Florida's quality improvement programs are the result of legislation passed in 1999, 2000 and 2001. Prior to the passage of the legislation, respondents explained that the atmosphere in the state was unsettled with a number of issues facing nursing home providers, regulators and consumers. There was increasing concern with the quality of care in nursing facilities and how quality was to be defined and communicated to consumers.
In 1999, HB 1971 was passed, which included provisions for a technical assistance program, a quality recognition program, development of a website to post facility information for consumers, training programs and medical director standards. In 2000 a minor bill was passed that revised the measures that would be posted on the website and modified the types of documentation required for the discharge and transfer of residents.
At the same time these actions were taken, there was increasing concern about rising rates of litigation against nursing facilities and the effects of litigation on facilities' financial stability. Lawsuits had become common, affecting facilities regardless of their reputation for high or low quality care. Facilities were reportedly paying 500-fold increases in insurance rates while other facilities were unable to secure any insurance. During discussions with agency staff, it was stated that Florida ranked third in the nation for skilled nursing facility bankruptcies (behind Texas and California) and that Florida had 10 percent of the country's nursing home beds but 50 percent of the nursing home litigation. In response to these concerns, lawmakers created a 19-member Task Force to study the affordability and availability of long term care in Florida. The group was mandated to study and make recommendations on a number of issues pertaining to long-term care. Those specific to quality of care were the following:
- The extent to which the quality of care in long term care facilities in this state is compromised because of market changes that affect the financial stability of the long term care industry;
- The kinds of incidents that lead to the filing of lawsuits and the extent to which frivolous lawsuits are filed,
- The difference between the quality of care provided by for-profit skilled nursing facilities and by not-for-profit skilled nursing facilities
- An evaluation of how the quality of care in long-term care facilities of this state compare with the quality of care in such facilities in other states.1
The Florida Policy Exchange Center on Aging at the University of South Florida (FPECA) was named to provide staff support to the Task Force. FPECA's research indicated that the number of lawsuits against Florida nursing homes had in fact dramatically increased, that insurance rates had been going up, that insurance companies were writing fewer policies and that consumers were complaining of poor quality of care and violation of residents' rights. They studied risk management in hospitals and concluded that the institution of an internal risk management program in nursing facilities "could be an appropriate step…to bring about a comprehensive quality care approach. Such a step could both encourage improved quality of care and remedy the prevailing litigious climate in the industry."2
In a 700-page report, released in February 2001, the Task Force presented their findings on the major task areas including options for improving nursing home quality. SB 1202 was signed into law in May 2001 based in part on the findings from the Task Force. As part of the compromise between consumer advocates and industry representatives, consumers agreed to tort reform in the form of limiting the amount of settlements against long term care facilities on the condition that this was partnered with increased oversight on quality. The quality improvement legislation contained the following components:
- Altered the technical assistance program by increasing the number of monitor positions and expanding the role of the quality monitors to include oversight of the risk management program;
- Instituted a requirement that every nursing facility have an internal risk management program which included tracking and reporting adverse incidents to the survey agency;
- Increased the required minimum nurse staffing ratios;
- Mandated additional training for caregivers;
- Added regulations regarding Medical Directors and grievance procedures;
- Required that the Nursing Home Watch List be released to consumers on a quarterly basis; and
- Established the Medicaid Up and Out program.
The legislation was passed on May 15, 2001 and enacted immediately. There was no period for facilities to prepare or for the State to develop interpretations of the bill.
Florida Policy Exchange Center on Aging, University of South Florida. "Informational Report of the Task Force on the Availability and Affordability of Long-Term Care for the Florida Legislature in Response to House Bill 1993." February 16, 2001, p. 9.
Florida Policy Exchange Center on Aging, p. 496.