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Administration Officials Propose Sweeping New Rules For Modernizing Nursing Home Care

For almost 25 years the rules that govern whether and how nursing homes and long-term care facilities qualify for Medicare and Medicaid — and in the process determine residents’ quality of care and safety — have remained largely unchanged. Medicare and Medicaid beneficiaries, who make up the majority of the 1.5 million residents in the country’s more than 15,000 long-term care facilities, have failed to reap many of the benefits of significant advances in the science and delivery of health care and from the advent of electronic recordkeeping and communications.

Addressing this critical need for modernization, Obama administration officials announced proposals on Monday, July 13th to make sweeping rules changes the White House said will “improve quality of life, enhance person-centered care and services for residents in nursing homes, improve resident safety, and bring these regulatory requirements into closer alignment with current professional standards.”

The announcement was made as the once-a-decade White House Conference on Aging convened Monday to set the agenda for meeting the diverse needs of older Americans, including those in need of long-term care. This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans.

The 403 pages of proposed changes — some required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance — contain numerous proposals that Health and Human Services Secretary Sylvia M. Burwell said “set high standards for quality and safety in nursing homes and long-term care facilities.” “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility,” the Secretary said, “they need to know that their loved one’s health and safety are priorities.”

Specific proposed rules changes, which include a section on electronic health records and measures to better involve patients or their families in care planning and the discharge process, address many of the areas in which nursing homes have been found to be deficient, by mandating rules and procedures for:

• updating nursing homes’ infection prevention and control programs;

• properly training nursing home staff in caring for residents with dementia and in preventing elder abuse and minimizing the use of antibiotic and antipsychotic drugs;

• ensuring that nursing homes take into consideration the health of residents when making decisions on the kinds and levels of staffing a facility needs to properly take care of its residents;

• developing individual care plans and hiring and training staff to provide person-centered care that take the resident’s goals and preferences into consideration;

• involving dietitians and therapy providers where appropriate in writing patient orders; and

• strengthening the rights of nursing home residents, including placing limits on when and how binding arbitration agreements may be used.

A report by the Center for Medicare Advocacy last year found that serious violations often were not penalized in a weak enforcement system that at best urges facilities to comply rather than imposing penalties for noncompliance. While there are no provisions specifically providing for enforcement, experts say the proposed measures will permit detection of violations to enable enforcement by lessening the noise. As Dr. Shari Ling, Medicare’s deputy chief medical officer, observed, “It’s a competency approach that goes beyond a game of numbers. If residents appear agitated, figure out why, get at the cause of the problem.”

Battle lines are already being drawn between the nursing home industry and patient advocates. If finalized, the proposals would cost the nursing home industry $729 million in the first year the rule is in effect and $638 million in year two, according to the CMS. “We would oppose such a large unfunded mandate, especially given the overall narrow margins of 1% to 3% that MedPAC calculates for skilled-nursing-care centers,” Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, said in a statement.

The reactions of advocates were mixed. The Long Term Care Community Coalition, for example, was happy to see HHS takes some steps to improve the care of residents in facilities but was disappointed that the agency didn’t go farther to push for mandatory staffing minimums.

Comments on the proposed rule changes are due September 16.

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