State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. 1.1 Policy Context


The traditional approach to ensuring adequate quality of nursing home care is regulatory--through the long-term care (LTC) survey and certification process. The Omnibus Reconciliation Act (OBRA) of 1987 strengthened federal requirements for the LTC survey and enforcement requirements, establishing a set of minimum standards that nursing homes must meet in order to gain (and retain) Medicare and Medicaid certification. The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, contracts with state survey agencies to monitor compliance with these standards through annual facility surveys, and states are primarily responsible for regulating the quality of nursing homes. The Federal Government pays 100 percent of the costs of Medicare skilled nursing facility surveys and 75 percent of the costs of Medicaid nursing facility surveys.

Despite the survey process, quality of care in nursing homes continues to be a concern, and the effectiveness of the survey process continues to be debated.1 Enforcement regulations have been criticized by providers and consumer advocates alike as either too stringent or not stringent enough. Many critics say the problem is the lack of consistency in how the survey, certification, and enforcement processes are implemented--that wide intra and inter-state variation exists in the number and type of deficiencies issued, scope and severity ratings assigned, and penalties imposed.2

Some states have established programs to improve nursing home quality through information and guidance to nursing homes on ways to improve quality of care--both generally and in relation to a facility's particular problems. In some states, these programs are intended to "raise the bar" by providing technical assistance to facilities so that they can perform at levels that exceed regulatory standards.

Similarly, the Federal Government has recently implemented nursing home quality improvement programs provided by the Quality Improvement Organizations (QIOs, formerly known as Peer Review Organizations) under contract to CMS. The CMS effort also includes a public reporting component. As of November 2002, CMS made available, through the QIOs, technical assistance to nursing homes in all states and began posting quality measures for nursing homes, in addition to other facility-level information, for nursing facilities nationwide through the Nursing Home Compare website (

The impetus for this recent federal initiative is similar to that of some of the states-- to stimulate the nursing facilities to improve performance through the provision of technical assistance and to furnish consumers with comparative information with which to make an informed choice about initial or continued residence in a given facility. How these federal nursing home quality improvement efforts will interact with state TA programs has not yet been determined.

  1. For example, see GAO (2000, 2002), OIG (1999a, 1999b).

  2. See OIG (1999c), CMS (1998).

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