The History Of Nursing Home Regulations

When the US enacted the Social Security Act of 1935, a public assistance program for the elderly called Old Age Assistance (OAA) made installments to care facilities for impoverished elderly. Nursing homes started to open due to regulations forbidding payment to public institutions like poorhouses. Rules on the industry followed, and “by the time of the first national survey of nursing homes in 1954, there were 9,000 homes classified as skilled nursing or personal care homes with skilled nursing facilities.”

The structure of this Act in the long term care industry was built through the 1950's with legislation on the federal level, directing states to license nursing homes. Congress set up rules and funding through various legislation throughout the decade and then turned its attention to the quality of care in the 1960's. 

1963 saw the introduction of the first set of regulations and guidelines for nursing homes and skilled nursing facilities

“The struggle to develop Federal requirements for nursing homes focused on two central concerns: physical safety and adequacy of treatment and services.”

From the sixties onward, state and federal government worked to make sure regulations continue to evolve with the times, the research, and public expectations of quality of care within nursing homes. 

The 1980's brought to light the failure of the federal government’s ability to effectively regulate the industry:

“The various conflicting forces, including consumer, industry, and State government, made it, in effect, impossible for the Federal Government to establish a reasonable, respectable set of proposed regulations.”

Independent, third-party research led to the examination of existing standards and made recommendations strengthened by new data. Safety and adequacy of treatment were no longer enough: there was a movement to bring a quality of life and personal choice, fair treatment and retention of rights as citizens of the US, and stricter professional standards of those providing care. The federal government now has more remedies to address the shortcomings of nursing homes, including the ability to take over management of a facility, non-payment, civil penalties, and the ability to close a facility that continues to fail to meet regulations. 

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LTC staffing challenges

In 2009, a scholarly article entitled “The Accumulated Challenges Of Long-Term Care” was published with an in-depth analysis of the LTC (Long Term Care) industry: 

“During the past century, long-term care in the United States has evolved through five cycles of development, each lasting approximately twenty years. Each, focusing on distinct concerns, produced unintended consequences. Each also added a layer to an accumulation of contradictory approaches—a patchwork system now pushed to the breaking point by increasing needs and financial pressures. Future policies must achieve a better synthesis of approaches inherited from the past while addressing their unintended consequences. Foremost must be assured access to essential care, delivery of high-quality services in an increasingly de-institutionalized system, and a reduction in social and economic disparities.”

The COVID-19 pandemic has served to bring significant attention to long term care facilities, and with good reason. Inadequate staffing = poorer outcomes. As important as it is, infection control is not diligently overseen in most facilities.

There is not enough staff to give it the attention it deserves 

Employee turnover results in chronically low staffing levels. Leadership development is non-existent when nurse-managers are mandated to serve as staff nurses because of staffing problems; this leads to routine management tasks and projects and federally mandated quality assurance/performance improvement activities becoming neglected. Facility administrators cannot focus on long-term staff development or leadership training goals because there are not enough people to put out the many ever-present daily fires that are so time-consuming. These embers exist and flare up because of inadequate staffing. Current corporate practice is to merge departments or divide and reassign the work from departments made newly defunct. Staffing ratios on a good day are abysmal because the actual Nursing department is given no agency in determining safe staffing levels; that determination is made by non-clinical entities in an accounting office that is usually a state or two away. 

Staffing is an enormous challenge

Low wages have long been a problem, even as a corporation’s yearly profits total millions of dollars. Nurses and CNA's perform all of the patient care and treatment, yet they are often the lowest-paid employees. Staffing ratios are unmanageable, particularly with the high-acuity patients that are too rapidly discharged from the hospital. 

The “new” patient

Care staff needs education on how to manage the new population that is moving into facilities: patients with behavioral health (BH) and substance abuse (SA) problems.  As the limited staff tries to manage these situations, older, more frail people fall, hygiene and nutrition go to the wayside, medications are not administered, and dressings are not changed. Potentially confused, older adults require reassurance and emotional support. 

Staffing challenges create more staffing challenges

LTC staffing, particularly in the Nursing department, is directly responsible for poor outcomes like morbidity and mortality in patient populations and the well-being of the staff. Staff cannot be adequately trained or oriented because they need someone attending to the floor. Sadly, the problems will not be solved until regulatory systems are updated to reflect the reality of today’s LTC settings.