the
gested that the patient be billed directly
tional, State and local organizations)
tection of the personal and property
Contracts, Nominations, and Notices
section is not a termination of the
term of a provider agreement were re-
by the person(s) furnishing the services.
The provision was retained because these
rights of patients; and that patient care
agreement by the Secretary pursuant
concerned with skilled nursing services
vised to extend the term of agreement
1. The heading for Subpart F is revised
and with the qualifications and duties of
to 60 days after the date specified for
policies include provisions to protect
to the provisions discussed in § 405.614.
services are part of extended care serv-
to read as set forth above.
health care personnel rendering services
the correction of deficiencies to enable
these rights. Additionally, discriminatory
A determination by the Secretary not
ices under Part A and billing for other
the State agency to survey and process
treatment in skilled nursing facilities
§ 405.601, 405.602 [Amended]
to accept such facility for participation
under Medicare. All of the comments re-
services under Part A is done by the fa-
ceived on the proposed regulations have
their recommendation to the Secretary
would be barred by the continued re-
2. In §§ 405.601 and 405.602, the words
following the end of such term shall be
cility. Furthermore, the Part A payment
been carefully considered.
before the agreement expires.
quirement that the facilities must be in
an initial determination relating to the
"extended care facility" are revised to
mechanism provides safeguards against
The most substantive comments re-
(5) The definition of a social worker
compliance with title VI of the Civil
read "skilled nursing facility."
facility's qualifications as a provider of
overutilization and exorbitant fees, and
services for the period immediately fol-
ceived recommended the inclusion of re-
has been revised to include a graduate
Rights Act of 1964. However, as previ-
3. A new § 405.604 is added to read as
focusing responsibility on the facility en-
ously indicated, a "bill of rights" for pa-
lowing such term and the facility shall
quirements for: (1) A medical director
of a school of social work approved or
follows:
ables the surveyor to readily review the
accedited by the Council on Social Work
tients will be published under the notice
be entitled to a hearing with respect to
or organized medical staff for skilled
circumstances under which the services
of proposed rulemaking procedures.
§ 405.604 Term agreements with skilled
such determination. (See Subpart O of
nursing facilities; (2) 7-day registered
Education. This will permit a social
are offered.
nurse services; (3) a discharge planning
worker with either a master's or bacca-
Some criticism of the revised format
nursing facilities.
this part.)
(3) Request was made that during the
program; and (4) a "bill of rights" for
of the conditions of participation was
Effective with respect to provider
(3) Where the Secretary determines
laureate degree in social work to serve
appeals process, benefits should continue
patients in such facilities. Since these
expressed. The skilled nursing facility
agreements accepted for filing on or after
that he will not accept an agreement
as a qualified consultant.
to be paid to a facility that had been
items were not included in the proposed
regulations are designed as performance
October 30, 1972, an agreement with a
with a skilled nursing facility for the
(6) The definitions of qualified profes-
terminated from participation in the
regulations as published, and are of con-
sionals in § 405.1101 frequently make
standards; greater specificity would di-
skilled nursing facility shall be for a
period immediately following the end of
program. This request was rejected be-
siderable impact, they are not included
reference to the standards of various
minish their applicability to all facili-
specified term and such term shall be
the term of such facility's existing agree-
cause facilities are terminated from pro-
ment, the Secretary shall give notice of
in these final regulations. However, they
national professional organizations. The
ties. Additionally, State agency survey-
determined by the Secretary in the fol-
gram participation when the health and
will be published with notice of proposed
ors have recently undergone extensive
lowing manner:
such determination to the facility at least
Department has examined the current
safety of patients can no longer be as-
rulemaking at a later date to afford
training to enhance their understanding
(a) (1) The term of an agreement may
30 days and to the public at least 15 days
standards of those organizations and is
sured and only after the facility has been
ample opportunity for comments. Fur-
of the program and the survey process.
be for a period of 12 full calendar months
before the end of such term. Each notice
adopting them. The Secretary will ex-
given notice of the nature of its deficien-
thermore, under another notice of pro-
amine future changes in the standards
Th e S e performance-oriented require-
where the facility is in full compliance
by the Secretary shall state the reasons
cies and been given ample time to make
posed rulemaking, to be published at a
ments will provide these surveyors cri-
with the standards contained in Subpart
for such determination, the effective date
of these organizations and determine
the necessary improvements. When this
later date, additional changes in the
teria on which to base their assessment
K of this part.
for the termination of the existing agree-
whether such changes should be re-
utilization review standards will be
decision has been made, it is not possible
of an individual facility's performance.
(2) Where the facility is not in full
ment, and the applicability of such ter-
flected in regulations.
issued.
to justify continuing payment to a facil-
compliance with standards contained in
mination as it relates to the services of
(7) Several provisions of existing reg-
Further, certification requirements for
A number of the comments recom-
ity beyond the 30-days benefits provided
ulations which were not included in the
all providers and suppliers of services
Subpart K of this part the term of an
the facility.
in the statute for those beneficiaries ad-
mended that: (1) Patient care policies
(hospitals, skilled nursing facilities,
agreement may:
(d) Notwithstanding the preceding
proposed regulations as published on
mitted to the facility prior to the effec-
be available to the public; (2) the fre-
July 12, 1973, have now been reinstated
home health agencies, providers of out-
(i) Be restricted to a term that ends
provisions of this section, an agreement
tive date of termination.
quency of physician visits be clearly de-
after reviewing comments that their de-
patient physical therapy services, inde-
no later than the 60th day following the
filed by an extended care facility (now
fined; (3) all nursing service staff re-
(4) Request was also made that Med-
letion could have an adverse effect on
icaid provide hearings for all facilities
pendent laboratories, and portable X-ray
end of the time period specified for the
defined as a skilled nursing facility)
ceive training in rehabilitative nursing;
patient care. These were: Time require-
services) are now centralized in the new
correction of deficiencies in a written
which was accepted by the Secretary
that had been terminated or where
(4) the definition of qualifications of
ments for physical examination of the
Subpart T.
plan which the Secretary has approved:
prior to October 30, 1972, and which was
agreements had not been renewed. This
certain health specialists be clarified;
patient at admission; the attending
In the definition found in § 405.1101
Provided, That such term shall not ex-
in effect on such date, shall be for a
appeals process will be determined by
(5) there should be a requirement for
physician must arrange for the medical
State practices consonant with Medicaid
(a) (2), administrator of skilled nursing
ceed 12 full calendar months; or
specified term ending at the close of
care of the patient in his absence; duties
being a State-administered program.
facility, the length of supervisory man-
(ii) Provide a conditional term of 12
December 31, 1973.
daily rounds by the charge nurse; and
(6) the director of nursing services par-
assigned food service employees outside
agement experience required was revised
full months, subject to an automatic
4. Section 405.605 is revised to read
ticipates at least annually in continuing
(5) Numerous comments were re-
the dietetic service cannot interfere with
ceived from social workers. consumer
from one year to three years to assure
cancellation clause that the agreement
as follows:
education. These comments were ac-
their dietetic work assignments; and
adequate experience to direct adminis-
will terminate at the close of a predeter-
cepted and the regulations clarified
groups and organizations, protesting the
space, supplies, and equipment must be
trative activities in such health facilities.
mined date which shall be no later than
§ 405.605 Provider of services; scope of
optional provision of social services by
term.
accordingly.
provided for a patient activities program.
This technical change reflects current
the 60th day following the end of the
The following changes have been
skilled nursing facilities. This change is
(8) A provision was added to require
the result of amendments found in sec-
title XIX requirements for administra-
time period specified for the correction
As used in section 1866 of the Act and
made to reflect other comments that
the retention of the medical records of
tors and thereby further achieves con-
of deficiencies: Provided, That such date
this Part 405, the term "provider of
were received:
tion 265 of Pub. L. 92-603, the Social
minors until 3 years after the patient be-
formance between the two programs.
will occur within such 12-month term,
services" (or "provider") refers only to
Security Amendments of 1972; hence, no
The amendments as announced under
unless the Secretary determines that all
a hospital, a skilled nursing facility, or
the notice of proposed rulemaking (38
required corrections have been satis-
a home health agency (see Subparts J,
FEDERAL REGISTER, VOL. 39, NO. 12-THURSDAY, JANUARY 17, 1974
FEDERAL REGISTER, VOL. 39, NO. 12-THURSDAY, JANUARY 17, 1974
108
109
THURSDAY, OCTOBER 3, 1974
35774
RULES AND REGULATIONS
WASHINGTON, D.C.
Title 20-Employees' Benefits
the outside resource bill the facility for
ARCHIVES
(j) A new provision has been added
OF
THE
CHAPTER III-SOCIAL SECURITY ADMIN-
covered services rendered directly to the
which provides that if married, the pa-
Volume 39
Number 193
ISTRATION, DEPARTMENT OF HEALTH,
patient. Considering the strong protests,
tient is assured privacy for visits by his/
NATIONAL
UNITED
EDUCATON, AND WELFARE
and that Medicaid has had administra-
her spouse, and if both are inpatients.
tive problems with the reimbursement
they are permitted to share a room,
[Regs. 5]
procedure, any reference in § 405.1121(i)
unless medically contraindicated and
PART II
THE
SAINS
PART 405-FEDERAL HEALTH INSUR-
to billing procedures has been deleted. Its
documented by the attending physician
ANCE FOR THE AGED AND DISABLED
deletion, however, does not mean that,
in the medical record.
1934
(1965
)
under Medicare, outside resources fur-
This paragraph (k) also was clarified
Skilled Nursing Facilities
nishing services to inpatients of a facil-
to reflect that the rights and respon-
ity under an arrangement with the facil-
sibilities in paragraphs (k) (1) through
On May 1, 1974, there was published
ity may bill the patient for services which
(4) as they pertain to a patient found
in the FEDERAL REGISTER (39 FR 15230)
constitute provider services. Further-
by his physician to be medically in-
a notice of proposed rulemaking which
more, pursuant to section 1861(w) of the
capable of understanding these rights
set forth proposed amendments to regu-
Social Security Act, such services fur-
devolve to such patient's guardian. next
lations relating to the conditions of par-
nished under an arrangement must be
of kin, etc.
ticipation for skilled nursing facilities.
billed through the provider exclusively.
4. Seven-day registered nurse services,
Included in the proposed amendments
Appropriate revisions to incorporate this
§§ 405.1124 and 405.1124(c) As proposed,
were several additional provisions to the
principle will be transferred to the per-
this revises the requirement for the em-
Medicare-Medicaid common standards
DEPARTMENT OF
tinent subparts of Regulations No. 5 at
ployment of a regisered nurse to at least
for skilled nursing facilities, which re-
a later date.
the day tour of duty on 7 days a week.
sulted from comments received with re-
3. Patients' rights, § 405.1121(k). On
For purposes of classification, a cross ref-
spect to the conditions of participation
the basis of numerous comments re-
erence to the waiver provision for this
published as proposed rules on July 12,
requirement was inserted after the con-
HEALTH,
1973 (38 FR 18620) Because of the sub-
ceived, including some 135 letters pro-
testing the separation of married couples
dition of participation. Most comments
stantive nature of these provisions, they
in skilled nursing facilities, the following
regarding this provision were supportive
were not included in the final regula-
substantive changes were made in the
and in addition suggested stronger re-
tions published on January 17, 1974 (39
patients' rights provision in consid-
quirements in line with some State re-
EDUCATION, AND
FR 2238), but were published in proposed
eration of the viewpoints expressed, and
quirements.
form on May 1. In addition to the pro-
the revised phrases are in italics:
The requirement for a registered nurse
posed provisions resulting from those
comments (a medical director, 7-day
(a) Policies and procedures regarding
on the day tour of duty is considered to
patients' rights are to be available to
be reasonable and necessary as a Federal
WELFARE
registered nurse services, discharge plan-
the public, as well as to patients, guard-
standard and does not preclude higher
ning, and patients' rights), other provi-
ians, and others identified in the pro-
State requirements.
sions designed to clarify or expand upon
posed regulations:
Regarding waivers of this provision,
existing regulations were included in the
(b) Written acknowledgement by the
some requests were received that waivers
proposed rulemaking. Interested parties
patient that he has been fully informed
be considered for urban as well as rural
were given the opportunity to submit
Social Security Administration
of these rights is required;
skilled nursing facilities. However, sec-
within 30 days data, views. and argu-
(c) The patient is fully informed of
tion 267 of Pub. L. 92-603, the Social
ments on the proposed amendments.
his medical condition, by a physician,
Security Amendments of 1972, provides
Comments were received from many
unless medically contraindicated (as
that waiver of the 7-day registered nurse
sources (including representatives of
documented by a physican in his medical
requirement applies to rural skilled nurs-
national, State, and local organizations)
record);
ing facilities. In addition, § 405.1911(a)
concerned with skilled nursing services,
(d) Reasons for patient transfer or
regarding waivers was revised to parallel
the quality of patient care, and the rights
discharge are now delineated to include:
the waiver language for medical direction
of these patients. All of the comments
Medical, for the welfare of the patient
in skilled nursing facilities in that the
received, including earlier public com-
or others, or for nonpayment for stay
facility must make good faith efforts to
SKILLED NURSING
ments and those reported from Senator
(except where prohibited by the pro-
meet the 7-day registered nursing
Frank E. Moss' subcommittee hearings,
gram(s)), with such actions documented
requirement.
have been carefully considered.
in the medical record;
5. Administration of drugs, § 405.1124
The following summarizes the changes
(e) The patient is encouraged to exer-
(g). Several comments were received re-
FACILITIES
made in consideration of comments
cise his rights as a patient, and as a
questing that the phrase "in compliance
received:
citizen;
with State and local laws" be added to
1. Dietitian (qualified consultant),
(f) Delegation by the patient to the
this section. This comment was not ac-
8 405.1101(f) proposed revision
facility of the right to manage his funds
cepted because it was felt that, in addi-
corrected a typographical error in this
now requires a quarterly accounting and
tion to meeting State and local laws as
Health Insurance For the Aged and
definition, by adding "or" between
specifies that the delegation be in con-
stipulated in § 405.1120, an appropriate
clauses (1) and (2) to proyide that a
formance with State laws;
Medicare-Medicaid requirement would
Disabled; General Administration
dietitian need meet only one of the
(g) Further limitations are placed on
be that drugs be administered only by
alternatives in this definition. No adverse
the use of restraints (that they be used
physicians, licensed nursing personnel, or
comments were received regarding this
only if authorized by a physician for a
other staff who have completed a State-
change. However, an additional change
specified and limited period of time;
approved program in medication admin-
was made for purposes of clarity and
that is, their use must be necessary to
istration. These controls permit only
consistency. This was to change the
protect the patient from injury to him-
qualified staff to administer medication.
phrase "on the publication of this pro-
self or others);
while making the best utilization of
vision" to January 17, 1974, the date the
(h) These regulations provide for the
health manpower.
final conditions of participation were
patient to send as well as receive mail
6. Staffing for specialized rehabilita-
published.
unopened unless medically contrain-
tive services, § 405.1126(a). The majority
2. Use of outside resources, $ 405.1121
dicated as documented by his physician
of comments received were in opposition
(i). This provision is addressed to the
in the medical record;
to this proposal because it was inter-
situation where a skilled nursing facility
(i) The patient retains and uses his
preted to mean that nonqualified per-
ordinarily furnishes a specific service to
personal clothing and possessions, as
its patients through an outside resource.
space permits, unless to do so would in-
sonnel could perform the professional
Considerable comment was received in
fringe upon rights of other patients, and
activities of a therapist if under the su-
opposition to the proposed amendment,
unless medically contraindicated and
pervision of a physician qualified in phys-
which would except an independent
documented by his physician in his
ical medicine. This was not the intent of
laboratory from the requirement that
medical record:
the revision, however. The regulation has
FEDERAL REGISTER, VOL. 39, NO. 193-THURSDAY, OCTOBER 3, 1974
129
Discharge summary
Information from the transferring facility concerning medical findings, diagnoses,
functional status, and response to previous treatment and care, as well as orders to
initiate care of the patient.
Drug administration
An act in which a single dose of an identified drug, or combination of drugs, is
given to a patient.
Dysarthic
Term referring to the imperfect articulation in speech.
Glossary
Edentulous
Condition which occurs when all teeth are missing; toothlessness. If a person has
a set of plates and does not use them, he is classified as edentulous.
Endocrine
Pertaining to internal secretions applied to organs whose function is to secrete into
the blood or lymph a substance that has a specific effect on another organ or part.
Aide
A person who acts as an assistant.
Facility personnel
Persons employed by the nursing home.
Facility specific form
Form which consists of the sections on management, patient care policies, nursing
Ambulatory
Term referring to the ability to move at will.
rehabilitation, pharmaceutical, nutrition and dietetics, and psychosocial behavior.
Analgesic
An agent that alleviates pain without causing loss of consciousness.
Financial form
Form used to assess the costs of providing care in the nursing home.
Anemia
Medical diagnosis of a condition in which the blood is deficient in red blood cells,
Fire door
A fire-resistive door assembly, including frame and hardware, which under standard
in hemoglobin, or in total volume. Types of anemia include aplastic anemia, B-12
test conditions, meets the fire protective requirements for the location in which it is
deficiency (pernicious) anemia, folic acid deficiency anemia, or sickel cell disease.
to be used.
Antipyretic
An agent that reduces fever.
Fire partition
Floor-to-ceiling partition capable of retarding or stopping fire at a tested, specified
rate.
Aphasia
Defect or loss of the power of expression by speech.
Fire safety form
A printed form which measures the conformance of facilities with established safety
Arteriosclerosis
A condition marked by loss of elasticity, thickening, and hardening of the arteries.
and fire standards.
Baseline data
Data or information collected which is necessary to identify needs, develop programs
Flame retardant
Having or providing comparatively low flammability or flame-spread properties.
and meet those needs, and to measure the overall success of the initiatives
Fracture
A broken bone.
undertaken.
Functional status.
Measure of the degree of ability to cope with the activities of daily living.
Bathing
Process of washing the body or body parts. It includes taking a sponge, shower, or
Geriatrics
A branch of medicine that deals with the problems and diseases of old age and
tub bath and getting to or obtaining the bathing water or equipment.
aging people.
Campaign survey (s)
Surveys of long term care facilities conducted solely as a data collection process
Governing body
An identifiable authority in every nursing home having full legal and moral respon-
with no formal relation to the certification procedure under Title XVIII and XIX.
sibility for all aspects of facility operations. This authority might be called
"governing body," "board of directors," "board of trustees," or other appropriate
Cathartic
A medicine that quickens and increases the evacuation from the bowels.
designation.
Chronic
Marked by long duration or frequent recurrence.
Health care facilities
Facilities defined in terms of State licensure requirements that are designed for
individuals with health needs.
Clinical status
Measure of the stage and severity of illness.
Hypertension
Medical diagnosis of a condition in which there exists an abnormally "high" blood
Comatose
Pertaining to a state of profound unconsciousness from which the patient cannot be
pressure measurement.
aroused, even by powerful stimulation.
Identifying form
A typed form used to collect data about the basic characteristics of the nursing
home, such as bed size.
Communication
A system of significant symbols which permit ordered human interaction.
Incontinence
Involuntary loss of urine and/or feces.
Consultant
Qualified individual who provides professional advice or services.
Indwelling catheter
A hollow cylinder passed through the urethra into the bladder and retained there
Continence
Physiologic process of elimination from the bladder and bowel, if required.
to keep the bladder drained of urine.
Licensed practical nurse (LPN)
A nurse who is a graduate of an approved school of practical nursing and/or is
Demographic characteristics
Profile of personal characteristics, including age, sex, marital status, and race.
licensed by waiver to practice as a practical nurse. Also named licensed vocational
Dentition status
Description of the number, kind, and arrangement of teeth in the jaw.
nurse (LVN).
Life Safety Code
Publication of the National Fire Protection Association, which includes those
Decubitus ulcer
Break in the skin exposing deeper tissue caused by pressure on soft tissues while
requirements which are intended to provide a reasonable degree of safety against
patient is lying down. Two other names which refer to the same condition are
fire.
bedsores and pressure sores.
Long term care
Services for symptomatic treatment, maintenance, and rehabilitative services for
Diabetes
A deficiency condition marked by habitual discharge of an excessive quantity of
patients of all age groups in various health care settings.
urine: particularly diabetes mellitus.
Intermediate care facility (ICF)
Facility certified by the Federal Government to provide an intermediate level of
Diagnosis
Common basis for defining patient needs for care and in organizing patient care
care. Facility providing health related care and services to individuals who do not
services.
require the degree of care and treatment that a hospital or SNF is designed to
provide but who do require care above the level of room and board. ICFs were not
Dietitian
A person who has a baccalaureate degree and has completed a dietetic internship
included in the survey.
or coordinated undergraduate program approved by the American Dietetic Associa-
tion, or who has the equivalent of such education and training.
Long Term Care Facility Improve-
An accelerated project directed toward upgrading the quality of care provided in
ment Campaign (LTCFIC)
the Nation's nursing homes.
Digestive
Pertaining to the process or act of converting food into materials fit to be absorbed
Medicaid
and assimilated.
Health care coverage under Title XIX of the 1965 amendments to the Social Security
Act (Public Law 89-97).
134
135
Medical director
The physician designated to help ensure the adequacy and appropriateness of the
Region
A large territorial area that is delimited by the Department of Health, Education,
medical care provided to patients/residents.
and Welfare on the basis of geographic, economic, cultural, or a combination of the
three categories.
Medical record
Clinical documentation of an individual's medical care.
Medical record administrator
A registered record administrator who has successfully passed an appropriate
Registered nurse (RN)
A nurse who is a graduate of an approved school of nursing and who is licensed to
examination conducted by the American Medical Record Association, or who has
practice as a registered nurse.
the equivalent of such education or training.
Rehabilitative patient care
Equivalent to restorative patient care.
Medicare
Health care coverage under Title XVIII of the 1965 amendments of the Social
Resident
An individual domiciled in the intermediate care facility for the purpose of receiving
Security Act (Public Law 89-97).
specialty care.
Medication
Any substance or drug, that is taken orally, injected, inserted, or topically or
Respiratory
Pertaining to the act or function of breathing.
otherwise administered to a patient.
Mental illness
A medical diagnosis of psychosis, anxiety, depression, or other psychiatric illness.
Restorative nursing service
That aspect of nursing care oriented toward restoring an individual to his former
capabilities.
Neoplasm
Any new and abnormal growth such as a tumor.
Neurological disorders
Diseases of the central nervous system and peripheral nerves.
Sample
A representative part of a group.
Nursing home(s)
Facilities which provide some level of nursing care, participating in the Medicare
Skilled nursing facility (SNF)
Facility certified by the Federal Government to provide a skilled level of care.
(Title XVIII and Medicaid (Title XIX) programs.
Facility or nursing home for patients who require skilled nursing and rehabilita-
Nursing home administrator
Person who is fully responsible for the day-to-day operation of the nursing home.
tion services on a daily basis to help them achieve their optimal level of functioning.
Nursing service
Patient care services pertaining to the curative, restorative, and preventive aspects
Social worker
An individual who is registered by the State, where applicable, has received at least
of nursing that are performed and/or supervised by a registered nurse pursuant to
the baccalaureate degree and has met the requirements of a 2-year curriculum in a
the medical care plan of the practitioner and the nursing care plan.
school of social work that is accredited by the Council on Social Work Education,
Nutritionist
A person who specializes in the science of nutrition.
or who has the equivalent of such education and training.
Orientation pattern
Range or degree of awareness of an individual within his environment, as to loca-
Sociological factors
Profile of characteristics including educational level attained, occupation, income,
tion, identity and time of day, month or year.
and employment status.
Ostomy
Surgical procedure that establishes an external opening into such parts of the body
Standard error of estimate
Statistical term which refers to the difference between the estimate which is made
as the ureter(s), colon, ileum, etc.
on the basis of a sample and that which would be obtained from a complete census.
Pathophysiologic
Descriptive term which refers to a variety of conditions and problems commonly
Stratified random sampling design-
Research procedure which ensures that every skilled nursing home participating in
described as accidental or developmental disabilities, chronic illnesses, and diseases
the Medicare/Medicaid program has an equal chance of being selected as a member
of the aging.
of the survey sample.
Patient assessment form
Form developed and used in this survey which contains questions to be answered
Stratum
A statistical sampling of various populations.
which described the individual patient at the time of the survey. Data are provided
about the patient's status from several perspectives: his physical functioning,
Stroke
A sudden cerebrovascular accident.
impairments, medical risk status, and social demographic status.
Survey instrument
Types of forms used to describe and record the characteristics of items being
Patient care policies
Policies adopted by the governing body of the facilities concerning the rules and
measured.
regulations for the care of patients.
Study team
A leader and seven members who composed the 15 groups employed by DHEW who
Patient care plan
A written program of care for the patient (a working tool) that is based on the
visited the selected sample of nursing homes to collect data.
assessment of individual needs, identifies the role of each service in meeting these
needs, and the supportive measures each service will use to complement each other
Tranquilizer
An agent which acts on the emotional state, quieting or calming the patient without
to accomplish the overall goal of care.
affecting clarity or consciousness.
Patient population
Beneficiaries in skilled nursing facilities.
Transfer agreement
A written arrangement to provide for reciprocal transfer of patients/residents
between health care facilities.
Patient specific form
Form developed and used in this survey which describes the care being provided to
the patient at the time of the survey. Data are provided about patient care policies,
medical care including diagnosis, nursing care, rehabilitation, pharmaceutical,
nutrition and dietetics, and psychosocial aspects of care.
Patient classification assessment
tool
Data collection tool used to determine if patients are properly placed in a facility.
Pharmacist
An apothecary or druggist.
Physical therapist
An individual who is licensed by the State and is a graduate of a program in physical
therapy approved by the Council on Medical Education of the American Medical
Association and the American Physical Therapy Association, or who has the equiva-
lent of such education and training.
Postadmission diagnosis
Medical description of patient condition(s) identified after admission to facility.
Primary diagnosis
Medical description (s) of the main reason for admission to the facility.
Proprietary homes
Privately owned nursing homes. This category does not include those homes which
are under voluntary nonprofit, Government, and religious auspices.
Random selection procedure
Statistical procedure used to ensure that homes selected in the sample were repre-
sented in the same proportion as they are among the total number of skilled nursing
LIBRARY
facilities.
136
137
U.S. GOVERNMENT PRINTING OFFICE 1975-O-588-459
U.S. DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
POSTAGE AND FEES PAID
Public Health Service
U.S. DEPARTMENT OF H.E.W.
HEW 391
U.S.MAIL
OFFICE OF NURSING HOME AFFAIRS
5600 Fishers Lane
Rockville, Maryland 20852
OFFICIAL BUSINESS
Penalty for Private Use, $300
DHEW Publication No. (OS) 76-50021
Nursey homes
Long tem care
FACT SHEET
Long-Term Care Facility Improvement Study
INTRODUCTORY REPORT
BACKGROUND
THE FINDINGS
On June 21, 1974, the Department of
A complete report of the survey findings
Health, Education, and Welfare announced
(Long-Term Care Facility Improvement
a campaign to improve long-term patient
Study: Introductory Report) contains
care in nursing homes. One of the
three broad sections: PATIENT
projects in this campaign was a survey of
CHARACTERISTICS, FACILITY
skilled nursing facilities. The survey
MANAGEMENT, and PATIENT CARE.
asked three basic questions: Who are the
Another section presents recommenda-
patients? How are nursing homes
tions for NEEDED ACTION.
FORD
managed? How good is patient care?
PATIENT CHARACTERISTICS
THE SURVEY
WHO ARE THE PATIENTS?
Designed cooperatively by several
government organizations and consultants
They are old: the median age is 82, and
from leading universities, the survey was
50% are over 80. 73% are women; 90%
conducted by teams of specially trained
are Caucasian. 87% are single (mostly
experts. Each team consisted of a
widowed). 52% completed grade school;
physician, a nurse, an administrator, a
16% graduated from high school; 4%
nutritionist, a pharmacist, a physical
finished college.
therapist, a fire safety engineer, and a
social worker.
They are retired, or have never worked
(95%). 60% were formerly skilled,
To insure statistical reliability, the
semi-skilled, or clerical workers;
nursing homes surveyed were chosen
farmers; or housewives. 8% were in
proportionally from ten regional lists.
professional or managerial positions.
Homes and patients in them were selected
At present, 68% have less than $3, 000
by random sampling techniques. All
annual income from all sources, and 22%
visits were unannounced.
have no income at all.
The survey covered 288 homes -- enough
IN WHAT DAILY ACTIVITIES DO
to provide a reliable sample of all skilled
PATIENTS NEED HELP?
nursing facilities. The survey data were
processed according to approved statisti-
They cannot bathe without difficulty: 60%
cal techniques. The result is a valid,
need some help, and 33% more cannot
comprehensive picture of long-term
bathe themselves at all. 72% require
nursing home care.
help in dressing. 34% need some help in
U.S. DEPARTMENT OF HEALTH, EDUCATION,
Single copies of the full document,
AND WELFARE
Long-Term Care Facility Improvement
Study: Introductory Report, may be
Public Health Service
obtained from the Office of Nursing
Office of Nursing Home Affairs
Home Affairs, 5600 Fishers Lane,
Room 17B07, Rockville, Md. 20852.
eating, and 16% must be fed by others.
or none at all. 29% of facility admini-
HOW WELL ARE FIRE CODES MET?
HOW ARE PATIENTS' NUTRITIONAL
45% must be helped in using the toilet;
strators are not so-designated in writing
NEEDS MET?
29% cannot use it at all. 50% experience
by their governing bodies.
At least one fire safety deficiency was
some degree of incontinence from
found in 96% of all facilities (though in
Most facilities have the services of a
occasional to total. 87% are not fully
Administrative policies are made and
69%, there are fewer than 10 deficien-
dietician (part-time, in 90% of all cases).
ambulatory; 9% suffer pressure sores
revised as needed in 80% of cases.
cies). The points most commonly found
Dieticians spend anywhere from half a
because of reduced ability to move in
Physicians and nurses contribute to
deficient are: properly illuminated exit
day to 20 days at a facility each month.
bed.
patient care policy planning 98% of the
signs, 52%; weekly testing of alarm
Dietetic service supervisors are also
time, but other specialists are consulted
system, 49%; enforcement of smoking
retained: 60% part-time. In 29% of
WHAT OTHER IMPAIRMENTS HAVE
less often: pharmacists, 64% of the time;
regulations, 37%; fire protection of
facilities, too few nutrition staff are on
THEY?
dieticians, 55%; therapists, 43%.
hazardous areas, 33%; electrical moni-
duty in any 12-hour period to permit
toring of main sprinkler valve, 31%.
preparation of meals immediately prior
Impaired vision is suffered by 68%; 3%
WHAT ARE STAFF EMPLOYMENT
to serving. 60% of all patients' overall
more are legally blind. 33% have at
PRACTICES?
PATIENT CARE
care plans lack dietary information.
least some hearing loss. 32% have some
degree of speech impairment. 92% are
Written job descriptions are not provided
WHAT PHYSICIAN SERVICES ARE
More than 14 hours between major meals
missing some or all natural teeth, and
to prospective employees in 26% of cases.
PROVIDED?
is allowed by 20% of facilities. 28% do
38% lack compensating restorations or
35% of facilities do not require pre-
not offer an appropriate snack at
dentures. 54% show some confusion as
employment health examinations. 22% do
Of the patients who have been in a
bedtime. 73% of patients who reject half
to time, place, or their own identity (27%
not verify the registration or license
nursing home less than four months, 90%
or more of a meal are not offered an
occasionally and 27% continuously). 41%
numbers of professional staff upon hiring
are reviewed by a physician at least
appropriate substitute. 19% of patients
display inappropriate behavior
them, and 20% do not re-check these
every 30 days. For long-term patients,
who need help in feeding themselves do
typically wandering or disruptiveness.
numbers periodically. 32% do not
the proportion reviewed monthly by a
not receive it promptly at each meal.
maintain employee health records.
physician drops to 75%. Of the physi-
34% who need mechanical devices to help
WHAT ARE THEIR MEDICAL
cians who review their cases monthly,
them eat do not receive them.
CONDITIONS?
HOW DO FACILITIES UPGRADE
90% actually see their patients and 80%
STAFF SKILLS?
examine the overall care plans.
WHAT EFFORTS AT REHABILITATION
Patients' commonest primary and secon-
ARE MADE?
dary diagnoses when admitted to skilled
Staff development programs are com-
nursing facilities are: heart disease,
pletely lacking in 20% of facilities.
HOW RELIABLE ARE PHARMA-
38%; chronic brain disease, 29%;
Where they do exist, these programs are
CEUTICAL SERVICES?
Of the patients who need physical therapy
generalized arteriosclerosis and
often incomplete: 22% of the facilities do
31% receive it; 11% of those needing
hypertension, 23%; diseases of the
not provide an orientation program; 22%
Pharmacists are not able to work
occupational therapy get it; and 11% who
musculo-skeletal system, 20%; stroke,
do not offer skills training; 37% do not
directly from a physician's written drug
could benefit from speech therapy get it.
18%; fractures, 16%; neurological
provide an ongoing education program;
order 76% of the time. 28% of the time,
disease, 15%.
and 66% have no leadership training
physicians do not confirm their drug
Skilled physical therapists are retained
program for supervisory personnel.
orders in writing within a two-day period.
by 72% of all facilities. 40% retain
FACILITY MANAGEMENT
Staff members do not apply the training
occupational therapists, and 32% have
they receive 26% of the time.
Drugs are administered only by licensed
speech therapists. Of facilities offering
HOW ARE POLICIES MADE AND
personnel 93% of the time. Pharmacists
physical therapy, 56% have it at least
IMPLEMENTED?
HOW DO FACILITIES MANAGE THEIR
make at least monthly reviews of
daily and 29% offer it 2 or 3 times a week.
FINANCES?
patients' overall drug profiles in 68% of
For 33% of patients undergoing therapy,
In 16% of the facilities, the governing
cases. 69% of facilities do not have
there is no written therapy plan. And
bodies (responsible for overall policy)
The survey was unable to determine this,
separate rooms for drug storage. Con-
84% of patient records do not contain
meet less frequently than their by-laws
partly because there is no uniformity of
trolled drugs are properly inventoried in
baseline data for use in determining
require, and 50% keep inadequate minutes
accounting procedures.
79% of all facilities.
therapy needs.
HOW ARE SOCIAL AND PSYCHOLOGICAL
NEEDED ACTION
NEEDS MET?
Several clear needs for action emerge
The proportion of facilities employing
from the survey findings. These needs
staff for social work is 49% (26%
include:
full-time). 62% of the time, patients'
psychosocial needs are evaluated as
A total review of the survey/certification
part of the admitting process. In those
process.
facilities with social work staff, 70% of
patients have written plans for psycho-
social care. Family counseling is
Nationwide training and certification of
carried on 66% of the time.
all state surveyors.
In 72% of all facilities, social activities
programs are conducted by qualified staff
A complete analysis of the entire fiscal
(working part-time in 28% of cases).
approach to reimbursement for services
About 50% of medical records note
provided.
patients' needs for activities and their
responses to them. 75% of all facilities
have space available for activities, and
Alternatives to institutional care, such
71% have equipment available.
as home health care and day care.
LONG TERM
OF HEALTH. EDUCATION:
Department of
CARE
Health, Education, and Welfare
DEPART REPARTMENT :
Washington, D.C. 20201
USA
Sarah-
Date:
Per request. If you have questions
The attached may be of interest to you. please call.
Trene Schully
LH 57450
Room 5448 North
Frank E. Samuel, Jr.
330 Independence Avenue, S.W.
Deputy Assistant Secretary
Telephone: (202) 245-7450
for Legislation (Health)
OREGAT U.S.A. EDUCATION
HEALTH
DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
Sent to OMB for clearance 11/20/75
not cleared asof 12/5
The Honorable Al Ullman
DRAFT OF PROPOSED REPORT
Chairman, Committee on
Ways and Means
House of Representatives
Washington, D.C. 20515
Dear Mr. Chairman:
This is in response to your request of February 19, 1975, for a report
on H.R. 2268 and your request of October 29, 1975, for a report on
H.R. 9607, identical bills "To amend title XVIII of the Social Security
Act to establish a program of long-term care services within the Medicare
program, to provide for the creation of community long-term care centers
and State long-term care agencies as part of a new administrative
structure for the organization and delivery of long-term care services,
to provide a significant role for persons eligible for long-term care
benefits in the administration of the program, and for other purposes."
We are greatly concerned about the serious problem of financing and
providing access to adequate long-term care for the elderly and disabled.
However, we are opposed to enactment of the bills because Medicare is
not the appropriate vehicle for financing long-term care.
The bills would establish under Medicare a voluntary program of long-term
care benefits for aged and disabled individuals. This program would be
financed from premiums paid by those who enroll in the program and
Federal and State general revenue funds. The bills would also provide
for establishment of community long-term care centers throughout the
country, and State long-term care agencies to coordinate and arrange
for the organization and delivery of long-term care services.
Long-term care necessarily includes a high proportion of social services
and income support. The Medicare health insurance mechanism, which is
designed to provide protection against unexpected costs of short-term
acute illness, is not easily adaptable to these long-term and less
medically oriented types of care and support. Moreover, many of the
types of benefits proposed in the bills are similar to those services
currently included in Medicaid and the social services programs
(titles XIX and XX of the Social Security Act). The additional cost
FORD
of adding these long-term care benefits to Medicare would be $5 to
$10 billion in the first year.
LIBRARY
Page 2 - The Honorable Al Ullman
In addition to our general objections to the bills, we are particularly
troubled by one of their specific provisions. Under the bills, a person's
social security cash benefits would be reduced by two-thirds beginning
with the seventh consecutive month he receives institutional services
as an inpatient, or foster home care for which payment is provided under
the proposed new long-term care services program, apparently because he
would not need as much in the way of social security benefits. This
reduction in cash benefits would go contrary to the basic purpose of
the social security program--to replace, in part, earnings from work
that are lost when a worker retires in old age, becomes disabled, or
dies. The amount of a person's benefits is not based on his or her
individual need at a given time or under given circumstances, but is,
instead, based on the average monthly earnings the person had in work
covered under the social security program. The enactment of a provision
that would reduce a person's monthly social security benefit because his
living costs are being met through other means would, we believe, set an
undesirable precedent for relating social security benefits to individual
need or personal circumstances.
We therefore recommend that the bills not be favorably considered.
We are advised by the Office of Management and Budget that there is no
objection to the presentation of this report from the standpoint of the
Administration's program.
Sincerely,
Secretary
HEALTH.
OF
FINICATION
FOR RELEASE ONLY UPON DELIVERY
DEPART any PARTMENT DEPARTMENT
DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
U.S.A.
STATEMENT
OF
PETER FRANKLIN
SPECIAL ASSISTANT TO THE SECRETARY
BEFORE THE
SUBCOMMITTEE ON HEALTH AND LONG-TERM CARE
SELECT COMMITTEE ON AGING
U.S. HOUSE OF REPRESENTATIVES
WEDNESDAY, NOVEMBER 19, 1975
FORD is LIBRARY GERALD
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
I am pleased to appear before you today to review with you
the Department's efforts in an important part of our health
care system--home health care and related services for the
elderly.
As you know, the Federal government will invest over $17 billion
for the financing and direct provision of hospital and medical
services for the aged in 1976. During FY 1975, Medicare
payments for services to the elderly amounted to $13.9 billion; and
the Federal share for the elderly under the Medicaid program
was $2.4 billion. These FY 1975 figures do not include expenditures
by the Department for other health services for the elderly
rendered by Community Health Centers, Community Mental
Health Centers, Health Maintenance Organizations, Vocational
Rehabilitation and Developmentally Disabled programs, or the
National Health Service Corps. And these FY 1975 figures do not in-
clude expenditures for research and development programs directly
related to the health and well-being of the elderly. For ex-
ample, the proposed budget for the National Institute on Aging
of the National Institutes of Health is over $16.2 million for
FY 1976.
- 2 -
The Subcommittee has requested that we focus our remarks
today on three specific areas of interest: home health
services for the elderly, health clinics for the elderly,
and multi-purpose centers for the elderly. After I review
the first two topics with you, Dr. Arthur Fleming, Commissioner
of the Administration on Aging, will discuss the multi-
purpose centers.
Home Health Care
The Department of Health, Education, and Welfare encourages
the development of an access to home health services through
the efforts of several programs. These several programs have
attempted to be catalysts for community development of effective
home health care mechanisms. The health financing activities have
sought to provide financial access to Federal beneficiaries
in need of services that can be provided by home health agencies.
The human resource programs have encouraged the integration
of home health services with other services for the ill, elderly,
and poor.
Additionally, the Office of Nursing Home Affairs chairs an
Interagency Task Force on home health services. This Task
Force includes representation from the Public Health
Service, the Social Security Administration, the Social and
Rehabilitation Service, the Administration on Aging and the
- 3 -
Office of the Secretary. It is through this group that
the Office of Nursing Home Affairs coordinates all the
Department's home health services activities.
The Task Force was specifically asked to develop a plan that
would provide for increased Federal participation in both
the utilization and reimbursement of home health services for
Medicare and Medicaid recipients, and to show ways that would
be available to develop, expand, and improve home health services.
Since January, Interagency efforts have produced tangible
results, all of which respond to recommendations by the GAO.
For example:
The staff has reviewed State Medicaid programs, and we
will, for the first time, know what population is being
served and what kinds of services are in fact provided
and covered by reimbursements. This analysis will clearly
define the extent of the current programs.
-Proposed new home health regulations, which I will discuss
later, have been published this year.
--SSA staff has carried out a careful study of Medicare
guidelines and fiscal intermediary practices and is now
preparing a report that will provide a background to
Interagency discussions for revision of these guidelines
where needed.
- 4 -
Today, when our nation's medical care system is producing an
unprecedented escalation of cost, there is a great need to
foster use of more economical approaches to the delivery of
health care to American people, and especially to our older
population. Home health care is one such approach. Properly
run home health care programs have demonstrated an ability to
expand the capacity of a delivery system by providing needed care
while conserving some forms of scarce and costly resources, both
institutional and professional. The appropriate use of home
health care services can also have a restraining influence on
overall medical care costs. It is also possible, however, that
use of home health services may add more services to the medical
care system and increase costs. At this point, it is not pos-
sible to draw firm conclusions from the evidence on the cost
effectiveness of home health services.
Home health services cannot and should not be looked upon as
a replacement for medical care that must be delivered in an
institutional setting. Rather, home health care should be
viewed as a component of a comprehensive health care delivery
system--an alternative for treatment and medical support for
those who do not need institutional care. Obviously, there are
- 5 -
times when institutional care is essential, just as there
are times when home health care is more appropriate.
Ideally, the aim should be a balanced system, enabling
patients to continue participation in home and community
life as long as possible, and the availability of an insti-
tutional care setting when that is necessary or desirable.
We are unable to say, however, to what extent this type of
system is now available to Americans or to estimate its costs
and benefits.
For the past four years, the Department has been undergoing
an extensive review of the broad spectrum of long-term care,
with a view to developing a comprehensive approach to provision
of adequate long-term care services for persons of all ages.
Home health service is an integral part of this review.
Mr. Chairman, in the hearing before your Subcommittee and
the Senate Subcommittee on Long-Term Care on October 28,
Departmental witnesses testified on HEW's programs which
are designed to develop home health services as a more effective
resource for health care delivery.
GERALD FORD LIBRARY
- 6 -
I would like to review briefly the Department's involvement
with home health care, through the Public Health Service,
the Social Security Administration, and the Social and Rehabilition
Service.
Public Health Service
Since 1796, health professionals have been deeply involved
in overseeing both the program organization and development of
medical services in the home, and in supervising quality control
to ensure appropriate and effective patient care. For the past
two decades, the Public Health Service has supported the concept
of home care as that phase of comprehensive medical care that
provides medical, nursing, social and other services as well as
ancillary services to the patient who requires intermittent care
in the home.
Even after enactment of Medicare and Medicaid to finance home
health services to the aged and the poor, the Public Health
Service continued efforts to promote, develop and expand home
health services through organizing workshops and conferences,
stimulating non-governmental involvement in sponsorship, by
distribution of literature, development of technical assistance
materials and data, and by conducting and funding research and
development projects.
- 7 -
In January of this year the Secretary reaffirmed the
Public Health Service as the lead agency for coordinating
and monitoring the implementation of the Department's short-
term home health care improvement efforts. This responsibility
has been assigned to the Office of Nursing Home Affairs.
We recognize that home health services, when prescribed by
a physician and when properly monitored, offer an effective
alternative to long-term care for some patients. Neverthe-
less, we do not believe that it is either necessary or
desirable for the Federal government to undertake a new
narrow categorical grant program for home health agencies
such as that authorized in recent legislation. There already
are over 2,000 certified home health agencies participating
under Medicare and Medicaid programs. These Medicaid and
Medicare services have expended rapidly in recent years and
will continue to do SO due to several proposed changes which
I will be explaining later in my testimony. Moreover, reimburse-
ment from these programs will be available to finance services
by new home health agencies to program beneficiaries.
Medicare
Home health services for the aged and disabled are an
important component of the coverage provided under the Medi-
care program, which is administered by the Social Security
- 8 -
Administration. Under Medicare, home health benefits were
designed primarily to meet specific, medically-related, home
care needs of patients who do not require the round-the-clock
care or supervision by a registered nurse that is available
in hospitals and skilled nursing facilities. Such patients
nevertheless suffer from conditions of such severity that
they are confined to their homes under the care of a physician
and are in need of either skilled nursing care on an inter-
mittent basis, or physical therapy or speech pathology.
As of July 9, 1975, there were 2,123 home health agencies
participating in the Medicare program. In order to participate,
these agencies must meet prescribed standards relating to
qualifications of personnel providing services and to mainten-
ance of appropriate records and other conditions deemed
necessary to protect the health and safety of beneficiaries.
For fiscal year 1972, home health expenditures amounted to
$59 million. Home health benefit payments increased to
$110 million for fiscal year 1974 and are estimated to reach
$185 million in FY 1977.
The Social Security Amendments enacted in 1972 contain several
provisions which may significantly affect the structure of
Medicare home health benefits in the future.
- 9 -
Under Section 222 of the Social Security Amendments (P.L.
92-603), the Department is funding research and demonstration
projects using, when medically appropriate, certain day care
and homemaker services as alternative options to
institutionalization in hospitals and skilled nursing
facilities. Through these experiments we hope to determine
whether such coverage would provide quality and effectively
lower long-range costs by reducing the demand for higher
cost institutional care. We also hope to ascertain the
costs of providing various types and groupings of alternative
services and to evaluate alternative eligibility regulations.
The 1972 Amendments should also improve overall administra-
tion of home health benefits in that we are authorized
to establish in advance specific minimum numbers of home health
visits, under Part A, which a patient would be presumed
to require following hospitalization. On July 9, 1975, the
implementing regulations were promulgated for a 30-day public
comment period (later extended) and drew a large number
of responses. I would like to re-emphasize that the
limits set forth in these regulations are only guaranteed
minimums and that other services and additional periods
of coverage may be approved and reimbursed. Implementa-
tion of this authority should reduce uncertainty on the part
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of physicians and patients as to whether or not home
health care services would be covered, thereby encouraging
prompt discharge from institutional care to the home
care setting.
Another significant new regulation was proposed in the
June 9 Federal Register which would greatly expand the
ability of home health agencies to provide a large range
of services by allowing such agencies to contract with a
proprietary provider of home health services.
A further change in the rules governing proprietary home
health care providers has been included as part of the
Administration's proposed "Social Security Amendments of
1975," transmitted to the Congress as draft legislation.
Section 302 of this proposal would repeal the requirement
that proprietary agencies be licensed under State law and
subject them to the same licensure requirements as public
and private nonprofit agencies. In this way we hope
to increase the number of participating home health
agencies and make home health services more accessible.
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A number of bills have been introduced in the House which
would expand the scope of the Medicare home health
benefit. Most, such as H.R. 4772, introduced by
Representative Koch, seek to encourage the use of home
health services by making these services available to
patients who require less intensive treatment and by
providing an expanded number of home health visits
and services to beneficiaries. We share the concerns of
the sponsors of this and similar legislation that the
costs of hospital and other institutional services are high
and could be reduced in part by the substitution of appropri-
ate high quality home health services. We would caution,
however, that such substitutions can be effective only if
they are professionally controlled to prevent misutilization.
Nevertheless, we are opposed to such legislation because there
is inadequate justification for making such changes at this
time.
We are hopeful that the results of the experiments now under-
way under Section 222 will provide a basis for identifying
additional, more definitive research which will provide a
sound basis for any proposed changes in the present home
health benefit package.
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Medicaid
As you know, Title XIX, known as Medicaid, is administered
by the Medical Services Administration of the Social and Re-
habilitation Services. It provides Federal matching payments
for State expenditures for health care for the poor. States
participating in the program must generally provide payment for
specified types of medical assistance to recipients of cash
assistance--poor persons aged 65 and over, low-income blind
and disabled individuals and poor families with dependent
children. In addition, States may extend their programs to
cover the medically needy--those persons who have incomes
above the cash assistance eligibility levels but whose
income is insufficient to pay for medical care.
The Medicaid program devotes over $5 billion, or 38 percent
of its expenditures, to the area of long-term care. Almost
all of these funds are for institutional care. Over one million
Medicaid recipients spent some time this year in a nursing
home, mental or tuberculosis hospital as a long-term care
patient.
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As I stated before, we recognize that hospital and nursing
home care are essential elements of a continum of care; how-
ever, so too are suitable alternatives, such as a viable home
care program, for Medicaid patients who can be maintained in
their own homes.
Although home health services are mandatory under Medicaid,
it has been recognized for some time that clarification of
existing home health regulations was necessary in order that
the service be adequately implemented by the States as a
mechanism of non-institutional care.
On August 21, the Department published proposed regulations
which clarified mandatory and optional home health services
and recipient eligibility. The proposed regulations also would
expand the number of qualified providers capable of delivering
home health services. Although the 30-day comment period was
scheduled to close September 20, that date was extended to
October 7 because of the quantity and quality of comments
received. We have received well over 1,000 comments and we
are presently analyzing them in order to prepare final regulations.
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Dr. Keith Weikel, Commissioner of the Medicaid program,
discussed the proposed regulations in detail before your
Subcommittee on October 28. However, I would like to state
again that the intent of the regulations to implement the
law and permit the use of home health care where such care
is appropriate and determined by a physician to be necessary.
Moreover, the regulations clarify and define services that
were mandated by Congress.
In summary, the proposed regulations:
(1) Clarify which home health services are required and which
are optional with States. The States must provide nursing
services (RN or LPN as appropriate), home health aide
services, and medical supplies, equipment and appliances
suitable for home use. They may, at their option, pro-
vide physical, occupational, or speech therapy. Any
service, whether required or optional, must first be
found necessary by the patient's physician and must be
included in a written plan of care developed by the
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physician and home health agency personnel, and reviewed
by him as the patient's condition requires. This re-
vision will assure that all States will reimburse a
basic package, and at the same time encourage expansion
of coverage of other optional services.
(2) Clarify which recipients are eligible. Some States
have limited home health care to those who need "skilled"
care or those either leaving or about to enter institu-
tions. No such limitation appears either in statute or
regulation, and it should not, since many persons need
some home care to maintain or recover their health in
order to avoid institutionalization. They should receive
home care before they reach the crisis point of
institutionalization.
The revised regulation clearly repeats the statutory
requirement that all "categorically needy" persons age
21 or over must receive home health services when de-
termined necessary by the physician (the categoically
needy are generally those eligible for cash payments under
SSI or AFDC). The revision also clarifies that certain
groups chosen by the State to be eligible for nursing
home care must also be eligible for home health services,
and that the State may provide home care to all Medicaid
eligibles if it wishes to do so. This clarification ex-
pands the population eligible for coverage.
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(3) Expand the types of agencies which may participate under
Medicaid, in addition to those certified under Medicare.
Under the proposed expansion, agencies offering the
single service of either nursing or home health aide
services as well as proprietary agencies may be certified
for Medicaid if they meet certain prescribed Federal
standards. These changes are intended to make home
health services more available to Medicaid recipients and
thus in future years decrease the need for institutional
services under Medicaid. The proposed standards for
such agencies parallel those for the Medicare program
whereever possible.
The objection to single-service agencies is that they may pro-
vide only fragmented care for patients who need multiple
services. We do not think this concern is valid, since in
all cases a registered nurse must make an initial home eval-
uation visit and must supervise the care given by home health
aides. This will provide coordination of care and guard
against fragmentation of services. Allowing single-service
agencies of this type to participate will overcome the current
lack of care for recipients who need only one service provided
in a community and who live in neighborhoods where multi-
service agencies do not exist.
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We realize that there is potential for abuse of the program
by both proprietary and non-proprietary providers of home
health care services, just as there is potential for fraud
and abuse by proprietary and non-prorietary providers of
all types of services. As you know, the Commissioner of the
Medical Services Administration has made the fraud and abuse
surveillance effort one of his highest priorities. It is
the Department's intention, to include home health within
this effort.
We believe the proposed regulatory changes will be instru-
mental in expanding access to home health care for Medicaid
recipients. However, as we stated on October 28, the
regulations are not final. We are in the process of review-
ing the many comments received.
On November 17, the Department held a major meeting with
members of proprietary and non-proprietary home health service
agencies, consumer groups and staff from State program and
licensing agencies to discuss the proposed changes in Medicaid
regulations. The major issues were removal of the restrictions
on provision of home health services by proprietary agencies,
the feasibility of strong State and Federal monitoring of
providers and inclusion of provider offering only a single
service.
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A number of valuable concepts and ideas were offered which
the Department will take into consideration in developing
final regulations.
Another provision of H.R. 4772, introduced by Representative
Koch, would make home health services available to all Medi-
caid recipients, both medically and categorically needy,
without regard to the recipient's entitlement to skilled
nursing services. At present, home health services are
required to be provided to all categorically needy individuals
21 years of age or over, to all categorically needy individuals
under 21 years of age if the State provides skilled nursing
facility services for such individuals and to all correspond-
ing groups of medically needy individuals for whom skilled
nursing services are provided.
As noted earlier, the proposed regulations would clarify
the entitlement of the categorically needy to home health
services, without regard to their need for skilled care.
However, we oppose mandating the expansion of these services
to individuals other than those currently entitled.
There are other objectionable provisions in H.R. 4772. For
example, rent payments under the Medicaid program. The
Department will submit a report on the bill shortly.
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Mr. Chairman, I would like to discuss briefly health clinics
for the elderly and then proceed with Dr. Fleming's presenta-
tion on multi-purpose centers.
Outpatient Clinics for the Elderly
Your letter of invitation to participate in this hearing also
mentioned the need for "outpatient clinics designed specifically
to meet the medical needs of the elderly." While we are aware
that the elderly need care on an outpatient basis, we would be
opposed to establishment of clinics whose sole purpose would
be to treat the elderly.
The Department believes that health care for the elderly
should be provided through existing health care delivery
systems serving the general population. It has been the Depart-
ment' S philosophy to avoid segregating the aged from the
mainstream of society, but instead to integrate their invole-
ment with all age groups. We believe one of the most
detrimental attitudes that can be expressed by society is to
treat the aged separately, thereby creating a new minority
segment of our population. However, we recognize the fact that
aged people do have problems peculiar to their age group. We
are concerned that those who provide treatment to older people
are fully oriented to the nature and scope of their problems
and that they are prepared to treat them with the most effective
methods known.
FORD is LIBRARY 078870
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The aged have more health care needs than any other popu-
lation group within our society. This Administration, as
have past Administrations, recognizes this need and seeks,
therefore, to provide the aged an adequate number of entry
points into the health care system so that they readily may
secure adequate primary care services. If, as with other
population groups, there are needs which must be handled by
a medical specialist, then the primary care physician would
refer the person to the appropriate medical specialty. To
establish separate clinics to treat all the medical needs
of the older patients, generally, would be wasteful and
duplicative. The Department is continuing to follow the
policies and approaches which have been developed since the
passage of Medicare which are: (1) to provide financial re-
sources to assist the elderly in purchasing their own medical
care; (2) to allow the elderly citizen freedom of choice in
choosing a physician; and to promote and preserve the physi-
cian-patient relationship. To have the Federal government as
a general policy promote and establish out-patient clinics for
the elderly through new categorical program authorities would
not contribute to the welfare of the aged nor would it make
effective use of the health service delivery capacity which
now exists.
Mr. Chairman, I would like to turn to Dr. Flemming for a discussion
of multi-purpose centers for the elderly and then we would be
pleased to answer any questions the Committee has.
file- long term care
MEMORANDUM
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
TO
: Sarah Massengale
DATE: OCT 29 1975
Special Assistant to the President
FROM : Director, Division of Policy Development
Office of Nursing Home Affairs
SUBJECT: Re: Provider/Consumer Meeting of October 14
As we discussed a few days ago, I am enclosing a copy of the paper
Dr. Carl Adams presented at our Provider/Consumer Symposium on Patient
Assessment. The full agenda is also enclosed to give you an idea of
how the subject was handled from the Federal Government, provider and
consumer points of view. Dr. Abdellah's notes are also attached.
Dr. Adams' paper is evidence of how the industry is giving full support
to this concept. It deals with how his chain of nursing homes is
using patient assessment as a management tool toward improving patient
care. Dr. Abdellah, in her remarks, stressed ONHA's and HEW's concern
that patient assessment also become a viable tool in the survey and
certification process. The ongoing cooperative project in Region IV
brings these two interests together.
We are planning to edit all papers from the October symposium and make
it a part of the monograph we are preparing now on Patient Assessment
as it pertains to the Nursing Home Improvement Survey. We will be
happy to send you the completed document as soon as it is available.
Claire Ryder
Claire F. Ryder, M.D., M.P.H.
Enclosure
OFFICE OF NURSING HOME AFFAIRS
PUBLIC HEALTH SERVICE
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
AGENDA
SYMPOSIUM ON PATIENT ASSESSMENT:
AN ESSENTIAL FACTOR IN IMPROVING QUALITY OF CARE
Tuesday, October 14, 1975
1:00 PM to 4:00 PM
Snow Room, HEW North
1:00 - Welcome and Introductory Remarks
Peter Franklin, M.Ed., M.B.A.
Special Assistant to the Secretary
Moderator - Claire F. Ryder, M.D., M.P.H.
1:15 - Faye G. Abdellah, Ed.D., LL.D.
"Patient Assessment: Vantage Point Federal Role"
1:45 - Joan Quinn, R.N., M.S.N.
"Patient Assessment: Vantage Point Researcher"
2:15 - Carl E. Adams, M.D.
"Patient Assessment: Vantage Point Provider"
2:45 - Coffee Break
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3:00 - Iris Schneider, M.A.
"Patient Assessment: Vantage Point Consumer"
LIBRARY
3:30 - Questions and Answers
4:00 - Adjournment
Secretary David Mathews hopes to join us at some point during the program
as his schedule permits.
"PATIENT ASSESSMENT AND THE PROVIDER"
October, 1975
Carl E. Adams, M.D.
Chairman, Medical Advisory Committee
American Health Care Association
Washington, D.C.
Chairman of the Board
National Health Corporation
Murfreesboro, Tennessee
GERALD LIBRARY FORD
PATIENT ASSESSMENT AND THE PROVIDER
Patient assessment, as used, is the summarization of the patient's identifying
and population characteristics (social demography); the diagnoses and/or conditions;
the functioning status as to physical, mental and psychosocial; the medical care,
health care and social care needs; the services rendered, the treatments given and
the outcomes.
The idea of patient assessment is not new. For many years patient assessments
have been done in one way or another, perhaps for as long as there have been
patients and Health Care or Medical Care Practitioners. The use of a broad base
of information and uniformity is new in long-term care patient assessment.
The items to be discussed are methodology or the process of doing the patient
assessment, its use in the quality assurance program and its use as an aid in
management. It becomes apparent that quality assurance and good management are
practically synonymous and that the one follows the other.
METHODOLOGY
The patient assessment is done on admission, continued stay, with change of
level of care, discharge or death.
The essential tools for doing patient assessment are:
1. A dictionary of definitions of terms, descriptors and identifiers used
(The Denson - Jones User's Manual)
2. An abstract form
(There are many different forms in process of development.)
3. A procedure manual with instructions for completing the specific
abstract form
It is important that the person or persons completing the abstract and
responsible for its correctness and accuracy be knowledgeable in its use. This
personnel may include the physician advisor or medical director, the director
of nurses, charge nurse, coordinator, or other persons knowldegeable and capable
in its use. The in-house social worker is a possible resource person.
The abstract form is in duplicate. The original is retained by the facility
and placed in the patient's medical record. The duplicate (NCR copy) is sent for
data processing. The time consumed in completing the initial abstracts is about
15 minutes. Subsequent abstracts require 3-4 minutes each.
The abstract is completed in a uniform manner at the indicated time. On
arrival at the data processing point the completed abstract is audited, edited
and a detail listing of the abstract material is printed out in code form. The
detail listing is the data base for all future printouts.
The printouts from the detail listing include, but are not limited to the
patient assessment, profiles, and other profiles as special groups of patients,
special types of care, facility and practitioner profiles. The facility summary,
other summaries including special groups as company (corporate), area, state,
regional, national, and a condensed summary of comparative statistics of critical
items are available. Level of care summaries, as skilled and intermediate, may be
done. These printouts constitute the tools gained from patient assessment for
use as aids in evaluating patient care and management efficiency.
QUALITY ASSURANCE
This is the foundation for the justification of patient assessment.
Quality assurance includes in its envelope the assurance that:
1. The patient needs the care, that is, medical necessity exists
2. The care needed is being given
3. The care is being given in the most appropriate setting as regards
quality and cost.
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The use of the patient assessment facilitates the review of the patient in the
entirety and aids in the evaluation of the patient in many ways.
Staff
The Coordinator has use of the assessments and profiles when doing admission
certification or preparing for utilization review. A review of the patient's
status can be more readily evaluated and decisions made with more uniformity as
to the need for recertification or review.
The Physician has an aid for use in reviewing the patient's problems, conditions,
status and the services, treatments and medications. Changes in the patient's
condition are noted; the drug review and profile helps to monitor the medications.
The Director of Nurses has available a complete set of profiles of all of
the patients in the facility for use in checking or discussing any patient or
group of patients. These profiles are updated monthly. Changes in a patient's
condition may be noted and attention given. The profiles do not replace making
rounds and visiting patients, but they do help in identifying needs and areas of
concern. Indications may be noted for the moving of patients to areas with different
staffing or for implementing involvement of the patient in particular programs
of activity or rehabilitation.
The Patient Care Plan is more complete and comprehensive as a result of
having the patient assessment and patient profile for a point of reference. Also
the nursing assessment history blends with the patient profile and the patient
care plan.
All of the department heads and the staff may use the profiles and summaries
in a manner similar to what has been described, with adaptation to their individual
or special needs.
Improvement of efficiency and functioning of the staff is noted with implementation
of the patient assessment program. There is an improvement in the attitude and
objectivity of the staff. A meaning comes into the charting and the efforts of the
-3-
staff. Accuracy and completeness come to have a new meaning as it is recognized
that the information is being seen and used by others. The staff personnel become
better aware of each patient's condition and treatments. The completion of the
abstracts and the patient profile printouts on all patients in a uniform and
orderly manner gives a better base for comparison and evaluation. Social service,
activities, rehabilitation and dietary departments can each find their work made
easier and more comprehensive. The medical records area is greatly improved.
The patient assessment is oriented toward identifying the conditions and
problems confronting the patient and the treatments being given.
The improvement in charting, recording and accurate coding make the diagnostic
index and the cross-referencing possible and more meaningful.
The coding of accidents and incidents, the recording of decubitii and the
originof their occurrence, as well as the progress of the condition, the uniform
definition of restraints and the incidence of use all bring the items into focus
and give a basis for comparison that evaluations may be arrived at for recognition
of achievement or that attention may be given to correction of problems.
The facility summary calls attention to the use of different services and the
percentage participation of the patients in relation to the incidence of problems or
conditions.
Further identification is made by noting the diagnostic summary and the
individual patient profile or assessment which can be readily identified for study
and/or evaluation. Frequency and type of social visitations are noted. Patients'
psychosocial problems or needs are recognized. Drugs as to types or kinds and
numbers of medications are identified. The time saved in retrieving information is
material.
Utilization Review
There is increased organized information available for use in the different
components of evaluation as in:
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Concurrent Review
1. Admission Certification has the diagnosis, needs and conditions of
the patient identified on the completed abstract form. This form
is replaced in the medical record by the patient profile printout.
The admission assessment and profile may become a permanent part
of the medical record for documentary evidence and remains as a
constant for future reference. Also a copy of the assessment may be
sent to the state agency for verification of the reasons for the
need for admission.
2. Continued Stay Review
The profile may be used to evaluate the need for recertification and to
evaluate the services, treatments and medications in relation to the
diagnosis, problems and conditions. Any change in the patient's
condition since admission or last review is noted, as are changes
in treatments. The required level of care is compared to the source
of payment for evaluation of the propriety of the care and the need for
continued stay.
3. Discharge Planning
a) The patient may be followed in sequential manner as to problems,
conditions and required services, treatments and medications.
b) The coordinator, social worker, director of nurses, physician and
Utilization Review Committee are better able to evaluate and
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make decisions with the use of the patient profile.
LIBRARI
c) The information is available to all in a uniform manner.
The patient profile saves a great deal of time by virtue of it not being
necessary to gather and write information on forms, as the information is already
in an organized arrangement on the profile.
-5-
The profile indicates many things including diagnosis, problems, conditions,
treatments, medications, as well as the frequency of physician visits and the
incidence of consultations. Outcomes and discharge destination are noted, in
addition to admission source, age and length of stay.
Medical Audit (Medical Care Evaluation Studies)
The profiles of groups of patients as to diagnosis, problems, or conditions,
services rendered, treatments given or medications, length of stay, age, required
level of care, source of payment, etc., all lend themselves for use in evaluating
the care given to the patients.
From the facility summary can be noted the percentages of different problems
and treatments as tube feeding, multiple injections, the participation in physical
therapy and the outcomes are noted as related to frequency of treatments and
indications for giving the therapy. Frequency and types of social visitations are
noted. Patients' psychosocial problems or needs are recognized. Medications
as to number and kinds are identified. Drug review indicates frequency of errors,
reactions, interactions, allergies, toxicities, etc.
Physician visits as to frequency and type are identified and with the physician's
code number the physician profile can be developed.
Medical care evaluation and studies have the bulk of the source material
collected, assimilated, organized and tabulated for use in doing evaluations
and studies or for making decisions. Problems are identified and the mechanics
are provided for gathering the data needed for the study regarding the quality
of the basic care of all of the patients; groups of patients by diagnosis, procedures,
services, treatments or medications. Educational needs may be recognized and correct
programs implemented.
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Profiles are developed for the:
1. Consumer
a. Patient - - (individual)
b. Population group, as the types and kinds of patients of a given
facility, community, area, state, etc.
2. Provider
a. Physician as to types or kinds of patients, practices regarding
admission or care, treatments and other characteristics as regards
quality of care and cost.
b. Other practitioners as physical therapists, dietitians, social
service workers, activity directors, etc.
C. Institutional - types and kinds of patients, services offered, and
amount of participation in, treatments given and outcomes.
3. Modalities of Care
a. Drug services
b. Rehabilitative departments
C. Nursing care
d. Dietary departments
e. Medical records
f. Others
The committees, such as the pharmaceutical services, infection and medical
records all find the material and information useful in evaluation and decision
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making. Research becomes a feasible and effective method as new innovative programs
LIBRARY
and ideas can be tried and evaluated.
The items mentioned in the foregoing are but a few of the many that may be
identified with a few minutes of effort, study and evaluation.
-7-
Through the documentation in permanent form as a part of the medical record
patient assessment lends itself to being capable of being monitored as to accuracy
and validity by either in-house or external methods. The assessments, profiles and
summaries include the information necessary for PSRO and can be modified to adapt
to the changing needs.
The collected material provides a data base for use in the development of
norms, standards and criteria and gives information for evaluation of differences
in individual localities and regions.
MANAGEMENT
Management finds many uses for the patient assessment and its profiles and
summaries.
The Administrator has available a current printout of the patient profiles,
the other profiles, and the summaries. The patient profiles are a source for
ready reference concerning the different medical, health and social aspects of the
patient. It becomes easy to keep in touch with the welfare and condition of the
patients. It is no longer necessary to go to the nurses station or the director
of nurses, etc. for each bit of information. The profiles and summaries offer
information as to the types and kinds of patients, their ages, number and kinds of
problems, frequency and kinds of diagnoses, the services, treatments and medications.
This information offers a method for monitoring the required level of care, the
payment source, the discharge planning and its adequacy. Better information is
available as to why certain patients remain in the facility. Discussions with
families and others can be carried on with more clarity and depth of understanding.
By doing patient assessment at the time of admission proper level of care
determinations may be made, compliance requirements may be met and unnecessary
admissions may be avoided.
-8-
The Administrator and the Staff can use the profiles and summaries in
interdepartmental meetings for evaluation and determination of adequacy of staffing.
The percentage patient participation in the different programs of activities,
rehabilitation and training give an index as to the adequacy of the staff, available
equipment and allocated floor space. Study of the problems or impairments indicate
the need or lack of need for personnel in the respective areas.
A study of the incidents and accidents gives an alert as to hazards, type
of care, medication problems, as tranquilizers, smoking or flammable agents, or
laxness in supervision of patient activities. At the same time excellence of
care may be noted for example, by seeing a smaller number of accidents.
Performance Evaluation
This becomes a practical matter of using critical items and looking at numbers
and percentages in a realistic manner. The participation of the patients, the
treatments given, the services rendered and the outcomes are seen by management in
relation to hours of labor per patient day and the allocation of the labor as to
areas or departments. Nursing stations may be compared to one another. Characteristic
patterns of personnel behavior will develop.
The Governing or Corporate body find the assessments, profiles and summaries of
value in evaluating the patient care and the efficiency and adequacy of the operation.
Comparisons may be made between different facilities in the same corporate
structure or in other groups.
Cost Determinations
The services provided, the types and kinds of patients cared for and the
outcomes are seen in a more accurate and valid relation in comparison to cost.
Health Service Areas have information available as to needs, supply of types
of personnel and physical facilities and numbers of patients receiving or needing
care and their diagnosis, problems, treatments, etc. The population area from which
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the patients come may be identified through use of the zip code number. There is
available information for use in determining need for and the present available
services.
Health Care Insurors (Proprietory and Non-Proprietory)
Health care insurors are provided a method of evaluation of patients
in long-term care facilities, as to age, diagnosis, conditions, length of stay,
procedures, treatments, medications and outcomes as to risk and cost. Sources
of payment as self-pay, government programs and private insurance coverage, etc.,
and the relative percentages of each are identified.
This information has previously been available for Medicare Skilled Patients;
however, no valid information has been available for Medicaid Skilled, Medicaid
Intermediate Care, private pay or those covered under the various health care
plans other than Blue Cross.
Public Relations
The information is available to properly inform the public, the consumer groups
and families or friends of patients.
Statements in the media and those made by critical agencies may be properly
handled and when true the acknowledgement can be made and information given as to
what is being done to remedy, improve or correct the situation.
In summary patient assessment is a valuable, if not indispensable, tool for
use in any program of quality assurance. The information gathered is essential
regardless of the method used. It is important to continue to concentrate on
important and critical items and to discard the unimportant items as they are
found to be unnecessary. Patient assessment, utilization review and self-assessment
are critical and necessary components in the totality of giving better patient
care.
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Many peer review groups, state and national survey agencies find considerable
help in evaluating the area of patient care through the use of the assessments,
profiles and summaries,
The utilization review and indeed the entire facility and its performance can
be monitored by the PSRO, the state agency and HEW through the use of the assessment
information.
Management has a bottom line opportunity to use patient assessment for quality
assurance and managerial improvement as to proper allocation of labor and costs with
accurate and valid information as to the adequacy of each. Just as financial
statements show the results of financial management, the patient assessment gives the
information for the evaluation of the patient care and effectiveness of the management
system.
The patient assessments, profiles and summaries provide an opportunity for
dialogue of a constructive nature between the provider, consumer, government and
intermediaries.
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List of Illustrations
# 1 -- Abstract Form
# 2 -- Abstract Detail (Detail Listing)
# 3 -- Patient Profile
# 4 -- Facility Summary (Extracts)
(2 pages)
# 5 -- -- Diagnosis Summary (Extract)
# 6 -- Condensed Summary (Critical Items)
FORD is LIBRARY 077839
LONG TERM CARE
CONTINUED STAY AND MEDICAL CARE EVALUATION ABSTRACT
1. PHYSICIAN CODE
2. PROVIDER NO.
3. MEDICAL RECORD NO.
DATE THIS
4
1 ADMISSION
3 CONTINUED STAY
MO.
DAY
YR
EXPRESSION
ABSTRACT
2 CHANGE OF CARE
4 DISCHARGE
27
1 VERBALLY
3 LANG. BARRIER
OF NEEDS
2 NONVERBAL
4 DOES NOT COMM.
I BASIC DATA
CODE
DAILY
SPOUSE-CHILDREN-CODE:
2 WK
S
M
F
M&PH
MO.
DAY
YR
28
SOCIAL
MINISTER
3 WEEK
SEX &
5
CONTACTS
FRIENDS & OTHER
1 MALE
2 FEMALE
4 MONTH
BIRTH DATE
MAIL & PHONE
5 INFREQ.
5 NEVER
6
RACE & ETH
1 WHITE
3 BLACK
5 RED 7 YELLOW
ACTIVITY
ACTIVITIES
CODE
1 OPTIMAL
ACT
R
A&C
REST
NICORIGIN
= MEXICAN 4 PUERTO RICAN 6 OTHER
29
PARTICI-
RELIGION
2 MODERATE
7
MARITAL
ARTS & CRAFTS
3 SLIGHT
1 SINGLE
3 MARR.
5 DIVORCED
PATION
RESTORATIVE SERVICES
4 NONE
STATUS
2 WIDOWED
4 SEP.
6 UNKNOWN
LIVING
1 ALONE
4 WINON-RELATIVES
IV EVALUATION POTENTIAL
PROJECTED
8
ARRANGE
2 W/SPOUSE
5 FOSTER HOME
LOS
MENTS
3 W/RELATIVES
6 INSTITUTION
PROJECTED
: ADMISSION
3 CONTINUED STAY
30
9
ZIP CODE
LOS
2 CHANGE OF CARE
PATIENT'S HOME ADDRESS
REHAB.
31
OPTIMAL
3 SLIGHT
NACTIVE
POTENTIAL
2 MODERATE
4 NONE
RELIGIOUS
1 PROT
3 JEWISH
5 CATH.
10
STATUS
2 7TH D ADVENTIST
4 MOHAM.
6 MORMON
LEVEL
1 SKILLED
5 PERSONAL/CUSTODIAL
7 ORIENT
ICF
6 ROOM RESERVED
32
OF
1 YRS
4 GRAM. SCH
6 HIGH SCH.
3 ICF-M.R.
7 HOME HEALTH SERV.
11
5 GRAD. STUDY
7 MASTERS
CARE
EDUCATION
2 BACH. DEG.
4 SPECIAL THERAPY
8 RESIDENTIAL
3 HS TECH
INDOOR
OUTDOOR
Y REHABILITATION SERVICE
12
OCCUPATION
1 BLUE COLLAR
3 WHITE COLLAR
5 LABORER
CLASS
2 HOUSEWIFE
4 PROFESSIONAL
6 OTHER
1 P.T.
6 MEAL TRAINING
33
TYPES
2 SPEECH THERAPY
7 REALITY RE-ORI'T
NEVER WORKED
4 WORKING PART TIME
3 VISUAL THERAPY
8 REC. THERAPY
13
WORK
2 WORKING FULLTIME
5 SICK LEAVE
4 O.T.
9 GAIT TRAINING
STATUS
3 RETIRED W/PENSION
6 RETIRED W/O PEN.
5 BLAD/BOW. TRG.
0 NONE
FREQ. OF
1 DAILY
4 MONTHLY
34
01 SELF PAY
06 MEDICARE 11 CHAMPUS
SERVICE OR
2 2-3 WEEKLY
5 OCCASIONALLY
6 NONE
SOURCES OF
02 MEDICAID SK.
07 MEDICAID ICF
THERAPY
3 WEEKLY
14
03 BLUE CROSS
08 VETERANS
1ST
2ND
3RD
PAYMENT
04 WORKMEN'S COMP. 09 CHARITY
RESULTS OF
35
1 OPTIMAL
3 NO IMPROVEMENT
05 NO PAYMENT
10 OTHER (SPECIFY)
SERVICE
2 MOO. IMPROV.
1 HOME
6 CUSTODIAL
VI CONSULTATIONS
TRANSFER
2 FOSTER HOME
7 PSYCH FACILITY
15
DESTINATION
ORG. HOME CARE
3 COUNTY HOME
FACILITY CODE
: NURSHOME
9 OTHER
1 PHYSICIAN
5 SOC. SERVICES
3 HOSPITAL
TYPES
PODIATRIST
36
6 O.T.
3
DENTIST
7 SPEECH THER.
1 PHYSICAL THER.
3 OTHER
II DIAGNOSIS & MAJOR COMPLAINT
FREQ. OF
: DAILY
4 MONTHLY
PROJECTED
37
CONSUL
2 2.3 X WEEKLY
5 OCCASIONALLY
SPECIFY
CDA
LOS
TATION
3 WEEKLY
6 NONE
PRIMARY
16
DIAGNOSIS
VII PHYSICIAN VISITS
1 ROUTINE
3 SPECIAL
38
TYPE
2 EMERGENCY
4 CONSULTATION
FREQ. OF
DAILY
5 EVERY 30 DAYS
OTHER
39
2 WEEK
6 EVERY 60 DAYS
PHYSICIAN
17
2 EVERY DAYS
7 INFREQUENTLY
DIAGNOSES
VISITS
4 EVERY is Davs
8 NEVER
VIII SPECIAL TREATMENTS & SERVICE
01 DECUBITUS CARE
07 STERILE CRESSINGS
02 TUBE FDG.
08 RESTRAINTS
SPECIAL
03 TRACH CARE
09 DRUG REGULATION
40
TREATMENT
04 SUCTIONING
10 MULTIPLE INJ.
05 THER. DIET
11 IRRIGATIONS
06 SPEC OSTOMY CARE
12 02 THERAPY-
FLU VACCINE
INCIDENTS &
YES
NO
LABORATORY
MORPHOLOGY
X-RAY
18
ACCIDENTS
SERVICES
CHEMISTRY
5 BLOOD CT.
1 CHEST
LIST ABOVE IF TO BE CODED
was
SUGAR
6 PRO. TIME
2 BONES
Blood Tests
CHOLESTEROL
7 L.W C.T.
3 ABDOMEN
Other Tests
41
3 B.U.N.
8 OTHER
4 OTHER
XII
III PROBLEM IDENTIFICATION
Spec. Exams
4 OTHER
«
Treatment
SPECIAL TEST
CODE NO HELP
Code
X-Rays &
9 URINE
1 TB
4 EATING-FEEDING
T. 3. Skin Test
OPROFILE
2 HELP
2 CULTURES
$
MOBILITY
5 WALKING
1
19
3 OTHERS
1 SELF CARE
6 BATHING
STATUS
7 TOILETING
01 TRANQUILIZERS
2 WHEELCHAIR
12 INSULIN
8 TRANSFER
2
02 SED./HYPNOTICS
13 HYPOGLYCEMIC
2 SED-FAST
03 ANTIMICROBIALS
14 DIURETICS
Blander
Bower
04 ANTINEOPLASTICS
15 VITAMINS/IRON
BOWEL &
: CONTINENT
4 CATH/HOSPITAL
05 VASODILATORS
16 HORMONES
20
BLADDER
OCCAS. INCONTINENT
5 CATH/ NO HOSP
42
06 ANTIHYPERTENSIVES1T LAX./ST SOFTNERS
3 INCONTINENT
6 COLOSTOMY
MEDICATIONS
07 CARDIAC DRUGS
18
ANTACIOS
08 ANTICOAGULANTS
19 ANTICONVULSANTS
09 NARCOTICS
Code
20 ANTIHISTAMINES
CODE 1 IMPAIRMENT
3 HEARING
10 PAIN RELIEVERS
SPECIAL
OTHER (SEE
2 COMPLETE LOSS
1 SWALLOWING
11 STEROIDS
PROCEDURE MANUAL)
21
SENSES &
1 VISION
5 TOUCH
01 ALLERGY
07 2+ MEDS
CONDITIONS
2 SPEECH
6 MOVING
2
02 DRUG INTERACTION
DRUG
SAME RX. EFFECT
43
03 FOOD/DRUG INTERACTION
08 ERROR/DRUG
REVIEW
04 EXCESSIVE USE
09 ERROR/TIME
1 CONTENT
5 INSOMNIA
05 TOXICITY
10 ERROR/AMOUNT
22
EXPRESSION
2 RESTLESS
6 ANGRY
06 PROBLEM WITH AOMINISTRATION
3 UNCOMFORTABLE
T
P
7 DEPRESSED
R
à
0
OF FEELING
4 PAIN
44
VITAL SIGNS
1 STABLE
3 CHEERFUL
3. INCREASED
T.P.R.S.D.
2. UNSTABLE
4. DECREASED
MENTAL AND PSYCHOSOCIAL
AGE WEIGHT INDEX
45
WEIGHT
1. NORMAL 2. INCREASED 3. DECREASED
MENTAL &
CLEAR
3 DISORIENTED
23
ORIENT STA
2 OCC. DISORIENTED
4 UNKNOWN
1 WELL
5 DETERIORATING
PATIENT
2 MAX REHAB.
6 EXPIRED AUTOPSY)
BEHAVIOR
1 APPROPRIATE
3 FREQ. INAPP
46
STATUS
3 PART REHAB.
7 EXPIRED NO AUTOPSY)
24
PATTERN
= OCC. INAPP
4 INAPPROPRIATE
4 STATIONARY
8 CORONER
TOBACCO
TOB
ALC
COF
CODE:
EXCESSIVE
4 NONE
DEATH
AS SHOWN ON DEATH CERTIFICATE
CDA
25
HABITS
ALCOHOL
2 MODERATE
5 NEVER
47
COFFEE
3 SLIGHT
CONFORMANCE
TIME
CODE
1 OPTIMAL
T
26
A
WITH FAC
3
AREAS
AVERAGE
STANDARDS
BEHAVIOR
3 POOR
ILLUSTRATION # 1 Abstract Form
LONG TERM CARE PROGRAM AUSTRACT DETAIL TN# 7440147 83-BEDS 32-SK 51-INT AUGUST 1975 PG
1
COMBINED CARE
I BASIC DATA
MEDICAL
PHYSICIAN
ABSTRACT
SEX &
AGE RAC M
1.
ZIP
REL
E
OCC
WORK
PAYMENT
TRANSF
L P
RECORD #
CODE
TYPE
&
DATE
BIRTH
DATE
5
A
A-I
0
1-0
SOURCES
DEST
C S
21
18001
3 8/31/75
2
2/05/81
94
1
2
2
37130
1
2
I
07
5 1107 2 4
424
18001
1
8/09/75
1
6/10/81
94
1
2
3
37130
1
1
5
3
01
1 1996 2 5
42
18001
3
8/31/75
1
6/18/81
94
1
2
3
37130
I
1
5
3
01
1 1996 2 5
86
18003
3
8/31/75
2
11/14/06
68
1
2
1
37130
1
3
6
01
1 1996 2 3
245
18001
3
8/31/75
2
8/28/90
85
1
2
3
37130
1
1
2
1
07
1 1996 2 4
11 DIAGNOSIS AND MAJOR COMPLAINT
MEDICAL PRIM LOS DX A LOS DX B DX C DX 0 VITAL WGT INCIO DEATH PHY-VISIT L PMT DAYS
RECORD # DIAG
TPRSD
& LOS CAUSE TYPE FREQ C SRC NSF
21 820.2 999
713.0
999
41111
2
1
6
2
07
3180
42*
09.9
30
437.9
30
309.9
11111
2
2
01
42
09.9
30
437.9
30
309.9
11111
2
1
6
2
01
22
86 344.2
F707.0
11111
2
1
5
2
01
2202
245 820. 999 342. 999
11111
1
1
6
2
07
1347
III PROBLEM IDENTIFICATION
MEDICAL MOBILITY 8 6 8 -SENSES- EXPAS MEN BEH PABIT CONFR EXP SOCIAL ACTIVIT
DEATH
L
PMT
DAYS
RECORD # NHLP HELP BBC IMP. LOSS FEELS
IAC
TAB
SMFP
ARCR
CAUSE
C
SRC
NSF
21 247 68 11 36
1
1
2
552
222
1
25
3
4
3341
2 C7 3180
42*4
5678 l' 1
16
7
2
1
553
1
2
01
42 4
5678 11
16
7
2
1 553 222 1 5 6 6 6 4444
2
01
22
86 2467 8
53
6
1
1
1
544
322
1
3641
3343
2
01 2202
245 4
2678 33
2
6
1
3
3
554
333
1
1634
2332
2
07
1347
- IV EVALUATION POTENTIAL-
-V
REHAB.
SERVICE-
-VI CONSULTATIONS- -vii PHYSICIAN VISITS-
MEDICAL
PROJECT
REHAB
L
TYPES
FREQ
RESULT
TYPES
FREQ
TYPE
FREQ
DEATH
L
PMT
DAYS
RECORD # TYP LOS PUT C
CAUSE
C
SHC
NSF
21
3
999
3
2
1
6
2 07 3180
42*
1
999
3
2
2
01
42
3
399
3
2
1
6
2
01
22
86
3
999
2
2
4
2
2
1
5
2
01 2202
245
3
999
3
2
1
6
2
07 1347
VIII SPECIAL TREATMENTS E SERVICE
MEDICAL
SPECIAL TREATMENT
SERVICES
MEDICATIONS
DEATH L PMT DAYS
RECORD #
LAB X/RAY TESTS
CAUSE C SRC NSF
21
15 06 20 10
2 07 3180
42%
15 20 01 03 18
2
01
42
02
958
15 20 01 03 18
2
01
22
96
2
01 2202
245
05 01 20 18 10
2
07 1347
ILLUSTRATION # 2 (Detail Listing)
FORD
LIBRARY
PHYSICIAN CODE-
25001
DATE
OF
BIRTH
9/19/90
AGE- 84 SEX-F RACE-WHITE
OCCUPATION -HOUSE WF
MARITAL STATUS-WIDOWED
PROVIDER
NBR.
7440147
ADMISSION
DATE
12/03/74
ADMISSION SUURCE-NORS. HOME
WORK STATUS-NEVER WK
RELIGION-PROTESTANT
MEDICAL RECORD-
358
DISCHARGE DATE
/
/
TRANSFER DESTIN.-
EDUCATION -GRAM.SCH
ZIP CODE- 37211
ADM. DIAG. 820. FRACTURE OF NECK OF FEMUR
LIVING ARNG-INSTITUTION
ADMISSION
04/30/75
05/31/75
06/30/75
ADMISSION 04/30/75 05/31/75 06/30/75
LEVEL OF CARE
ICF
ICF
ICF
ICF
REHAB TYPE
NONE
P.T.
P.T.
P.T.
SOURCE PYMNT
MED.ICF
MED.ICF
MED.ICF
MED.ICF
3
PRIMARY DX
820,
820.
820.
820.
4
5
FRACTURE OF NECK
OF FEMUR
OTHER DX
998.5
998.5
998.5
998.5
599.0
599.0
599.0
599.0
795.
795.
795.
795.
REHAB FREQUENCY NONE
DAILY
DAILY
DAILY
10
11
INC. ACCID.
NO
NO
NO
NO
12
13
10
SELF CARE
NO
NO
NO
NO
14
MOBIL HELP
BEDFAST
15
12
EAT-FEED
REHAB RESULTS
MOD IMPV MOD IMPV MOD IMPV
16
17
13
BATHING
BATHING
BATHING
BATHING
TOILET
TOTLET
TOTLET
is
TRANSFER
TRANSFER
TRANSFER
21
16
1/
BLADDER
CATH/NHO
CONT.
OC.INC.
OC.INC.
CONSULT TYPE
23
15
BOWEL
OC.INC.
CONT.
OC.INC.
OC.INC.
24
25
SENSES IMP.
26
20
27
21
HEARING
SWALLOW
PHYSICIAN VISIT
ROUTINE
ROUTINE
ROUTINE
29
JO
23
MOVING
MOVING
MOVING
MOVING
FREQUENCY
EVERY 60
EVERY 60
EVERY 60
31
24
SENSES LOSS
SP. TREATMENTS
IRRIGATN
DEC.CARE
32
25
STER.OR.
33
DEC.CARE
34
26
35
27
36
37
28
38
29
EXP. FEELING
RESTLESS
UNCOMFT
CONTENT
CONTENT
39
30
UNCOMFT
40
41
31
42
LAB
OTHER
43
45
34
MENTAL STATE
OC/DISOR
OC/DISOR
CLEAR
CLEAR
46
35
BEHAVIOR
FREQ/INA
OCC/INAP
APPROPRT
APPROPRI
47
38
HABITS TOB.
NONE
NEVER
NEVER
NEVER
48
49
37
ALC.
NONE
NEVER
NEVER
NEVER
X-RAY
50
38
COF.
NONE
NONE
NONE
NONE
51
39
CONF. FAC. ST.
52
53
40
TIME
AVERAGE
AVERAGE
AVERAGE
54
41
AREA
POOR
AVERAGE
AVERAGE
TESTS
55
42
BEHAVIOR
AVERAGE
AVERAGE
AVERAGE
56
57
43
EXP. NEEDS
VERBALLY
VERBALLY
VERBALLY
VERBALLY
58
44
SOCIAL CONTACT
MEDICATIONS
CARDIAC
TRANQUZR
TRANQUZR
TRANQUZR
45
SPOUSE-CHD
MONTHLY
MONTHLY
MONTHLY
DIURETIC
CARDIAC
CARDIAC
CARDIAC
46
MINISTER
NEVER
NEVER
NEVER
DIURETIC
DIURETIC
DIURETIC
61
62
47
FRIENDS-OT.
NEVER
MONTHLY
MONTHLY
VIT/IRON VIT/IRON VIT/IRON
63
43
MAIL-PHONE
NEVER
INFREQ
INFREQ
65
49
ACTIVITIES
NONE
SLIGHT
SLIGHT
50
RELIGION
NONE
SLIGHT
SLIGHT
67
51
ARTS CRAFTS
NONE
NONE
NONE
66
69
52
RESTORATIVE
NONE
MODERATE
MODERATE
70
53
REHAB POTENTIAL SLIGHT
SLIGHT
MODERATE
SLIGHT
71
54
PROJ. L.O.S.
EXTENDED
EXTENDED
EXTENDED
EXTENDED
55
TEMP.
STABLE
74
56
PULSE.
STABLE
PATIENT STATUS PAR.REHB STATION. STATION. STATION.
75
RESP.
STABLE
DEATH DIAG
SYSTOLIC
STABLE
DIASTOLIC
STABLE
WT. INDEX
NORMAL
ILLUSTRATION # 3 Patient Profile
LONG TERM CARE PROGRAM
FACILITY
SUMMARY
TN#
7440147
83-BEDS
32-SK
51-INT
AUGUST
1975
PG
1
COMBINED CARE
ADMISSIONS
LEVEL OF CARE
CONT. STAY
DISCHARGES
DEATHS
ITEM
NUM.
%
NUM.
%
NUM.
of
NUM.
:
NUM.
%
-SEX-
MALE
4
33
18
22
1
13
1 100
FEMALE
8
67
65
78
7
88
TOTAL PATIENTS
12
100
83
100
8 100
1
100
-RACE AND ETHNIC ORIGIN-
WHITE
11
92
75
90
7
88
1 100
BLACK
1
8
8
10
1
13
MEXICAN
PUERTO RICAN
RED
YELLOW
OTHER
-AGE DISTRIBUTION-
UNCER 60
5
6
60-64
1
8
4
5
2
25
65-69
2
2
70-74
3
25
8
10
2
25
75-79
4
33
21
25
1
13
80-84
2
17
17
20
1 100
85-89
1
8
20
24
2
25
90-94
1
8
6
7
1
13
95-99
1
1
100 AND OVER
AVERAGE AGE
77
78
75
83
-MARITAL STATUS-
SINGLE
4
5
MARRIED
2
17
17
20
2
25
1 100
SEPARATED
DIVORCED
2
2
WICCWED
10
83
60
72
6
75
UNKNOWN
-OCCUPATION CLASS-
PROFESSIONAL
3
25
4
5
WHITE COLLAR
7
8
BLUE COLLAR
1
8
3
4
1
13
LAPORER
2
17
15
18
1
13
1 100
HOUSEWIFE
6
50
50
60
6
75
OTHER
3
4
UNKNOWN
1
1
-WORK STATUS-
WORKING FULL TIME
1
8
7
8
1
13
WORKING PART TIME
1
8
1
1
SICK LEAVE
RETIRED WITH PENSION
3
25
9
11
1
100
RETIRED WITHOUT PENSION
2
17
21
25
2
25
NEVER WORKED
5
42
48
58
4
50
UNKNOWN
3
4
1
13
-PRIMARY SCURCE OF PAYMENT-
SELF PAY
6
50
25
30
3
38
1 100
BLUE CROSS
MEDICARE
1
8
4
5
MEDICAID SKILLED
MEDICIAD ICF
5
42
54
65
5
63
VETERANS
CHAMPUS
WORKMENS COMPENSATION
CHARITY
OTHER
NO PAYMENT
-LEVEL OF CARE-
SKILLED
4
5
1 100
ICF
12
100
79
95
8 100
ICF M.R.
SPECIAL THERAPY
PERSONAL/CUSTODIAL
ROOM RESERVED
HOME HEALTH SERVICE
RESIDENTIAL
FORD
ILLUSTRATION # 4 Facility Summary (2 pages)
Extracts to give examples of information available.
LIBRARY
LONG TERM CARE PROGRAM FACILITY SUMMARY TN# 7440147 83-BEDS 32-SK 51-INT AUGUST 1975 PG 2
COMBINED CARE
ACMISSIONS
LEVEL OF CARE
CONT.
STAY
DISCHARGES
DEATHS
ITEM
NUM.
%
NUM.
:
NUM.
:
NUM.
:
NUM.
:
-TRANSFER DEST., DISCHARGES ONLY-
HOSPITAL
3
38
PSYCHIATRIC FACILITY
HOME
4
50
ORGANIZED HOME CARE
FOSTER HOME
NURSING HOME
1
13
COUNTY HOME
CUSTODIAL
OTHER
-NUMBER OF DIAGNOSES-
ONE
4
33
20
24
2
25
TWO
2
17
27
33
4
50
1 100
THREE
3
25
20
24
1
13
FOUR
3
25
11
13
1
13
FIVE AND ABOVE
5
6
-INCIDENTS & ACCIDENTS-
YES
4
5
NONE
12
100
79
95
8 100
1 100
-MOBILITY STATUS WITH NO HELP-
SELF CARE
1
8
2
2
WHEELCHAIR
4
5
BEC-FAST
EATING-FEEDING
9
75
73
88
7
88
WALKING
1
8
15
18
1
13
BATHING
5
6
TOILETING
18
22
1
13
TRANSFER
16
19
-MOBILITY STATUS WITH HELP-
SELF CARE
WHEELCHAIR
9
11
1
13
BEC-FAST
1
1
EATING-FEEDING
2
17
9
11
1
13
1 100
WALKING
10
83
45
54
5
63
1 100
BATHING
11
92
75
90
8 100
1 100
TOILETING
11
92
55
66
6
75
1 100
TRANSFER
8
67
55
66
8 100
-DECUBITUS PROBLEM-
HAD WHEN ADMITTED
1
1
1
13
DEVELOPED DURING NSF STAY
2
2
NO PROBLEM
12 100
80
96
7
88
1 100
-SPECIAL TREATMENTS-
DECUBITUS CARE
1
1
IV/TUBE FEEDING
4
5
1
13
1 100
TRACH. CARE
SUCTIONING
1
1
THER. DIET
1
1
SPEC. OSTOMY CARE
1
1
STERILE CRESSINGS
1
1
RESTRAINTS
DRUG REGULATION
MULTIPLE INJECTIONS
3
4
IRRIGATIONS
1
8
4
5
02 THERAPY
1
1
FLU VACCINE
NO SPECIAL TREATMENTS
11
92
73
88
7
88
-MEDICATIONS-
TRANQUILIZERS
6
50
44
53
5
63
HYPNOTICS
2
17
26
31
2
25
ANTIBIOTICS
4
33
13
16
1
13
CHEMOTHERAPY
VASODILATORS
20
24
1
13
ANTI-HYPERTENSIVES
14
17
CARDIAC DRUGS
7
58
27
33
3
38
ANTICOAGULANTS
NARCOTICS
4
5
PAIN RELIEVERS
6
50
43
52
4
50
STEROIDS
8
10
INSULIN
2
17
3
4
1
13
ANTI-DIABETICS
3
4
DURETICS
1
8
19
23
2
25
VITAMINS
2
17
20
24
1
13
2 MEDS SAME RX EFFECT
3
4
HORMONES
7
8
OTHER
7
58
38
46
2
25
ERROR
LAXATIVES
9
75
46
55
3
38
NONE
1
8
2
2
1 100
-PATIENT STATUS-
WELL
MAXIMUM REHABILITATION
1
1
PARTIAL REHABILITATION
2
17
12
14
1
13
STATIONARY
7
58
61
73
6
75
DETERIORATING
3
25
9
11
1
13
EXPIRED WITH AUTOPSY
EXPIRED WITHOUT AUTOPSY
1 100
CORONER
ILLUSTRATION # 4 Facility Summary (continued)
113255
5
LONG TERM CARE PROGRAM
DIAGNOSES REPORT
TN# 7440147
APR-JUN 1975
PAGE 16
SKILLED CARE DISCHARGED ALIVE
I
2
-PROBLEM IDENTIF-
3
D
MEBTBBSMP
LC PRIM
4
E
OAAOLOEES
VA PAYMI
5
PRIM
SECONDARY DIAGNOSES MEDICAL
S PAI BITLAWNNY
LR SOURCE
a
DIAG DX A DX B DX C DX D RECORD # AGE LOS I STAT LNHIDLSIC
-TREATMENTS-
-MEDICATIONS--
E
,
a
713
,
82.1
411 83 371 4 101100001 14
02 07 18
1 SELF
10
"
82.5
418 71 251 3 101100001 14
07 10
1 SELF
12
13
162 MALIGNANT NEOPLASM OF TRACHEA. BRONCHUS E LUNG
14
162.1 492.
44058 65 5111100001
02 10 12 01 02 05 09 18
1 SELF
15
16
401 ESSENTIAL BENIGN HYPERTENSION
"
401. 438.0
424
81
20 4
,
101100001
14
05
02 07 06 03
1 M/CARE
18
19
427 SYMPTOMATIC HEART DISEASE
20
427.0 412.9 Y10.0 319.1
447 79 175 5 111O00001
10 12
02 06 07 18
1 M/CARE
21
22
438 OTHER & ILL-DEFINED CEREBROVASCULAR DISEASE
23
438.
435 72 12 1 4 101100000 14
05 07 02 14 18
1 M/CARE
14
25
26
27
118195
LONG TERM CARE PROGRAM
IN# 7440147 83-BEDS 32-SK 51-INT APR-JUN 1975 P G 16
SKILLED CARE DISCHARGED ALIVE
#
COUNT MR# MOBLIY EATING BATHING TOTLET BLADDR BOWEL SPECL MENTAL PSYCHO LOS PAYMENT LEVEL TRANSFER
?
FEEDING
SENSES
SOCIAL
SOURCE CARE DEST.
3
4
435
12 MEDICARE SKILLED HOME
5
1
6
,
411
37 SELF PAY SKILLED HOME
a
418
I
1
1
25 SELF PAY SKILLED HOME
,
424
20 MEDICARE SKILLED NURS HM
10
1
"
12
447
1
17 MEDICARE SKILLED HOSPITAL
13
1
14
15
440
1
1
1
1
6 SELF PAY SKILLED HOSPITAL
16
-
17
6 TOT PATIENTS
18
19
for PATS E %
#
of
#
N
#
-
#
%
#
%
#
$
#
M
#
%
#
%
20
PROBLEM TYPE
6 100
2
33
6 100
5
83
5 83
21
22
PROBLEM GROUP
NONE
ONL
TWO
THREE
FOUR
FIVE
SIX
SEVEN
EIGHT
NINE
23
TOT PAIS L %
1
17
4 67
1 17
24
ILLUSTRATION # 5 Diagnosis Summary (Discharged Alive
Done on Admission, Continued Stay, Discharged Alive, and Death
CRITICAL ITEMS REPORT
JUNE, 1975
PG. 1
CRITICAL ITEMS REPORT
JUNE, 1975
PG. 2
PROVIDER NO. 7440147
PROVIDER NO. 7440147
FACILITY
COMPANY
STATE
REGIONAL
NATIONAL
FACILITY
COMPANY
STATE
REGIONAL
NATIONAL
Sk ICF Comb
Sk
ICF
Comb
Sk
ICF Comb
Sk ICF Comb
Sk ICF Corb
Sk ICF Comb
Sk ICF Comb
Sk ICF Comb
Sk
ICF
Comb
Sk ICF Comb
INCIDENTS & ACCIDENTS
BED CAPACITY
83
2438
1439
2468
2541
1
1
2
3
3
1
2
2
2
3
3
2
3
3
Avg. Daily Census
80
2310
1418
2341
2413
: Occupancy
95
99
95
95
SELF CARE
96
2
2
4
15
12
2
12
11
4
14
11
4
15
12
, ADMISSIONS
5
22
27
96 150
246
32 126
158
96 154
250
96 158
254
# DISCHARGES
3
10
13
52 144
196
14 113
127
52 141
193
52 144
195
ADL
# DEATHS
3
3
30 23
53
7
19
26
30 22
52
30
23
53
Help with walking or wheelchair
63
59
58
61
55
87
49
57
56
61
53
56
61
55
56
TOTAL PATIENTS
11
86
97
758 1788
2546
85 1432
1517
760 1768
2528
760 1843
2603
Bedfast
36
2
6
16
7
10
35 10
12
16
9
11
16
9
11
Help with eating
45
10
14
36
21
26
48
24
25
36
21
26
36
21
26
AVERAGE AGE
73
80
79
78
77
77
75
78
76
78
77
77
78
77
77
CATHETER
On admission
2
2
% SEX Male
36
20
22
30
30
30
24
30
30
30
30
30
30
30
30
12
5
7
18
5
6
12
5
7
12
4
7
Female
64
80
78
70
70
70
76
70
70
70
70
70
70
70
70
During stay
27
9
11
9
5
6
20
5
6
9
5
6
9
5
6
RACE White
91
92
92
91
92
91
INCONTINENCE
92
92
92
91
92
91
91
92
91
Bladder
17
Black
9
8
8
9
8
8
15
18
13
17
9
22
17
17
22
17
18
22
17
18
7
7
7
9
8
8
8
8
Bowel
Other
1
9
17
16
31
1
1
1
20
23
35
20
21
31
15
23
31
20
24
PRIMARY SOURCE OF PAYMENT
SOCIAL CONTACTS
Self
36
28
29
13
28
24
Spouse (none)
9
16
15
24
29
27
19
27
27
24
28
27
24
28
27
15
31
30
13
28
24
13
28
23
32
3
11
Minister (none)
27
56
53
Medicare
12
16
15
19
18
18
12
16
15
12
15
14
55
2
8
56
2
5
32
3
12
32
3
11
Medicaid Skilled
47
2
15
Friends (none)
7
6
5
7
7
8
6
7
5
7
7
5
7
7
9
1
1
47
2
15
47
2
15
Medicaid ICF
3
63
45
Mail & phone (none)
18
23
23
13
17
16
21
17
18
13
18
16
13
17
9
16
69
62
15
61
58
3
63
45
3
63
46
All Other
1
-
4
4
4
3
4
4
4
4
4
4
4
4
ACTIVITY PARTICIPATION
17
22
33
23
26
38
24
25
33
23
REQUIRED LEVEL OF CARE
Activities (none)
55
26
33
23
26
100
30
Arts 8 crafts (none)
64
28
32
50
44
46
55
49
49
50
45
47
50
45
47
Skilled
100
11
100
6
100
30
100
29
91
64
Religion (none)
27
16
18
31
21
24
36
21
22
31
21
24
31
22
24
ICF
99
88
92
87
91
64
91
65
Personal/Custodial
1
1
1
1
1
RESTORATIVE (none)
45
16
20
30
32
31
34
29
30
30
31
All Other
1
1
8
6
31
30
31
31
7
,
8
6
8
6
ADMISSION SOURCE
REHABILITATION
Hospital
100
59
67
82
61
69
Physical therapy
36
14
16
16
10
11
38
14
15
16
12
13
16
11
12
93
64
72
82
61
69
82
61
69
Home
23
13 21
17
Speech therapy
1
2
1
1
19
5
25
20
13
21
17
13
21
17
3
Occupational therapy
9
30
28
3
2
1
1
1
1
1
3
Nursing Home
18
15
17
12
2
3
8
7
3
17
12
3
17
12
All Other
2
2
0
1
1
2
2
0
2
2
0
PHYSICIAN VISITS
TRANSFER DESTINATION (Discharge Only)
at least q30d
91
15
24
88
30
46
79
23
26
88
33
48
88
30
47
Hospital
67
15
56
46
48
at least q60d
9
84
75
1
61
43
12 68
65
1
57
41
1
50
45
46
56
45
48
56
46
48
59
42
Home
33
80
19
35
infrequently
1
1
9
8
8
4
7
7
7
Nurs Ing Home
20
15
23
16
19
35
8
9
8
36
37
35
19
8
18
14
17
17
16
18
23
16
All Other
2
3
3
1
1
2
3
3
2
3
3
CRITICAL ITEMS REPORT
JUNE, 1975
PG. 3
CRITICAL ITEMS REPORT
JUNE, 1975
PG. 4
PROVIDER NO. 7440147
PROVIDER NO. 7440147
FACILITY
COMPANY
STATE
REGIONAL
NATIONAL
FACILITY
COMPANY
STATE
REGIONAL
NATIONAL
Sk ICF Comb
Sk ICF Comb
Sk
ICF
Comb
Sk
ICF
Comb
Sk
ICF
Comb
5k ICF Comb
Sk ICF Comb
Sk ICF Comb
Sk
ICF
Comb
Sk ICF Corb
LABORATORY
36
8
11
20
10
13
19
8
10
20
10
13
20
10
13
X-RAY
18
2
4
2
4
3
8
5
5
2
4
3
2
4
3
VITAL SIGNS PROBLEM
TPR
27
17
19
22
12
19
29
17
18
22
17
19
22
18
19
SPECIAL TEST
1
4
2
2
1
2
1
B/P
2
37
30
30
2
31
35
34
39
32
32
31
34
33
31
34
33
WEIGHT PROBLEM
SPECIAL TREATMENTS
Increased
15
13
Special Skin Care
9
5
5
10
4
6
28
5
7
10
5
6
10
5
6
5
4
5
4
Decreased
27
15
6
8
7
8
8
?
5
4
16
8
7
:
5
4
IV/tube feeding
12
36
1
5
7
1
3
33
1
3
7
1
3
7
1
3
8
7
Trach care
9
1
1
4
1
1
Suction
18
2
4
1
2
12
1
4
2
4
2
Therapeutic Diet
9
8
34
25
28
35
26
27
34
25
28
34
25
28
Special ostomy care
9
1
1
1
1
4
1
1
1
I
1
1
Sterile Dressing
9
1
2
8
2
-
11
2
3
8
2
4
8
2
4
Restraints
10
4
6
7
5
5
10
6
7
10
5
7
Drug Regulations
55
5
16
6
7
55
5
5
5
5
Multiple Injections
55
6
11
53
4
16
3
4
5
3
4
5
3
.4
Irrigations
27
12
13
15
7
10
26
8
9
15
7
10
15
7
10
02
18
2
2
1
1
7
1
1
2
1
1
2
1
Flu Vaccine
1
1
1
1
1
None
36
78
73
39
61
54
15
59
57
39
59
53
39
60
53
DECUBITUS PROBLEM
On adm.
9
2
3
4
1
2
13
1
2
4
1
2
4
2
During stay
9
2
3
1
1
1
2
-
1
1
1
1
1
1
1
No problem
82
95
94
95
98
97
85
97
97
95
98
97
95
98
97
MEDICATIONS
Tranquilizer
64
58
59
60
57
58
54
57
57
60
59
59
60
58
58
Hypnotics
36
24
26
35
26
28
34
22
23
35
24
27
35
25
28
Antibiotics
27
10
12
17
13
14
28
13
14
17
13
14
17
13
14
Narcotics
27
3
6
10
3
5
20
3
4
10
3
5
10
3
5
Insulin
3
3
6
4
4
7
4
4
6
4
4
6
4
4
2 med with same # Rx effect
1
1
14
6
9
7
7
7
14
7
9
14
7
9
Error
1
None
1
1
1
3
3
2
3
3
1
3
2
1
3
3
ILLUSTRATION # 6 Condensed Summary - Comparative Statistics