Government Regulation of Nursing Homes
Most Birmingham nursing homes are subject to federal government regulation because they receive payments from federal Medicare or Medicaid programs. A significant portion of Medicare and Medicaid funds is spent each year in covering the costs of nursing home care and services for the nation’s elderly and disabled. The Center for Medicare & Medicaid Services (CMS) is the branch of the federal government’s Department of Health and Human Services that regulates Medicare and Medicaid programs in the U.S. Alabama has a contract with CMS to regulate the nursing homes within the state that receive Medicare and Medicaid funds.
The Omnibus Reconciliation Act
Nursing homes are regulated by the federal government under the Omnibus Reconciliation Act of 1987 (OBRA). OBRA guidelines specify that nursing homes are ultimately responsible for the health, medical care, and well-being of their residents. Under OBRA, however, each state's government is ultimately responsible for licensing and certifying nursing homes within its state's borders. In order for nursing homes to receive Medicare or Medicaid, these institutions must comply with OBRA mandates.
The federal Health Care Financing Administration (HCFA) oversees state compliance with these regulations by enforcing guidelines for the evaluation, care, and treatment of nursing home residents. If a nursing home facility can demonstrate substantial compliance with these regulations, certification of the home is continued, and the home can receive government funds, such as Medicare and Medicaid. If substantial compliance can not be shown, the home may lose its ability to receive federal benefits.
In enacting OBRA, legislators were primarily concerned with establishing uniform standards for nursing homes that receive federal funding, thereby ensuring the health and safety of elderly patients. One of OBRA's provisions requires nursing homes to undergo annual inspections. Nursing homes are also required to create individualized care plans, reduce the use of chemical and physical restraints, and ensure that staff members are properly trained for special need situations. Although OBRA seeks to protect residents in nursing homes, the Act does not allow nursing home residents to file a lawsuit in order to enforce OBRA regulations. State and federal agencies, however, are able to impose penalties or seek legal action for OBRA violations.
Most states, including Alabama, have adopted similar provisions to those contained in OBRA. For example, most states have drafted a “Resident Bill of Rights" for those entrusted to the care of nursing home facilities. A Resident Bill of Rights requires nursing homes to provide certain rights, such as a right to a dignified existence, self-determination, and access to persons and services inside and outside the facility. Residents also have a right not to be coerced, discriminated against, interfered with, and fear reprisal from nursing home employees or administrators. If a nursing home fails to grant these basic rights, it may be penalized or have its license revoked altogether. In Alabama, the Department of Public Health (DPH) is responsible for ensuring the health and safety of nursing care institutions.
Annual Inspections
On average, the State of Alabama conducts yearly inspections of each nursing home that participates in Medicare and Medicaid. Nursing homes are required to cooperate with the Alabama DPH in mandatory unannounced inspections. If the nursing home is performing poorly, however, state inspectors may decide to investigate the facility more often. The state also conducts independent investigations regarding specific complaints about nursing home care. During inspections, state officials scrutinize all aspects of the quality of care, including resident care processes, staff/resident interaction, and overall quality of the institution. Using an established protocol of residents’ rights, the investigation team also interviews a sample of residents and family members about their experience with and overall assessment of the nursing home, as well as interview caregivers and administrative staff.
If inspectors determine that a home is in noncompliance with one or more of the over 150 regulations with which it must comply, the team will issue a deficiency citation. Depending on the nature and severity of the violation, CMS may take one of several allowable actions. For example, CMS may fine the nursing home, deny payment to the facility, assign a temporary manager, or install a state monitor. CMS considers the extent of harm caused by the failure to meet requirements when it takes an enforcement action. If the nursing home does not correct its problems, CMS will terminate its agreement with the home. As a result, the nursing home will no longer be certified to provide care to Medicare and Medicaid beneficiaries. Any beneficiaries residing in the home at the time of the termination will be transferred to certified facilities. |
