ACTION ANNOUNCED BY THE PRESIDENT, PROGRESS CLAIMED, AND COMMENTARY

1. FEDERAL TRAINING FOR 2,000 STATE NURSING HOME INSPECTORS

What the President said:

"I am ordering that the Federal program for training State nursing home inspectors be expanded so that an additional 2,000 inspectors will be trained over the next 18-month period. The major responsibility for surveillance and regulation in the field is now carried out by State governments and this action will enable them to increase their effectiveness most significantly.

"One of three places in the country where such training is now provided is the W. K. Kellogg Center for Continuing Education at the University of New Hampshire in Durham. This program trains people not only to inspect nursing homes but also to provide technical assistance and consultative services which can help improve these facilities. This New Hampshire program is funded through a grant from the Department of Health, Education, and Welfare, and it is our intention to establish similar programs in other areas of the country. This expansion effort will cost approximately $3 million."

Action:

HEW contracted with two additional universities-the University of Maryland ($204,546) and the University of Colorado ($185,146)for the training of State nursing home inspectors. About 1,100 health surveyors had been trained by July 1972. The remaining 900 were scheduled to complete their 4 weeks training by July 1973. The actual cost was $1.2 million.

In addition to the training planned by HEW headquarters, there is now a coordinator in each region responsible for the Health Facility Surveyor Improvement Program, and funds allocated so that special needs identified in States in that area can be met.

Comment:

Undoubtedly, the training programs will be helpful. If all that is accomplished is the education of State inspectors in the essentials of Federal requirements which they can then apply in certifying nursing homes to participate in Medicare and Medicaid, the program will be constructive.

Critics, however, suggest that inspectors in the States should not be given total blame for the existence of substandard facilities. Their point has some value, particularly in Illinois where inspectors time and again pleaded with the State to take action against chronic violators but to no avail.16

It is also suggested that a training program a month long cannot be of much value. Moreover critics suggest that it would be less costly to the Government to transport instructors to the States rather than to bring students to the three universities providing the training.

Finally, some argue that the money could be better spent for the direct training of personnel rather than for facilitating greater policing.

16 See Part 5, p. 80.

2. 100 PERCENT FEDERAL FINANCING OF STATE INSPECTIONS

What the President said:

"I am asking the Congress to authorize the Federal Government to assume 100 percent of the necessary costs of these State inspection teams under the Medicaid program. This will bring the Medicaid law, which now requires the States to pay from 25 to 50 percent of these costs, into line with the Medicare law, under which the Federal Government pays the entire costs for such inspections. Again, State enforcement efforts would be significantly enhanced by this procedure.” Action:

This proposal was enacted as section 249 (b) of H.R. 1, P.L. 92.603.

Comment:

In H.R. 1, the Federal government agreed to assume 100 percent of the cost of State Medicare and Medicaid inspections through June 1, 1974. At the administration's request, the provision was recently extended by action of Senator Wallace Bennett, ranking Republican member of the Senate Finance Committee.17

Full Federal 100 percent financing should enable the States to add muscle to their inspection and enforcement teams. Unfortunately, the funding carries no preconditions or standards. There have been many complaints about untrained and inexperienced people being hired by the States for enforcement purposes.'

18

These charges, however, only serve to distract from the major eriticism. There continues to be heavy reliance upon State enforcement machinery. The Federal Government essentially offers a blank check. In addition to State licensure functions the States have responsibility to insure that (1) facilities conform to Federal and State standards. and (2) quality care is provided. This is taking too much for granted. A stronger Federal role is necessary.

3. CONSOLIDATION OF RESPONSIBILITY FOR ENFORCEMENT

What the President said:

"I am ordering that all activities relating to the enforcement of such standards-activities which are now scattered in various branches of the Department of Health, Education, and Welfare-be consolidated within the Department into a single, highly efficient program. This means that all enforcement responsibility will be focused at a single point-that a single official will be accountable for success or failure in this endeavor. I am confident that this step alone will enormously improve the efficiency and the consistency of our enforcement activities."

17 S. 3622 introduced June 11, 1974, Congressional Record, p. S 10242. Later added as an amendment to P.L. 93-368.

18 Washington Report on Long-Term Care, May 5, 1974, reveals report of Faye Abdellah. Director, Department of Health, Education, and Welfare, Office of Nursing Home Affairs, indicating bartenders performing inspections in Pennsylvania.

Action:

The Office of Nursing Home Affairs was established at HEW and Dr. Marie Callender was appointed as Special Assistant for Nursing Home Affairs. The new office was charged with coordinating enforcement programs of the Social and Rehabilitation Service, Medical Services Administration, Social Security Administration, and Health Services and Mental Health Administration. (In late 1973 Mrs. Callender accepted new responsibilities in AoA and was replaced by Dr. Faye Abdellah.)

Comment:

The creation of the Office of Nursing Home Affairs and the selection of Dr. Callender and later Dr. Abdellah was widely praised. In this respect, the move was positive and helpful.

However, the duties and powers of the Office of Nursing Home Affairs (ONHA) have not been well defined. There continues to be confusion. Under Secretary John Veneman in October 1971 told the Moss subcommittee that Dr. Merlin K. Duval, and specifically, his office of Assistant Secretary for Health and Scientific Affairs, was to be responsible for the coordination of nursing home enforcement activity. But it was never clear who had the responsibility.

It is evident that given the lack of clarification of this role the director of ONHA is not in a position to coordinate activities between the Social and Rehabilitation Service and the Social Security Administration, which administer Medicaid and Medicare respectively.

The Office of Nursing Home Affairs has no direct authority over any other HEW unit. The director serves at the pleasure of the Secretary and Assistant Secretary. With the departure of Secretary Elliot Richardson and Under Secretary John Veneman, Dr. Callender's ability to influence policy appeared to wane. (See page 107 of this part for details of HEW reorganization giving the Office of Nursing Home Affairs more enforcement authority.)

In short, the reality is far from the rhetoric of August 1971, wherein the President promised a nursing home "czar." The term "czar" was used by the White House to symbolize centralization of authority in one person. This hasn't happened. Responsibility for nursing homes within HEW is still diffused."

4. ENLARGING THE FEDERAL ENFORCEMENT CAPABILITY

What the President said:

"I am requesting funds to enlarge our Federal enforcement program by creating 150 additional positions. This will enable the Federal Government more effectively to meet its own responsibilities under the law and to support State enforcement efforts."

Action:

A staff expansion was requested and authorized by Congress as part of a $9.6 million nursing home supplemental appropriation sent to the Congress on October 7, 1971 and signed by the President on December

28, 1971. The new funds enabled deployment of 227 additional enforcement personnel, with most distributed among 10 HEW regional offices to provide technical assistance to State inspection programs.

Comment:

The request for 150 new positions in HEW accounts for the greatest portion of the $9.6 million appropriation. Some $3.7 million went to create the new positions. An additional $300,000 went to put HEW's audit and review procedures on a 2-year cycle. The discrepancy between the new 150 positions requested and the 227 enforcement personnel deployed is not otherwise explained by HEW. Mal Schechter, Washington editor of Hospital Practice comments: "This 25-fold increase indicates what Medicaid staffing should have been in recent years, it may also indicate why reforms legislated by Congress have failed to emerge at the bedsides of Medicaid patients." 99 19

Despite the increase in the numbers of personnel, enforcement will continue to remain a State function. State inspectors who inspect for purposes of State licensure will also continue the inspections for Medicare-Medicaid. Decisions to discipline or close a nursing home will be State decisions. The Federal Government is still in an advisory position. There are a great many more advisors with no real powers to compel proper performance. Pressure from Federal personnel on State officials will continue to result in pressures on the State elected representatives to stop the "harassment" by the Federal Government. The intervention of such elected officials in the past has been enough to nullify even the feeble efforts HEW offered. There is no reason to believe this pattern will not continue.

5. SHORT-TERM TRAINING OF PERSONNEL

What the President said:

"I have directed the Department of Health, Education, and Welfare to institute a new program of short-term courses for physicians, nurses, dieticians, social workers, and others who are regularly involved in furnishing services to nursing home patients. Appropriate professional organizations will be involved in developing plans and course materials for this program and the latest research findings in this complex field will also be utilized. In too many cases, those who provide nursing home care though they be generally well prepared for their profession-have not been adequately trained to meet the special needs of the elderly. Our new program will help correct this deficiency."

Action:

Federally sponsored programs operated in conjunction with national professional associations and nursing home groups are programed to reach 40.000 of the Nation's 500,000 long-term care personnel. The primary focus will be on physicians, nurses, nursing home administrators, and patient activity directors.

19 Washington Star, August 13, 1972.

Comment:

Short-term training for nursing home personnel is the most potentially beneficial part of the entire Nixon Plan. As of July 1973, the promised 40,000 (of the Nation's over 500,000) nursing home employees had received such training.

First, it should be stated that the program is nowhere near the scope it should be to solve the problem. In terms of duration these training programs were 2 and 3 day seminars. In terms of numbers, 40,000 out of 500,000 employees is hardly significant. Finally, the overwhelming need in nursing homes is for the training of aides and orderlies who account for the great majority of nursing home personnel. Moreover, they provide about 90 percent of the patient care. Some cities charge that these individuals have benefited little from the training grants.

The following is a partial list of HEW training grants out of the total allotment of $2.4 million: 20

The American Nursing Home Association received $139,000 to provide 2-day training programs for 10,000 individuals in ways to expand, develop, and enrich the lives of the Nation's nursing home patients. In short, one-fourth of those 40,000 personnel are not trained to take care of patients but how to "enrich their lives." The latter suggests recreation, activities, and crafts which are important. But spending for elementary training in patient care and the administration of drugs and their effects would certainly appear to be a more appropriate use of the money.

The American Medical Association received $172,000 to hold 10 seminars; one in each HEW region, with the specific purposes of identifying a medical director's specific duties in a nursing home, preparing physicians to serve as medical directors, and upgrading the abilities of those who already hold such positions. These seminars anticipated that the new skilled nursing facility regulations would require all participating facilities to have a medical director. The require ment, while present in early drafts, was deleted in final regulations, but reincorporated in October 1974.

The Association of University Programs in Hospital Administration received $71,124 for the development of curriculum modules in long-term care administration. Apparently it was assumed that there were no existing educational programs to serve as prototypes for wider duplication.

The American Nurses Association received $355,760 to train 3,000 registered nurses now employed in nursing homes in geriatrics. This is perhaps the most beneficial of all the contracts evaluated in this sequence.

20 Press release, HEW NEWS, Department of Health, Education and Welfare, Health Services and Mental Health Administration, Community Health Service. HEW Comments: As early as FY 73 the thrust of provider (patient care) training has been away from contracts with professional groups to identification of "centers of excellence", facilities in each region where team training of personnel can be conducted on site. Of the approximately 44,000 workers trained, 10,612 have been RNs and almost 9,000 LPNs and aides. This activity is conducted by the Division of Long-Term Care in the Bureau of Health Services Research, HRA.

In addition to awards made to training sites, funds are allocated to each Regional Office, where the Long-Term Care Training Coordinator assigned by DLTC designs or plans for training to meet special needs of States in that region. Four contracts for training nurses aides in rural areas are in force.