Measuring Compliance in the Nursing Home Environment
The Long Term Care Inspection Process“Quality
means doing it right when no one is looking.”
- Henry Ford
Long term care facilities play an important role in the delivery
of senior health care to an aging population within the United
States. Along with retirement centers, home health care services
and assisted living facilities, nursing homes provide vital
care and services to elders and support to their family and
This article will summarize the long term care survey process,
one which measures long term care services by compliance with
federal regulations. As of April 2005 there were approximately
16,000 nursing homes in the United States. A large portion of
the individuals residing in these facilities receive care provided
by Medicare and Medicaid funding. Facilities are required to
be in compliance with federal regulations. The Centers for Medicare
and Medicaid Services (CMS), oversees the Medicare and Medicaid
programs and contracts with individual States to monitor long
term care facilities and to conduct onsite inspections. Within
individual States it is typically the Health Department which
conducts the survey inspections. The purpose of these inspections
is to determine whether the nursing center meets the minimum
Medicare and Medicaid quality and performance standards. In
the course of each survey inspection process, the survey team
evaluates the care within a center and determines whether that
care and service is provided in accordance with regulatory requirements.
These surveys are unannounced and take place every 9 to 15 months.
Prior to conducting the survey, the survey team reviews a broad
collection of information. This information includes the nursing
homes’ previous survey history (the OSCAR report) which
outlines four years of compliance history, the center’s
quality indicator report (which presents resident specific chronic
and post-acute care measures), as well as information from the
State Ombudsman Office, in addition to any complaint investigations
or occurrence reports for the center.
Utilizing this information, the survey team evaluates many different
aspects of compliance with federal regulations. The team interviews
residents, staff and family members. It evaluates regulatory
compliance in areas including nursing care, medication administration,
resident dignity, environmental quality, dietary services, recreational
activities and medical record review, among multiple other areas.
During this process, if the care and service present what is
termed a deficient practice, that is, a practice which does
not meet the compliance requirements, the survey team cites
a deficiency. Importantly, the deficiency is categorized by
the survey team and is assigned a scope and severity level.
The scope of a deficiency identifies if the deficient practice
is isolated in nature, presents a pattern or is widespread.
The severity of a deficiency identifies if the deficiency had
no actual harm or outcome, had the potential for harm or resulted
in actual harm.
For a variety of reasons, nearly all nursing home surveys result
in the citation of deficiencies. When evaluating a specific
nursing homes survey history, it is important to look at whether
the nursing home’s survey performance includes deficiencies
which were less or greater than the statewide average for all
nursing homes. Also, the specific kind of deficiency as well
as its related scope and severity are very important, reflecting
that deficiencies with lower scope and severity reflect much
less concerning compliance concerns.
Following a survey, the nursing home receives a list of deficiencies
(the 2567) and is given ten days to submit a plan of correction,
which is then followed up with a follow-up survey to determine
the implementation of the plan of correction by the center.