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Background
Quality problems in the US nursing-home industry
In the United States, approximately 1.6 million people receive care each day in approximately 16,000 nursing homes. More than 80 per cent of nursing-home residents have significant limitations in physical functioning, and most suffer from at least three chronic diseases. Two-thirds exhibit significant cognitive impairment, and about half have no relatives living near their nursing home. Public funds pay for just in excess of the majority of nursing home care in the USA. The industry that receives those payments is dominated by large for-profit corporations that operate multi-facility systems in several states (Phillips, Hawes and Leyk-Williams 2003, 2004).
Responsibility for assuring a high quality of care and life for these millions of individuals falls to state and federal agencies that regulate nursing homes. All nursing homes are licensed by the States. In order to receive funds through the Medicare or Medicaid programmes, however, homes must also be registered as eligible. Approximately 95 per cent of nursing homes are certified to participate in at least one of these two programmes. The federal Centers for Medicare and Medicaid Services (CMS) have developed extensive rules and regulations governing the operation of certified homes. CMS contracts with state agencies to perform annual, unannounced inspections to determine whether homes are meeting federal standards. These inspections involve a review of home policies and procedures, a review of a sample of resident records, observations of care, and interviews with a sample of residents. Failure to meet federal standards results in the citing of a deficiency by a survey team, which indicates a specific failing that must be corrected. More serious deficiencies may result in fines. A record of continuing, serious non-compliance with standards can result in de-certification.
Despite state licensure regulation, the introduction of federal standards, and the shared federal/state role in upholding those standards, a series of state reports document abysmally poor care and failed regulatory processes (Arkansas 1978; Colorado 1977; Governor's Blue Ribbon Commission 1980; Illinois 1984; Maryland 1973; Minnesota 1976; New Jersey 1978; New York 1975; Ohio 1978; Texas 1978; Virginia 1978). Essentially the same findings and criticisms were echoed in reports by federal agencies that regulate nursing homes (US DHEW 1958) and by Congressional...