Nursing Home Regulation Research Articles

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark.

Background and ObjectivesDespite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. A prior study has proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (STM) studies. This article aims to assess the extent to which NHs staff to this proposed STM benchmark, the extent to which regulators already implicitly apply the STM benchmark, and compute the additional operating expenses NHs would incur to adhere to the STM benchmark.Research Design and MethodsUsing NH Compare Archive data, the STM benchmark was compared to staffing levels reported by the facility and whether NHs received a nursing staff deficiency. Using financial information from Medicare Cost Reports, the additional annual operating expenses required to staff to the STM benchmark were calculated for each state and nationwide.ResultsThe vast majority of NHs did not staff to the STM benchmark; 80.2% for registered nurses and 60.0% for total nursing staff. Deficiency patterns showed that NH regulators were not using the STM benchmark to determine sufficiency of nursing staff. Implementing the STM benchmark as a regulatory standard would increase operating expenses for 59.1% of NHs, at an average annual cost of half-million dollars per facility. The nationwide increase in operating expense is estimated to be at least $4.9 billion per year.Discussion and ImplicationsWithout clear guidance on the staffing level needed to be sufficiently staffed, most NHs are subject to a community standard of care, which some have argued could be associated with suboptimal staffing levels. Implementing an acuity-based benchmark could result in improved staffing levels but also comes with significant economic costs. The STM benchmark is not economically feasible at current Medicare and Medicaid reimbursement levels.

Trauma-Informed Care Takes Center Stage in Ongoing Pandemic

Trauma-Informed Care Takes Center Stage in Ongoing Pandemic

Exploring evolving caring relationship experiences among nursing home residents and nurse aides in Shanghai: a dyadic perspective

AbstractAlthough research has shown that older nursing home residents can benefit from caring relationships with nurse aides, few studies have explored their dyadic, evolving relationship dynamics. Using a dyadic perspective, this study simultaneously explores caring relationships among older residents and nurse aides in Shanghai. In a government-sponsored nursing home in Shanghai, 20 matched resident–nurse aide dyads participated in semi-structured, in-depth interviews (N = 40). We performed thematic analysis to interpret and conceptualise the evolving caring relationships within dyads. Four types emerged during the evolution of caring relationships across the 20 dyads: (a) sharing strong rapport, (b) respecting each other, (c) hesitant responding, and (d) keeping emotional distance. Upon placement, all the residents kept emotional distance from nurse aides, and their assigned nurse aides provided care-giving by following nursing home regulations. As time passed, nurse aides began to create a family environment and tried to interact with residents on an emotional level; however, residents’ attitudes varied. The caring relationships in some dyads evolved as rapport and respect emerged, while others remained hesitant and distant. This suggests that residents and nurse aides prioritised caring relationships differently in terms of autonomy preservation and safety protection, respectively. This study sheds light on nursing home practice to facilitate building caring relationships between residents and nurse aides.

Does Nonprofit Ownership Matter for Firm Performance? Financial Distress and Ownership Conversion of Nursing Homes

In the past two decades, many nursing homes converted their ownership status from nonprofit to for-profit (NP-to-FP). These conversions have drawn public scrutiny and triggered a debate about the implications of ownership conversions on nursing home performance. Exploring a nationwide panel data set of U.S. nursing homes from 2006 to 2017, we observe that nursing homes with higher financial distress are associated with higher likelihood of NP-to-FP conversions. The postconversion operating margins increased significantly. Converted nursing homes improved their financial performance by reducing operating costs while keeping net resident revenues unchanged. Both cutting registered nurse staffing and cutting overhead staffing contributed to reductions in operating costs; however, only the former cost-reduction measure had a negative impact on quality. On average, the postconversion quality of care declined. The effects of NP-to-FP conversions on nursing homes were moderated by preconversion financial distress: High-distress nursing homes aggressively cut registered nurse staffing and experienced severe quality decline, whereas low-distress ones kept registered nurse staffing unchanged and largely avoided quality decline. These findings lead to both policy and managerial insights. To nursing home regulators, we recommend increased oversight on NP-to-FP conversions of nursing homes with high preconversion financial distress. To managers of nursing homes undergoing NP-to-FP conversions, our findings suggest that although cost reduction is an effective strategy to improve financial performance, they need to avoid the pitfall of cutting registered nurse staffing and instead focus on streamlining overhead operations in order to increase operating efficiency without compromising quality. This paper was accepted by Stefan Scholtes, healthcare management.

The Effect of Hands-on Practice on the Skills Proficiency of Nursing Home Nurses

Background: The most recent nursing home regulations indicate that nurses must possess the skills sets needed to properly provide residents’ care (“Reform of Requirements,” 2016). Nursing home directors of nursing (DONs) frequently meet the requirement to train their nurses using online continuing education programs. However, the hands-on practice of fundamental clinical nursing skills necessary to maintain proficiency cannot be accomplished with this method. Purpose: This study aimed to determine whether an educational intervention including hands-on practice of two clinical skills would improve the skills proficiency of nursing home nurses. Method: The study used a pretest-posttest design with skills fair-style educational intervention for nursing home nurses recruited from two nursing homes. The pretest and posttest each included a multiple-choice quiz and hands-on demonstrations of two different clinical skills. Statistical analysis using paired t-tests showed significantly improved skills proficiency for the participating nurses following the educational intervention with hands-on practice of the two clinical skills. Findings: The findings suggest that nursing home DONs should consider educational interventions that include hands-on practice to maintain clinical skills proficiency.

Does Ownership Conversion from Nonprofit to For-Profit Benefit the Public? Evidence from U.S. Nursing Homes

In the past two decades, many nursing homes converted their ownership status from nonprofit to for-profit (NP-to-FP). These conversions have drawn public scrutiny and triggered a debate about the implications of ownership conversions on nursing home performance. Exploring a nationwide panel dataset of U.S. nursing homes from 2006 to 2017, we observe that nursing homes with higher financial distress are associated with higher likelihood of NP-to-FP conversions. The post-conversion operating margins increased significantly. Converted nursing homes improved their financial performance by reducing operating costs while keeping net resident revenues unchanged. Both cutting registered nurse staffing and cutting overhead staffing contributed to reductions in operating costs; however, only the former cost-reduction measure had a negative impact on quality. On average, the post-conversion quality of care declined. The effects of NP-to-FP conversions on nursing homes were moderated by pre-conversion financial distress: High-distress nursing homes aggressively cut registered nurse staffing and experienced severe quality decline, whereas low-distress ones kept registered nurse staffing unchanged and largely avoided quality decline. These findings lead to both policy and managerial insights. To nursing home regulators, we recommend increased oversight on NP-to-FP conversions of nursing homes with high pre-conversion financial distress. To managers of nursing homes undergoing NP-to-FP conversions, our findings suggest that although cost reduction is an effective strategy to improve financial performance, they need to avoid the pitfall of cutting registered nurse staffing and instead focus on streamlining overhead operations in order to increase operating efficiency without compromising quality.

Nursing Home Regulations Redefined: Implications for Providers.

The Centers for Medicare and Medicaid Services (CMS) finalized a comprehensive update to nursing home requirements of participation in October 2016. Nearly 10,000 public comments were received regarding the proposed rule, and CMS made multiple modifications based on comments from providers, advocacy organizations, and others before issuing the final rule. The final rule describing nursing home requirements of participation modernizes nursing home regulation. It is being implemented in three phases-beginning in November 2016, November 2017, and November 2019. There are multiple provisions that have implications for clinicians caring for nursing home residents, particularly in terms of management of infections, medication prescribing and monitoring, and delegation of medical orders.

CMS Releases Final Rule Revising Nursing Home Regulations

CMS Releases Final Rule Revising Nursing Home Regulations

Study Suggests Nursing Home UTI Policies Lack Consistency

Study Suggests Nursing Home UTI Policies Lack Consistency

Battle of the Bugs: Progress in the Fight Against Antibiotic Resistance

Battle of the Bugs: Progress in the Fight Against Antibiotic Resistance

When Patient Rights and Physician Beliefs Collide

When Patient Rights and Physician Beliefs Collide

Are Nursing Home Regulations Like Cobwebs?

=2205111 Stevenson, D. G., Spittal, M. J., & Studdert, D. M. (2013). Does litigation increase or decrease health care quality? A national study of negligence claims against nursing homes. Medical Care, 51, 430–436. doi:10.1097/MLR.0b013e3182881ccc U.S. Department of Health and Human Services, Office of Inspector General. (2013). Skilled nursing facilities often fail to meet care planning and discharge requirements, OIE-02-02-00201 Retrieved from http://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf. U.S. Department of Health and Human Services, Office of Inspector General. (2014a). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries, OIE-06-1100370 Retrieved from http://oig.hhs.gov/oei/reports/oei-06-11-

Perceptions of abuse in nursing home care relationships in Uruguay.

To describe the care relationships between caregivers and elderly people in Uruguayan nursing homes. A qualitative study with an ethnographic approach conducted at nine nursing homes for elderly people located in four Uruguayan departments. Twenty-three purposively and theoretically selected participants were interviewed and observed between January 2011 and January 2012. Study of relationships among caregivers, managers, and residents revealed a number of issues: perception and experience of elder abuse, suffering when faced with death, and existential pain. A cultural context of discrimination against the elderly and other factors converge to perpetuate elder abuse and suffering in care homes: the lack of adequate regulations covering safety and quality of care, lack of a care model and regular inspections, absence of minimum training requirements for caregivers, and lack of support in situations that have psychic and spiritual repercussions. The inclusion of nurses could promote the development of educational interventions to modify abusive conduct. Nursing home managers need knowledge, skills, and communication strategies to identify and manage inappropriate behavior. An urgent review of nursing home regulations is required to protect elderly people's rights.

Changing Landscape of Nursing Homes in Singapore: Challenges in the 21st Century

The ageing population is posing new challenges to Singapore's healthcare system. The rise of dual income and the decline of extended families, as well as an increase in age-related degenerative disorders due to increased longevity render it difficult for the family to remain the primary social safety net to care for our elderly in their own homes. Consequently, nursing homes may become increasingly relevant for resource and expertise-challenged families to cope with the burden of caring for a frail and dependent elderly. However, as the recent Nightingale Nursing Home elderly mistreatment incident attests, the standards of some have been found wanting. This paper will trace the history of nursing homes in Singapore and the evolution of government policies towards them, discuss the challenges and trade-offs of nursing home regulation, and provide suggestions for better care and governance.

CMS Policy Updates and Priorities

CMS Policy Updates and Priorities

Life and Works of Sidney Katz, MD: A Life Marked by Fundamental Discovery

Fig. 1. Sidney Katz, MD. The late Sidney Katz, MD (Figure 1), who died on May 4 at age 88, founded a science of human functioning that fundamentally changed understandings and practice of long term care for older persons. By deconstructing and scaling the capacities required for independent living, the Katz Index of Activities of Daily Living (ADL)1, he provided a basis for measuring, predicting, and comparing declines and recovery in chronic illnesses of aging, or after catastrophic episodes such as stroke, cardiac events, and fractures; and a marker of needs for supportive care and/or a sheltered environment. This method of evaluation sprang from a seminal insight that all humans rely on being able to perform six functions for their basic independent survival: transferring from reclining to standing, feeding, dressing, bathing, using the toilet, and being continent. The Katz ADLs represent a universal language of need for health and social help that is understood worldwide and across disciplines. Those methods are the substrate of the contemporary national strategy for surveillance of standards of care in, and eligibility for admission to, nursing homes; and of the humanist movement to improve the well-being of older adults who are facing the challenges of aging and chronic illness. The common language provided by the terms he introduced to describe a patient’s functioning has united fields of research worldwide, facilitated such diverse services as multidisciplinary team management, determining whether a new intervention is effective, or deciding whether nursing home admission is advisable and eligible for insurance coverage. Since his initial paper in 1963 in JAMA on the ADL,1 it has been cited in over 46,886 professional publications. Virtually all Federal proposals to provide long term care include an ascertainment of the individual’s activities of daily living. Dr. Katz took a leadership position in many of the initiatives of the Institute of Medicine, including Chairing the 1983 Committee on Nursing Home Regulation, with the mandate to evaluate the Federal/ State regulatory system on quality of care in nursing homes: the recommendations of which laid the ground for the 1987 Federal Nursing Home Reform Act and Omnibus Reconciliation Act,2 leading to the 199

State Regulations for Nursing Home Residents with Serious Mental Illness

To identify state regulations for nursing home residents with Serious Mental Illness (SMI). We reviewed state regulations for policies relating to nursing home residents with SMI, and conducted interviews with expert stakeholders. A framework for analyzing state regulations was generated by identifying four discrete categories: States with specific mental illness regulations, Alzheimer's or dementia regulations, minor mention of mental illness, and no mention of mental illness. A large majority of the states have little or no mention of mental illness in their nursing home regulations, suggesting limited attention to all forms of mental illness by most state regulatory bodies.

Cost of Nursing Home Regulation

Cost of Nursing Home Regulation

Nursing Assistant Views on Nursing Home Regulatory Inspection

Nursing assistants provide more than 80% of direct care to residents. However, it is unknown whether or not they clearly understand the purpose of nursing home regulation and incorporate regulatory standards in their care delivery process. This study uses qualitative methods to explore their experiences with nursing home inspection. Findings suggest that the subtle nuances of human interaction between nursing assistants and residents tend to be overlooked in the midst of enforcing highly strict and detailed regulatory standards that mainly focus on visible outcomes of care. In addition, the state survey might deepen the chasm between nursing assistants and nursing home administration so that the hierarchical culture of mistrust and ritualism continues in nursing homes. To resolve such problems, it is critical to rethink the impact of nursing home regulation at the level of direct interactions between nursing assistants and residents and to consider increasing nursing assistant involvement in the inspection process.