CHAPTER

The regulatory and federal oversight to nursing homes has a long history. From the passage of the Social Security Act of 1935, which started federal involve- ment, investigating deaths from fires and food poison- ing in the 1970s to the more sweeping changes of the 1980s, the federal government continues to be the guiding force of regulatory control. This federal regu- latory oversight has evolved because of special com- missions, Senate subcommittees, public health services concerns, and general public outcry about the quality of care provided in nursing homes. There were also enforcement problems in the survey process itself. All of these issues are significant for the work of health care professionals today. In 1980, the Health Care Financing Administration (HCFA) proposed new rules. These changes would shift the focus of regulations from paper reviews of facility capability to an evalua- tion of patients and the care that was received. The proposed new rules also included deemphasizing the medical model, elevating resident rights, and calling for an interdisciplinary team approach. Changes to the enforcement and survey process were also discussed. These modifications were never implemented as planned due to industry and government disputes.

OMNIBUS BUDGET RECONCILIATION ACT OF 1987

The Omnibus Budget Reconciliation Act (OBRA) of 1987 mandated that nursing homes provide necessary care and services for each resident to attain or maintain the highest practicable well-being. With the passage of OBRA, Congress changed the process for all facilities certified to participate in the Medicare or Medicaid programs. Specifically, OBRA 1987 and the federal regulations created new standards for an assessment tool—the Minimum Data Set (MDS)—to identify resi- dent care problem areas that were then addressed in an individualized care plan. Data gathered via this tool are

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Federal Regulations

also used for Medicare and many state Medicaid reim- bursement systems and for the monitoring of the quality of care provided to nursing facility residents. In October 1995, the Centers for Medicare & Medicaid Services (CMS) published the Long-Term Care Resident Assessment Instrument User’s Manual, Version 2.0 for use with the MDS 2.0.The MDS 3.0 was implemented in October 2010, with revisions being made on an ongoing basis. Updates to the manual are generally made at least annually. It is up to the registered dietitian nutritionist (RDN) and the nutrition and dietetic technician, registered (NDTR) to be aware of all changes when they occur (1). Visit the CMS website to learn more (www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments /NursingHomeQualityInits/MDS30RAIManual.html to access the most up-to-date requirements).

REGULATORY GUIDANCE TO LONG-TERM CARE FACILITIES AND TO SURVEYORS

CMS establishes the survey process and the regulatory oversight for long-term care facilities. These require- ments are published in the State Operations Manual (SOM) (2) and are revised periodically. SOM Appendix PP (3) is the “Guidance to Surveyors for Long Term Care Facilities.” Definitions are provided, every regulation is defined by its legal description, and the intent of the regulation is identified. Some regula- tions are further explained by the use of interpretive guidelines, and in some cases, references are provided. Interpretive guidance provides additional information for both the facility and for the surveyors during the inspection process. Surveyors are instructed to only write citations based on the specific regulation and not on the interpretive guidance. Many of the regulations also define how to determine compliance or noncom- pliance with regulatory requirements and how to