Such questions intrude even when the best of care is given. In other settings, however, scandal and calamity enter the picture; and dark new questions emerge. The subcommittee, in this report and succeeding Supporting Papers, recognizes the importance of the nursing home industry; and it pledges every effort to continue communication with representatives of the industry and with members of the executive branch. For these reasons, the subcommittee has devised an unusual format: After publication of this Introductory Report, a series of follow-up papers on individual issues will follow; then we will publish a compendium of statements invited from outside observers; after this will come our final report. In this way, the subcommittee can deal with the many parts needed to view long-term care as a whole. Testimony from many, many days of hearings and other research have been tapped for this report, which is extensive and heartfelt. Concern about people has been at the heart of this effort. The subcommittee has, therefore, been especially dependent upon responsive staff effort. Mr. Val Halamandaris, associate counsel for the Senate Special Committee on Aging, deserves specific mention for his role in assuring that subcommittee inquiries remained directed at their real target: to wit, people in need of good care. Mr. Halamandaris has had the primary responsibility for directing the subcommittee's hearings; he is responsible for the excellent research on data and for writing this report. He is more than a skilled and attentive attorney; his investigatory skills are rooted in concern and, when necessary, outrage. He has made it possible for this subcommittee to compile and offer more information and insights into the nursing home industry than the Congress has ever had before. He has been helped considerably by other committee personnel. Staff Director William Oriol has provided guidance and consultation leading to the design and special points of emphasis in this report. Committee Counsel David Affeldt has given generously of his legislative expertise, as well as painstaking attention to detail. Particularly fortunate for the subcommittee was the fact that a professional staff member, John Edie, had special qualifications for making a substantial contribution to this effort. Mr. Edie, an attorney, formerly served as counsel to a program on aging in Minneapolis, Minn. When the subcommittee went to that city for intensive hearings. on scandalous shortcomings in nursing home care there, Mr. Edie testified and then continued his efforts on behalf of reform. In the preparation of this report, he has worked closely and at length with Mr. Halamandaris and his associates. The subcommittee also stands in debt to a select group in the nursing home industry and within the executive branch. Usually without much attention or encouragement, these public servants have stubbornly refused to compromise their goal, seeking high, but reasonable, standards of care. With the publication of this Introductory Report, the subcommittee begins a final exploration of issues. We will publish responsible comments on findings expressed in this document and the Supporting Papers which will follow. And we will, in our final report, perhaps 8 to 10 months from now, make every effort to absorb new ideas or challenges to our findings. The care of chronically ill older Americans is too serious a topic for stubborn insistence upon fixed positions. Obviously, changes are needed. Obviously, those changes will occur only when public understanding and private conscience are stirred far more than is now the case. FRANK E. Moss, Chairman, Subcommittee on Long-Term Care. Nursing Home Care in the United States: Failure in Public Policy- Supporting Paper No. 1: The Litany of Nursing Home Abuses and an Supporting Paper No. 2: Drugs in Nursing Homes: Misuse, High Supporting Paper No. 3: Doctors in Nursing Homes: The Shunned Supporting Paper No. 4: Nurses in Nursing Homes: The Heavy Supporting Paper No. 6: What Can be Done in Nursing Homes: Supporting Paper No. 7: The Role of Nursing Homes in Caring for Supporting Paper No. 8: Access to Nursing Homes by U.S. Minor- Supporting Paper No. 9: Profits and the Nursing Home: Incentives 10 Ratio of Employees to Patients_ III. Funding and Industry: The Substantial Public Share. References... 20 21 22 23 24 24 24 24 24 25 27 PART 3 Page The Federal Response.. I. An Evaluation of Medicare.. A. Early Beginnings Under Medicare.. 29 30 30 32 33 33 D. The Effect of H.R. 1 on Medicare Some Gains and Some Skilled Nursing The Congressional Response California: Forerunner of Disaster?. E. Summary: The Medicare Nursing Home Program Today.... II. Medicaid's Growing Role_-_ A. Levels of Medicaid Reimbursement.. Intermediate Čare.. B. How Large is the Medicaid Nursing Home Program?. C. Consequences of "Cost-Cutting". D. Wholesale Reclassification of Patients to Lower Levels of E. Cost Pressures Weaken Nursing Home Standards HEW's Default on Standards for Skilled Nursing Facili- How the Standards Were Diluted.. "Vague Generalizations". F. HEW's Default on Standards for Intermediate Care Facili- 51 G. The Sharp Increase in Boarding Homes and Unlicensed Nurs- C. How Many Home Health or Visiting Nurse Agencies are D. Home Health Benefits Under Medicare. 57 58 59 62 62 64 E. Home Health Benefits Under Medicaid_ ᏢᎪᎡᎢ 5 Failure To Enforce Nursing Home Standards... I. The Battle Over Nursing Home Standards and Implementation of the A. Default on the Moss Amendments for Medicaid Skilled Nurs- 3. HEW's Responsibility to Withhold Federal Funds II. Licensing the Administrator: Roadblock to Enforcement of the Summary III. Nursing Home Inspections: "A National Farce" 1. Inspections Infrequent. 2. Shortages in Staffing.. 3. Advance Notice of Inspection is Given.. 4. Inspections are Bureaucratic Rituals. 5. The Recommendations of the Inspectors Ignored.. 6. The Fragmentation of Responsibility for Inspection. 8. Fragmentation by Geographic Responsibility and Political 9. State Responsibility for Federal Inspections of Disciplinary Options.. 11. The Lack of Accreditation and "Self-Regulation" IV. Two Case Histories in Enforcement Breakdown.. Wisconsin... PART 6 86 The Nixon Nursing Home "Reforms": How Effective?_ 1. Federal Training for 2,000 State Nursing Home 92 94 95 95 2. 100 percent Federal Financing of State Inspections. 96 96 97 98 6. Committing HEW to Set Up "Ombudsman" or Investiga- 100 7. A Comprehensive Review of Long-Term Care Facilities.. 8. Cutting Off Federal Funds to Substandard Homes... II. The Nixon Nursing Home "Reforms": An Expert Evaluation. The HEW Nursing Home Reforms-Part II. Summary.. Initial recommendations: Toward a national policy on long-term care.. Recommendations for the improvement of the inspection and enforce 103 103 105 106 107 109 109 111 APPENDIXES Appendix 1. Examples of retroactive denials_ 113 Appendix 2. Table 10.-Changes in estimated Medicaid costs (+) and |