Nursing homes that receive federal funds are required to comply with federal laws that specify that residents receive a high quality of care. In response to reports of widespread neglect and abuse in nursing homes in the 1980s, the Congress enacted legislationin 1987 to reform nursing home regulations and require nursing homes participating in the Medicare and Medicaid programs to comply with certain requirements for quality of care. The legislation, included in the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), also known as the Nursing Home Reform Act, specifies that a nursing home “must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care…”
Care Requirements
To participate in the Medicare and Medicaid programs, nursing homes must be in compliance with the federal requirements for long term care as prescribed in the U.S. Code of Federal Regulation (42 CFR Part 483). Under the regulations, the nursing home must:
- Provide appropriate treatment and services to incontinent residents to restore as much normal bladder functioning as possible and prevent urinary tract infections (42 CFR § 483.25).
- Ensure that the resident receives adequate supervision and assistive devices to prevent accidents (42 CFR § 483.25).
- Ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein level (42 CFR § 483.25).
- Provide each resident with sufficient fluid intake to maintain proper hydration and health (42 CFR § 483.25).
- Have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care (42 CFR § 483.30).
- Conduct initially (no later than 14 days after admission) and periodically (after a significant change in the resident’s physical or mental condition and, in no case, less than once every 12 months) a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity (42 CFR § 483.20).
- Develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must be developed within 7 days after completion of the comprehensive assessment and describe the services that are to be furnished. Also, the care plan must be periodically reviewed and revised by a team of qualified persons after each assessment (42 CFR § 483.20).
- Prevent the deterioration of a resident’ ability to bathe, dress, groom, transfer and ambulate, toilet, eat, and to use speech, language or other functional communication systems (42 CFR § 483.25).
- Provide, if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal and oral hygiene (42 CFR § 483.25).
- Ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities (42 CFR § 483.25).
- Ensure that residents are free of any significant medication errors (42 CFR § 483.15).
- Care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life (42 CFR § 483.15).
- Promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality (42 CFR § 483.15).
- Ensure that the resident has the right to choose activities, schedules, and health care consistent with his or her interests, assessments and plan of care (42 CFR § 483.15).
- Ensure that the medical care of each resident is supervised by a physician and must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency(42 CFR § 483.40).
- Provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident (42 CFR § 483.60).
- Be administered in a manner that enable it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (42 CFR § 483.75).
- Maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized (42 CFR § 483.75).
In addition to federal laws regulating the quality of care in nursing homes, New York State has enacted laws as well. State law must be at least as stringent as the federal laws. In some instances New York State Law is tougher than federal law. In short, a nursing home must conduct an initial comprehensive assessment of each resident and periodic reassessments quarterly or as needed if there is a significant change in the condition of the resident. From the assessment, a plan of care must be developed that specifies the necessary care that must be provided. The facility must have sufficient nursing personnel to provide all the necessary care to each resident in accordance with the assessment and plan of care. The nursing home is required to document the assessments, plans of care, and the care provided, in the resident’s clinical record.
With both federal and state laws regulating nursing homes, almost every aspect of a nursing home’s operation and resident care are covered under the regulations. Thus, when a nursing home willfully does not provide required care that results in the deterioration and/or death of the resident, the nursing home may have violated federal and state laws. If the resident’s care was being reimbursed by Medicare or Medicaid, then the nursing home may have submitted false claims to the government.